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Skiing Injuries in Children, Adolescents, and Adults*

M. C. DEIBERT, M.D., D. D. ARONSSON, M.D., R. J. JOHNSON, M.D., C. F. ETTLINGER, M.S. and J. E. SHEALY, PH.D.#, BURLINGTON, VERMONT

Investigation performed at the Department of Orthopaedics and Rehabilitation, McClure Musculoskeletal Research Center, The University of Vermont College of Medicine, Burlington

	Abstract

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We prospectively gathered data on skiing injuries that had been sustained at the Sugarbush North ski area since 1972 and at the Sugarbush South ski area since 1981. The purpose of the current study was to document the overall rates of injury in children, adolescents, and adults participating in alpine skiing. We also sought to determine the ten most common injuries in each age-group. Finally, we analyzed short-term and long-term trends to determine if changes in equipment had had an effect on the frequency or pattern of injury. From the 1981–1982 to the 1993–1994 season, there were 2.79 injuries per 1000 skier days: 4.27 injuries in children, 2.93 in adolescents, and 2.69 in adults. During the last eight years of the study, the most common injuries were a contusion of the knee in children, a sprain of the ulnar collateral ligament of the thumb in adolescents, and a grade-III sprain of the anterior cruciate ligament in adults. The short-term trends revealed that, in children, the frequency of tibial fractures decreased 10 per cent while that of fractures of the upper extremity increased 8 per cent. The long-term trends showed that, in adults, the rate of tibial fractures decreased 89 per cent while that of injuries of the anterior cruciate ligament increased 280 per cent. The overall rate of injury decreased 43 per cent from the beginning of the study in 1972 to the end of the study in 1994; the decrease was 58 per cent in children, 45 per cent in adolescents, and 42 per cent in adults. Data on the types of equipment and the binding-release values were collected prospectively from injured skiers and from 2083 non-injured skiers. Of the fifty-nine skiers who sustained a spiral fracture of the tibia, forty-two (71 per cent) had binding-release values that were higher than the average for the uninjured group. We believe that the use of properly functioning modern equipment will decrease the rate of injury, particularly in children.

	Introduction

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Alpine, or downhill, skiing is one of the most popular winter sports in the world; however, it has earned the distinction of having an inherently high risk of injury. Before 1975, the rate of injury in alpine skiers ranged from 5.0 to 7.6 injuries per 1000 skier days^16,20,24,25. In other words, for every 1000 skiers who were skiing on a given day, between five and eight sustained an injury. Efforts to increase the safety of skiing by improving the ski-boot-binding system and by educating skiers have contributed to a reduction in the rate of injury¹³; by 1982 the rate had decreased to 3.0 to 3.5 injuries per 1000 skier days^{1,4,6,21,22,30}, and in 1989 the rate was 2.0 injuries per 1000 skier days¹⁸.

The rate of injury in children has not been well documented. Because investigators have used different parameters to define age-groups, comparisons between studies have been inconsistent and difficult to interpret. However, most investigators have agreed that younger skiers are at increased risk for injury^{3-5,11,17,20,27,28,31,33,35,37}.

We prospectively gathered data on skiing injuries at the Sugarbush North ski area since 1972 and at the Sugarbush South ski area since 1981; both ski areas are in Warren, Vermont. The purpose of the current study was to determine the frequency and pattern of injury in three age-groups—children, adolescents, and adults—at these two locations during this twenty-two-year period. We sought to identify the mean overall rate of injury, the ten most common injuries, and the short-term and long-term injury trends for each age-group to determine if changes in equipment had had an effect on the frequency or pattern of injury.

	Materials and Methods

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In 1972, a protocol was established to prospectively evaluate injured skiers at the base-lodge clinic at the Sugarbush North ski area. The same protocol was adopted at the base-lodge clinic of the Sugarbush South ski area in 1981. This protocol included collection of data on the mechanism of injury and the equipment used by injured skiers. We sought to identify skiers who had an equipment-related injury of the lower extremity that was not the result of a collision. A history was obtained from each injured skier, a physical examination was performed, and radiographs were made if indicated. All radiographs made at the base-lodge clinics were available for study. Tibial fractures were classified as spiral or non-spiral because we believed that each type may be related to a specific mechanism of injury (for example, a twisting injury may cause a spiral fracture). A fracture was defined as spiral if a spiral pattern could be seen on both the anteroposterior and the lateral radiographs and a distinct vertical crack connecting the two ends of the spiral also could be identified.

A group comprising 2083 non-injured skiers was selected at random from the lift lines. These skiers were asked the same questions concerning their equipment as the injured skiers. If the injury involved the lower extremity, the bindings were tested according to the standards of the American Society for Testing and Materials whenever possible^2,12. This technique includes measurement of torsional and bending moments on a simulated tibia at the time that the bindings are released. The bindings of both the injured and the uninjured skiers were tested at the Sugarbush North ski area from the 1972–1973 to the 1987–1988 season, and the binding-release data were recorded as the percentage of the recommended value. A value of 100 means that the release value is 100 per cent of what is recommended for the skill of the skier being tested, according to the standards of the American Society for Testing and Materials^2,12. The bindings were tested for fifty-nine skiers who had a spiral fracture of the tibia, sixty-five who had a non-spiral fracture of the tibia, and 278 who had a grade-III sprain²⁶ of the anterior cruciate ligament.

Comparison of the number of injured skiers who had been evaluated by the ski patrol with the number examined at the base-lodge clinics revealed that 5 per cent of the injured skiers did not agree to evaluation or treatment because of insurance-related or other concerns. During the same time-frame, 40,000 interviews were conducted in the parking lots of the ski areas to ensure that the uninjured skiers included in the study were truly representative of the population at risk, to determine the age distribution of the skiing population, and to ascertain the ratio of skiers to snowboarders for each season. The snowboarding injuries were excluded from the calculation of the rate of skiing injuries by subtracting the percentage of snowboarders from the total population at risk. At the base-lodge clinics, data on injured skiers were collected separately from data on injured snowboarders.

The injured and non-injured skiers were divided into three age-groups: children (one to ten years old), adolescents (eleven to sixteen years old), and adults (more than sixteen years old). The number of injured skiers from the 1981–1982 to the 1993–1994 season at both ski areas was divided by the total number of skiers during the same time-frame to determine the overall rate of injury. The overall rate of injury was also determined for each age-group. Data on the injuries at both ski areas from the 1986–1987 to the 1993–1994 season were analyzed to determine the ten most common injuries in each age-group (Table I).

A regression analysis of the skiing injuries and the population at risk at the Sugarbush North ski area from the 1972–1973 to the 1993–1994 season was used to determine the long-term trends in the rate and pattern of injury for each category of injury (Table I). The long-term trends were expressed as the mean days between injuries and reflect actual rates of injury. The mean days between injuries is calculated by dividing the number of skier visits by the number of injuries; for example, if a ski area had two injured skiers during a day in which there were 100 skier visits, there would be a mean of fifty days between injuries. The number of skier visits was calculated on the basis of the total number of sales of ski-lift tickets and was corrected for season-pass holders, multiple-day pass holders, ski-area employees, and other skiers who had not purchased ski-lift tickets. The mean days between injuries reflects the actual rate of injury: the higher the value, the lower the rate of injury. The per cent change in the mean days between injuries (MDBI) was calculated as: % change in MDBI = 1 - (MDBI 1972–1973/MDBI 1993–1994) x 100.

A Pearson correlation coefficient was used to evaluate the significance of the short-term trends. The significance of the long-term trends was calculated with use of a regression analysis of the mean days between injuries for injuries sustained from the 1972–1973 to the 1993–1994 season at the Sugarbush North ski area. The significance of the r² values obtained with regression analysis was evaluated with use of a one-tailed Student t test. The change in the rate of injury was calculated by comparing the regressed mean days between injuries for all injuries from the start of the 1972–1973 to the end of the 1993–1994 season.

	Results

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From the 1981–1982 to the 1993–1994 season, there were 3,641,041 skier visits: 123,795 (3.4 per cent) by children, 502,464 (13.8 per cent) by adolescents, and 3,014,782 (82.8 per cent) by adults. During the same time-frame, there were 10,162 injuries: 528 in children, 1473 in adolescents, 8112 in adults, and forty-nine in individuals whose age was unknown. The overall rate of injury (calculated as [10,162/3,641,041] x 1000) was 2.79 injuries per 1000 skier days: 4.27 injuries in children, 2.93 in adolescents, and 2.69 in adults. These differences show that the rate of injury in children was 59 per cent higher than that in adults.

From the 1986–1987 to the 1993–1994 season, there were 5758 injuries: 304 in children, 797 in adolescents, and 4657 in adults. In children, the most common injury was a contusion of the knee, representing thirty-four (11.2 per cent) of the 304 injuries in this age-group. In adolescents, the most common injury was a sprain of the ulnar collateral ligament of the thumb (skier's thumb), representing eighty-one (10.2 per cent) of the 797 injuries in this age-group. In adults, the most common injury was a grade-III sprain²⁶ of the anterior cruciate ligament, representing 858 (18.4 per cent) of the 4657 injuries in this age-group. The ten most common injuries for each age-group were also were ranked (Table II). Interestingly, tibial fractures, which had ranked high in all age-groups in the 1970s, ranked seventh in children and were not included in the top ten injuries in either adolescents or adults.

Testing of the bindings revealed that the percentage of the recommended release value for skiers who sustained a spiral fracture of the tibia averaged 158, whereas that for the uninjured skiers averaged 111 (p < 0.001, Student t test). Of the fifty-nine skiers who had a spiral fracture, forty-two (71 per cent) had a higher average percentage of the recommended release value than that for the uninjured group.

	Discussion

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From the beginning of this prospective study (the 1972–1973 season) to the end (the 1993–1994 season), there were major changes in alpine skiing. The overall safety of the sport has improved for several reasons. An important change has been advances in the release function of the ski-boot-binding system. Simultaneous with these changes, the most common injuries in each age-group have changed as well.

Blitzer et al.³ did not find the overall rate of injury in children to be increased compared with that in adults. In the present study, from the 1981–1982 to the 1993–1994 season the overall rate of injury was 4.27 injuries per 1000 skier days for children compared with 2.69 injuries per 1000 skier days for adults. Thus, the rate for children was 59 per cent higher than that for adults. The difference between the rates may be due to the fact that advances in binding technology were first introduced into equipment used by adults, with an approximate ten-year lag in the application of the new technology to equipment used by children.

In 1984, Blitzer et al.³ reported that tibial fractures were the second most common injury in children, the third most common injury in adolescents, and the eighth most common injury in adults. In the present study, tibial fractures ranked seventh in children and were not among the top ten injuries in adolescents or adults (Table II). This decrease in the rate of tibial fractures may be due to improvements in the ski-boot-binding system. The current system has evolved gradually from 1960 to the present, with the release function improving throughout the 1960s. Low-friction materials were introduced at critical contact points of the boots, bindings, and skis in 1973 and were used universally by 1980. Modern ski bindings with low-friction multidirectional release functions (in compliance with international industry standards) were introduced in the mid-1970s and were in common use by the mid-1980s. Modern ski boots, constructed of durable low-friction plastic with a standardized shape, were introduced in the mid-1970s and were in common use by the early 1980s. Calibration techniques and equipment for testing the release function of bindings were introduced in the 1960s, were in common use by the 1970s, became mandatory in the United States by 1980, and were established as an international standard in the early 1980s. Currently, more than 95 per cent of ski shops use release-testing equipment for the inspection and testing of ski equipment. Practice standards in ski shops have been developed to ensure compatibility among components and proper calibration of the release system. The multidirectional release capability of modern bindings and the almost industry-wide standardization of release settings (according to the age, height, weight, and skill of the skier and the length of the boot sole) probably contributed to the decrease in tibial fractures, ankle fractures, and other injuries distal to the knee. The duration that is required before new products begin to influence the skiing population probably is related to the 2.5-year half-life of alpine ski equipment.

The short-term trends documented in the present study showed that, in children, there was a 10 per cent decrease in the frequency of tibial fractures and an 8 per cent increase in the frequency of fractures of the upper extremity (p < 0.01 for both). Ungerholm et al.³⁵, in a study conducted between 1972 and 1979, found a decrease in the frequency of tibial fractures and an increase in the frequency of fractures of the upper extremity. They also reported that, despite a decrease in the frequency of tibial fractures in children, the frequency was still considerably higher than that in adults, even at the end of the study.

The long-term trends in the current study showed a decrease in the rate of ankle and tibial fractures in all age-groups; however, the rate of concussions increased 48 per cent in children and 37 per cent in adolescents (not found to be significant, with the numbers available, in either group), the rate of head injuries increased 66 per cent in children and 5 per cent in adolescents (not found to be significant in either group), and the rate of spine injuries increased 130 per cent in children (not found to be significant) and 407 per cent in adolescents (p < 0.01). Even though the long-term trends for head injuries in children and adolescents were not found to be significant, they are alarming. It is important to continue to reevaluate the potential benefits of wearing a helmet while skiing. A large helmet may increase the risk of an injury of the cervical spine, but a lightweight helmet with a diameter that is not substantially greater than the diameter of the skier's head could provide protection for the head while minimizing the problems associated with heavier helmets. Several reports have documented that helmets may be beneficial, particularly for children and adolescents^9,23,29; however, if they are not properly designed, they may interfere with hearing and sight and may increase the risk of other injuries²³.

In the later time-period of our study, sprains of the anterior cruciate ligament represented 19 per cent of all injuries sustained by adults while skiing; this was a significant increase from the earlier time-period (p < 0.01). We also noted an increased frequency of sprains of the anterior cruciate ligament in adolescents, although this finding was not found to be significant. Elmqvist and Johnson¹⁰ reported that injuries of the anterior cruciate ligament represented less than 5 per cent of all skiing injuries in the 1970s. We believe that the current epidemic has been caused by a combination of changes in alpine skiing, including those in skiing technique, skill acquisition, and equipment design. Modern boots usually have a high, rigid shell with a fixed forward-lean angle, and skis now have improved turning characteristics. Videotape analysis of skiers who sustained an injury of the anterior cruciate ligament revealed several potentially dangerous situations: (1) the skier was off balance to the rear, (2) all of the skier's weight was distributed on the inside edge of the tail of the downhill ski, (3) none of the skier's weight was placed on the uphill ski, (4) the hips were positioned below the knees, (5) the upper body generally was facing the downhill ski, and (6) the uphill arm was positioned back¹³. Under these circumstances, the downhill ski may carve and shoot forward, causing an injury of the anterior cruciate ligament of the downhill lower limb¹³. This so-called phantom-foot mechanism is one of the most common causes of injuries of the anterior cruciate ligament (Fig. 1). We believe that modern skis transmit torques to the knee that cannot be prevented by the ski-boot-binding system.

Fig. 1 Drawing showing the potentially dangerous situation in which the so-called phantom-foot mechanism can result in an injury of the anterior cruciate ligament of the downhill lower extremity. (1) The skier is off balance to the rear, (2) all weight is placed on the inside edge of the tail of the downhill ski, (3) no weight is placed on the uphill ski, (4) the hips are positioned below the knees, (5) the upper body generally is facing the downhill ski, and (6) the uphill arm is positioned back13. In this situation, the downhill ski may carve into the snow and shoot forward, causing the injury. (Reprinted with permission from William Hamilton, copyright 1988.)

Several investigators have reported that children have a higher rate of fractures of the lower extremity than do adults^3,14,17,28. The spiral fracture of the tibia has been reported to be the most common fracture of the lower extremity in children^17,32,34,36, and this finding is consistent with our observations. We believe that this higher rate of injury may be caused by the improper adjustment and poor quality of the bindings and boots used by children. Ekeland et al.^7-9 reported that fractures of the lower extremity were six to nine times more common in children less than ten years of age than in adults. Skiers less than ten years of age were found to have twice the risk of sustaining an equipment-related injury of the lower extremity compared with older skiers. We agree with these findings and believe that the rate of fractures of the lower extremity can be reduced if parents provide modern, properly functioning equipment for their children. Children often use outdated equipment that has been handed down from an older sibling. The older equipment often does not fit properly and may not function properly, particularly if the release values are not adjusted for the skier's age, height, weight, and skill and the length of the boot sole¹⁵. We believe that it is important to educate parents to provide modern equipment and to verify that the binding settings and function are appropriate for the child using the equipment.

	Footnotes

 
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

Bozeman Bone and Joint Clinic, 935 Highland Boulevard, Suite 4200, Bozeman, Montana 59715.

Department of Orthopaedics and Rehabilitation, The University of Vermont College of Medicine, Robert T. Stafford Hall, Burlington, Vermont 05405-0084. Please address requests for reprints to Dr. Aronsson.

P.O. Box 85, Underhill Center, Vermont 05490.

#425 French Road, Rochester, New York 14618.

	References

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