Downhill skiing

Downhill skiing is enjoyed by more than 200 million people worldwide. Downhill skiers are at risk of serious head injury through falls or collisions, sometimes at high speeds, which can lead to long-term disability or death. Head injury incidence is estimated to be in the range of 0.77 to 3.8/100,000 ski visits, with most cases involving beginner or intermediate-level enthusiasts. Head injuries are the leading cause of death in downhill skiing accidents, with an the average age of head-injured skiers of approximately 30 years, but traumatic brain injury is also the leading cause of downhill skiing injury fatalities in children. Head injury is also the most common diagnosis among child and adolescent skiers requiring admission to hospital. In s study of skiing related fatalities in Colorado from 1980 to2001, 42.5% of 174 deaths in that era resulted from head injury.

Approximately 50% of head injuries result from falls on the slopes, whereas 42% to 47% result from collisions. Collisions with other skiers and snowboarders account for 58% and 34% of collision-related head injuries respectively, whereas collisions with trees and lift towers account for only 4% and 3% respectively. Jumping accounts for only 2.5% of head injuries among skiers. The pattern of injury by head region is: occipital (31%), frontal (29%), diffuse (23%), temporal (14%), and parietal (3%). Most head injuries in skiing are mild, with concussion as the most frequent diagnosis. The most common organic head injury among skiers is skull fracture. Wearing a helmet has been shown to reduce the risk of head injuries in downhill skiers, even when other potential risk factors are considered. It was once assumed that helmet use would increase the incidence of cervical spine injuries in downhill skiers, but this controversial assumption has been shown to be unlikely.

Despite clear evidence that helmet use prevents or reduces the severity of injuries, use remains less than widely accepted. In one study examining helmet use in child enthusiasts, only 30% of injured skiers and snowboarders wore helmets. It has also been suggested that no suitable helmet exists to protect all skiers, and that helmet development should be based on injury data analysis and strict standards.

There are very few published data on the risk and nature of head injury among Nordic or cross-country skiers.

Snowboarding

Snowboarding is a downhill alpine sport that was initially assumed to have injury patterns similar to those of skiing, but recent studies have shown that the incidence of head and spinal injuries in snowboarding is higher than previously documented. Injuries to the head and face represent 25% of all snowboarding injuries, and the rate of head and neck injury among snowboarders is one and a half to three that of skiers. The incidence of head injury for snowboarders is estimated to be 6.5/100,000 visits, compared with 3.8/100,000 visits for skiers. Head-injured snowboarders tend to be an average of 3.6 to 6.3 years younger than their skiing counterparts, and are more likely to be male. It is speculated that higher risk-taking behavior in younger males may be responsible for higher incidences of head injury. Most head injuries occur as a result of falls on mild to moderate slopes among beginner to intermediate-level participants. Jumping accounts for 30% of head injury cases among snowboarders, compared with only 2.5% of cases in skiers, reflecting the differences between the two activities. Most severe head injuries have occurred on gentle or moderate slopes resulting from the “opposite edge” phenomenon, in which the edge of the snowboard facing upslope catches a ridge of snow during a turn at low speeds, causing the rider to lose balance and fall. The occipital region of the head is the area most frequently affected in snowboarding head injuries, with a pattern of injury by head region being: occipital (48%), diffuse (23%), frontal (19%), temporal (9%), and parietal (1%). Snowboarders suffer intracranial hemorrhage more than twice as often as skiers, and require a craniotomy nearly three times as often. The reason for the difference in injury patterns in snowboarders compared with those in skiers is unclear, but may be related to the rails and jumps commonly found in snowboard parks.

The most common organic head injury among snowboarders is subdural hematoma, as opposed to skiers, who exhibit a higher frequency of skull fractures. Acute subdural hematomas are related to falls on the slope, falling backward, and occipital impact, whereas subcortical hemorrhagic contusions are thought to be related to falling during a jump, temporal impact, and falling on a jump platform. Mild snowboarding head injuries may rarely lead to chronic subdural hematoma, even in the absence of other predisposing factors. Snowboarders suffering head injuries more frequently require longer terms of rehabilitation and ongoing care compared with skiers who have head injuries, suggesting that the injuries themselves are more severe. Helmet use in snowboarders has shown similar efficacy as in skiers, leading to a reduction in head injury even after other risk factors have been considered. As with downhill skiing, helmet use does not significantly increase the risk of cervical spine injuries in snowboarders.

Snowboarding

Snowboarding is a downhill alpine sport that was initially assumed to have injury patterns similar to those of skiing, but recent studies have shown that the incidence of head and spinal injuries in snowboarding is higher than previously documented. Injuries to the head and face represent 25% of all snowboarding injuries, and the rate of head and neck injury among snowboarders is one and a half to three that of skiers. The incidence of head injury for snowboarders is estimated to be 6.5/100,000 visits, compared with 3.8/100,000 visits for skiers. Head-injured snowboarders tend to be an average of 3.6 to 6.3 years younger than their skiing counterparts, and are more likely to be male. It is speculated that higher risk-taking behavior in younger males may be responsible for higher incidences of head injury. Most head injuries occur as a result of falls on mild to moderate slopes among beginner to intermediate-level participants. Jumping accounts for 30% of head injury cases among snowboarders, compared with only 2.5% of cases in skiers, reflecting the differences between the two activities. Most severe head injuries have occurred on gentle or moderate slopes resulting from the “opposite edge” phenomenon, in which the edge of the snowboard facing upslope catches a ridge of snow during a turn at low speeds, causing the rider to lose balance and fall. The occipital region of the head is the area most frequently affected in snowboarding head injuries, with a pattern of injury by head region being: occipital (48%), diffuse (23%), frontal (19%), temporal (9%), and parietal (1%). Snowboarders suffer intracranial hemorrhage more than twice as often as skiers, and require a craniotomy nearly three times as often. The reason for the difference in injury patterns in snowboarders compared with those in skiers is unclear, but may be related to the rails and jumps commonly found in snowboard parks.

The most common organic head injury among snowboarders is subdural hematoma, as opposed to skiers, who exhibit a higher frequency of skull fractures. Acute subdural hematomas are related to falls on the slope, falling backward, and occipital impact, whereas subcortical hemorrhagic contusions are thought to be related to falling during a jump, temporal impact, and falling on a jump platform. Mild snowboarding head injuries may rarely lead to chronic subdural hematoma, even in the absence of other predisposing factors. Snowboarders suffering head injuries more frequently require longer terms of rehabilitation and ongoing care compared with skiers who have head injuries, suggesting that the injuries themselves are more severe. Helmet use in snowboarders has shown similar efficacy as in skiers, leading to a reduction in head injury even after other risk factors have been considered. As with downhill skiing, helmet use does not significantly increase the risk of cervical spine injuries in snowboarders.

Sledding/tobogganing

Injuries in sledding affect a larger and younger contingent of winter sport participants than injuries in skiing or snowboarding, likely owing to its easy accessibility, high speeds of descent, limited control and stability, and dangerous venues fraught with hazards such as trees, rocks, and roadways. Sledding is the winter activity most commonly associated with admission to hospital for children under 16 years of age, with head injury being the most common diagnosis. The average age of a severely injured sledder is 18.8 plus or minus 11.9 years; 12 years younger than the average skier, and more than 5 years younger than the average snowboarder. More than half (59%) of injured children sledders are male. Injured children sledders are almost three times as likely to require hospital admission compared with children injured in other sports. Although head injuries represent 13% of all sledding injuries in general, they account for 55% of severe sledding injuries. In most pediatric studies examining sledding injuries requiring emergency department assessment, head/neck injuries are the most frequent type of injury. Among childhood sledding injuries, younger children (≤6 yrs) are more likely to experience head/neck trauma compared with older children, with a relative risk of 2.60 ( P <.001). The most serious sledding injuries were incurred after the rider struck a tree or another stationary object in 60% and 76% of injuries. Although the incidence of collisions with motor vehicles is low, these often have catastrophic consequences, with head injury much more common. Although many studies advocate helmet use for sledders, the efficacy of helmet use in sledding is uncertain, and there are no specific helmets designed for sledding.. Helmet use among sledders is significantly lower than for downhill skiing or snowboarding, with only about 3% of sledders wearing some form of head protection. In addition to helmet use, familiarity with the terrain, proper lighting conditions, and proper supervision in children may also lower the risk of injury.