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Helmet use is associated with higher Injury Severity Scores in alpine skiers and snowboarders evaluated at a Level I trauma center

Porter, Eleah D. MD; Trooboff, Spencer W. MD; Haff, Madeleine G. MD; Cooros, James C. MD, FACS; Wolffing, Andrea B. MD; Briggs, Alexandra MD; Rhynhart, Kurt K. MD, FACS; Crockett, Andrew O. MD, FACS

Journal of Trauma and Acute Care Surgery: November 2019 - Volume 87 - Issue 5 - p 1205–1213
doi: 10.1097/TA.0000000000002447

BACKGROUND There is uncertainty regarding the efficacy of ski helmets in preventing traumatic injury. We investigated the relationship between helmet use, injury types, and injury severity among skiers and snowboarders.

METHODS The trauma registry at a Northeast American College of Surgeons Level I trauma center was queried by International Classification of Diseases Codes—9th or 10th Revision for skiing and snowboarding injury between 2010 and 2018. The primary exposure was helmet use and primary outcome was severe injury (Injury Severity Score >15). We performed univariate and multivariable logistic regression to assess for injury types and severity associated with helmet use.

RESULTS Seven hundred twenty-one patients (65% helmeted, 35% unhelmeted) met inclusion criteria. Helmet use doubled during the study period (43% to 81%, p < 0.001), but the rate of any head injury did not significantly change (49% to 43%, p = 0.499). On multivariable regression, helmeted patients were significantly more likely to suffer severe injury (odds ratio [OR], 2.01; 95% confidence interval [CI], 1.30–3.11), intracranial hemorrhage (OR, 1.81; 95% CI, 1.10–2.96), chest injury (OR, 1.66; 95% CI, 1.05–2.61), and/or lumbosacral spine injury (OR, 1.84; 95% CI, 1.04–3.25) than unhelmeted patients. Helmeted patients were half as likely to suffer cervical spine injury (OR, 0.51; 95% CI, 0.30–0.89) and a third as likely to sustain skull fracture and/or scalp laceration (OR, 0.30; 95% CI, 0.14–0.64). More patients who hit a stationary object were helmeted compared with those who fell from standing height onto snow (70% vs. 56% respectively, p < 0.001). After adjustment, hitting a stationary object was the injury mechanism most significantly associated with severe injury (OR, 2.80; 95% CI, 1.79–4.38).

CONCLUSION Helmeted skiers and snowboarders evaluated at a Level I trauma center were more likely to suffer severe injury, including intracranial hemorrhage, as compared with unhelmeted participants. However, they were less likely to sustain skull fractures or cervical spine injuries. Helmeted patients were also more likely to hit a stationary object. Our findings reinforce the importance of safe skiing practices and trauma evaluation after high-impact injury, regardless of helmet use.

LEVEL OF EVIDENCE Prognostic and epidemiological, level IV.

From the Division of Trauma and Acute Care Surgery (E.D.P., S.W.T., J.C.C., A.B.W., A.B., K.K.R., A.O.C.), Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon; and Geisel School of Medicine (M.G.H., J.C.C., A.B.W., A.B., K.K.R., A.O.C.), Hanover, New Hampshire.

Submitted: January 11, 2019, Revised: April 22, 2019, Accepted: July 4, 2019, Published online: July 16, 2019.

49th Annual Meeting Western Trauma Association Earl G. Young Clinical Research Competition March 3 to 8, 2019 Aspen, CO.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (

Address for reprints: Andrew O. Crockett, MD, Division of Trauma and Acute Care Surgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr., Lebanon, NH 03756; email:

Online date: July 22, 2019

© 2019 Lippincott Williams & Wilkins, Inc.