AN INTRODUCTION TO SNOW SPORTS INJURIES AND SAFETY

Get well soon Schumi

Alpine snow sports remain very popular winter pastimes - it is estimated that there are currently more than 200 million skiers and 70 million snowboarders in the world today. In the winter season 2010/11, American resorts alone recorded a mammoth 60.1 million visits, just short of their record of 60.5m set in 2007/08. The average number of visits per year is 57.5 million. $5.8bn was spent at US resorts in 2010/11 (source NSAA).

In the UK, it is estimated that over £600m is spent every year on snow sports. The last 15 years have seen the emergence of new sports such as snowboarding and skiboarding (snowblading) which have helped to widen the appeal of snow sports - especially amongst a younger generation.  At the same time, more established sports like telemark skiing have also become increasingly popular as improvements in equipment design allow for faster speeds and increased technical manoeuvres.


Alpine skiing itself underwent a huge renaissance with the introduction of carving skis in the mid 1990's. and design improvements continue every year. Skiers can choose from a huge range of different ski designs all basically based on the carving system. New developments continue apace in all sports - advancements in soft ski boots, integrated and mechatronic binding systems, electronic filaments in skis, ski rails - to name a few. All in all, there are more opportunities to enjoy yourself both on and off piste now than ever before. I hope the information contained within this website will help you to have fun and also stay safe on snow. Unfortunately, as with every other outdoor sport, snow sports are associated with a risk of injury. But that risk is much lower than most people believe - less than 0.5% in fact to give you a ballpark figure. This website is written by an active ski patrol doctor who is a family doctor in a ski area with many years experience of not only treating these injuries both acutely on the slopes as they happen and but also in a nearby medical clinic. He also conducts in-depth research into their occurrence and prevention and is the current President of the International Society for Skiing Safety.

At least once a month the literature bases are checked for new publications and this website is updated as often as possible so that this information is passed on to the general public in a language most people can understand. Hopefully, by following the advice on this site, you will be able to enjoy many, many fantastic seasons on the snow without ever sustaining an injury. Or, if you've been unlucky enough to pick up an injury, I hope this website will help you to understand your injury and perhaps why it occurred, aid your rehabilitation and give you some useful advice that may help prevent an injury in the future.

I am always looking to improve and update this site. This includes integrating the latest injury data from our study here in Scotland as well as studies from other parts of the world. You can keep up to date with the latest updates and additions by linking to our Facebook page or else visit the update page. Several new pages and updates have been added and I really do welcome any feedback on this site - positive or negative. Use the contact page to get in touch.

Whenever possible, I also try to attend the major conferences pertaining  to snow sports safety, including the biannual ISSS and SITEMSH symposia. I aim to update this site with all the latest information from the worldwide literature base as soon as possible.

Finally, I wish you all a safe and snowy New Year. My thoughts and prayers continue to be with Michael Schumacher and his family at this very difficult time for them all. I wish him a speedy recovery from his injuries.


Dr Mike Langran
Aviemore, Scotland

21st February 2014

 
 

Overall injury rates and how they are calculated

Recreational Snow sports, you may be surprised to hear, are actually relatively safe and I personally dislike anyone describing them as "dangerous" sports, although sadly you see and hear this phrase used all too commonly, especially in the press. Some of the participants may do dangerous things, but the sports themselves are not inherently dangerous. One of the major aims of this website is to try and change people's perceptions that recreational snow sports are associated with a high risk of injury.

First, let me start by explaining how we derive figures for injury rates amongst skiers and snowboarders as this will help you to understand some of the terms that you're going to come across time and time again on these pages. Injury rates allow us to compare different sports and different time spans.

For snow sports they can be expressed in one of two ways

  • Injuries Per Thousand Skier Days (IPTSD) or
  • Mean Days Between Injury (MDBI)


IPTSD


IPTSD has been traditionally used to denote an overall injury rate. It is derived by dividing the number of injuries seen by the total number of skier/boarder days and then multiplying by 1000. Alpine skiing carries an injury risk of about 2 injuries per 1000 skier days. In other words, for every 1000 people skiing on any particular day, 2 will sustain an injury that requires medical attention. For skiboarding (snowblading) the current risk is slightly lower and for snowboarding the rate is slightly higher, somewhere between 3-5 injuries per 1000 boarder days in most studies. It follows therefore that the lower the IPTSD figure, the less likely injuries are to occur. Moreover, in many countries, the risk of injuries from alpine sports has been declining slightly in recent years which is of course good news.

You can also look at this risk in percentage terms too - i.e. 2/1000 or less than 0.2%. Pretty low I think you'll agree. If you're still not convinced, think of an average game of soccer. How many players normally sustain an injury within the space of 90 minutes? Lets say 3 (its often more). That's 3/22 = 14% or at least 35x the injury rate of skiing and snowboarding over a much smaller time frame! Think soccer's a dangerous sport? No, of course not. Well, it's more risky than skiing or snowboarding.....
 


Still not convinced?! Here's a bit more information - A study in the December 2006 New Zealand Medical Journal by Bentley et al looked at the involvement of adventure tourism and adventure sports activity in injury claims made to the Accident Compensation Corporation (ACC) during a one year period from July 2004 to June 2005. The Accident Compensation Corporation (ACC) administers New Zealand’s accident compensation scheme, which provides personal injury cover for all New Zealand citizens, residents and temporary visitors to New Zealand. In return people do not have the right to sue for personal injury, other than for exemplary damages. Nearly 19,000 incidents were included in the study. The authors found that four activities (horse riding, mountain biking, tramping/hiking, and surfing) were responsible for approximately 60% of all adventure tourism and adventure sports-related injuries. Skiing and snowboarding were responsible for only 0.7% and 1% of claims respectively. Out of 27 fatalities in the study, none were from snow sports (whereas there were 6 deaths associated with both mountaineering and fishing). Further proof that snow sports are well down the list when it comes to so-called "dangerous sports". You can read the study in full for free by clicking here.

MDBI

Mean days between injury (MDBI) is more usually used to define the frequency of injuries. It gives a statistical value for how many days you would have to ski or snowboard in order to sustain an injury. It is derived by dividing the total number of skier/boarder days by the frequency of the particular injury. For example, the MDBI for an anterior cruciate injury whilst alpine skiing is about 2100 days. This means on average, you would have to ski for approx 2100 days before you sustained an ACL injury. This time, the higher the MDBI the less likely an injury is to occur. Again, a very small risk really. Remember though that this is all population based statistics - before those of you who popped your ACL on day 1 start sending me loads of emails! For more information on IPTSD and MDBI and their derivation, click here for my page describing in much more detail how snow sports injury studies are performed. Below are a couple of charts of  the latest injury rates in Scotland from 1999-2010 inclusive.

A large scale American case control study published in the American Journal of Sports Medicine in 2012 (Kim et al, AJSM 2012; 40: 770) showed that the average MDBI for snowboarding was 345 days and for skiing 400 days.
 

If you're interested, click here for the latest data from the National Ski Areas Association of the USA

 


 

Fatalities

Whilst they usually receive media attention, deaths due to participating in a snow sport are thankfully very rare indeed. The most complete data series on fatalities comes from the USA. From the 1991/92 to the 2003/04 season inclusive, a total of 469 traumatic deaths have been recorded within the boundaries of ski resorts in the US. Deaths from any other cause (including heart attacks) are not included in these figures. 58 of these deaths were snowboarders and 401 were skiers. A total of 650.7 million skier days took place during these 13 seasons giving a death rate of 0.71 deaths per million skier days (or one death every 1.4 million skier days - really exceptionally low).

The very latest point data available is also American and comes from the 2008/09 season when 39 fatalities occurred out of the 57.4 million skier/snowboarder days reported for the season. Thirty of the fatalities were skiers (19 male, 11 female) and nine of the fatalities were snowboarders, (8 male, 1 female). Among the fatalities, eight of those involved were reported as wearing a helmet at the time of the incident. The rate of fatality converts to .68 deaths  per million skier/snowboarder visits.

Collisions of all sorts account for 90% of all fatalities - trees are the most commonly struck object accounting for some 60% of all fatalities. Collisions with other persons account for about 10% of all fatalities.



A more unusual mode of death is the so called "Non-Avalanche Related Snow Immersion Death" (NARSID). Also called "tree-well deaths", these result from a fall into the (often deep) pitted area under a snow-laden tree - as the victim tries to extricate themselves, they cause more snow to cave in on top of them and die from either asphyxiation or hypothermia. An additional factor is that its often hard to make others aware of what has happened to you - unless someone else witnesses you falling in you simply vanish from sight. A previously presented study by Bob Cadman, a ski patroller at Whistler Mountain B.C., reported that NARSIDs accounted for 25% of all deaths (8/32) in B.C. The majority occurred inside the ski area boundary and just off the designated runs....once you pop down one of those tree wells chances are no one will see or hear you and you're on your own.....scary thought eh? A website on the subject is available at www.treewelldeepsnowsafety.com. The latest figures from the US shows that NARSIDs account for less than 5% of deaths in the US, but they are still something to watch out for.

The issue of helmets continues to provoke much debate, despite the facts becoming clearer and clearer. Bahr and colleagues from Norway (amongst others) have recently published more data that supports the wearing of helmets. You can read all about it on either my head injuries or helmet page.
 

 

 

Serious injuries from snow sports


Fortunately, only a minority of injuries seen across all snow sports are classed as serious or potentially life-threatening. Defining such injuries as those with an Injury Severity Score (ISS) >= 12 shows that only about 1% of all snow sports injuries meet this criteria. In a comprehensive 10 year study from Canada looking at all such injuries, an incidence of 0.06 severe injuries per 1000 skier days was derived (ref McBeth et al, American Journal of Surgery, 2009). The mean ISS was 20.8. The commonest mechanisms of severe injury were falls and collisions with (static) natural objects - like trees. The head (52% of all injuries), chest (42.9%) and spinal column (34.2%)  were the commonest sites of injury. Unfortunately, in 87% of cases, it was not recorded whether the casualty had been wearing a helmet or not which would have been really useful data. 40% of all casualties required a surgical operation. 2.6% of casualties died.

The NSAA in America report that in the 2008/09 season in America, there were 44 serious snow sports related injuries. Twenty-one of these affected skiers (17 male, 4 female) and fifteen were snowboarders, (12 male, 3 female). Among the serious injuries, 12 of those involved were reported as wearing a helmet at the time of the incident. The rate of serious injury in 2008/09 was .77 per million skier/snowboarder visits.

McBeth's study and the NSAA data above both reinforce the relatively small but still definite potential for serious injury on the slopes. The take home message is the same as I repeat many times over on the various pages of this website - always try and ski/board on slopes and at speeds appropriate for your level of ability  to reduce the risk of an unexpected accident/injury.

 

Individual snow sports

The following is a brief overview of each snow sport - you will find much more information on each individual sports page.

Alpine Skiing

Current injury rate in Scotland  - 2.38 injuries per 1000 skier days (419 MDBI)

About one third of all alpine ski injuries affect the knee joint - these usually involve either the medial collateral ligament, anterior cruciate ligament (ACL), the meniscus (cartilage) or any combination of the three. There is increasing evidence that current ISO binding settings, whilst certainly protecting against lower leg fractures, could perhaps be lowered slightly especially for some groups (such as women and children) in order to better protect the knee (particularly injuries to the collateral ligaments and the mensicus). In France since 2000, they have used a different set of binding settings (under the auspices of AFNOR and Medicins de Montagne) which are generally lower and have shown a reduction in the number of knee injuries without an increase in the number of injuries from 'inadvertent release', where the binding releases when you don't want it to. There is fierce debate still has to whether current bindings can protect some of the anterior cruciate ligament (ACL) sprains that occur amongst skiers. A potentially promising new development in binding technology became available at the start of the 2008/09 season. It is claimed that it may offer the first realistic hope of a binding that could the potentially protect against the number one mechanism of ACL injury - click here for my page describing this binding. An ACL tear is a serious knee injury whose rate, having remained static until about the year 2000, now shows a slight trend towards becoming less frequent - perhaps due to the shorter tail on newer carving skis. This and other trends will be kept under close scrutiny to see whether it continues or not. Other areas commonly injured include the thumb, shoulder joint and head. Click here for the alpine ski page

Snowboarding

Current injury rate in Scotland  - 5.31 injuries per 1000 boarder days (188 MDBI)

Boarding was the fastest growing snow-sport during the 1990's but its popularity has levelled out in the last three seasons at about 25% of all slope users. The resurgence in skiing's popularity (mainly due to freestlye skis) plus the attraction of skiboarding (snowblading) has had an undoubted effect on the plateau in snowboarding popularity. The current injury rate for snowboarding in Scotland is 5.31 injuries per 1000 snowboarder days - about twice that seen in alpine skiing. Snowboarding has a different injury profile to skiing. Upper limb injuries predominate, usually as a result of falls onto an outstretched hand. The incidence of wrist fractures is particularly high, especially amongst beginners and children. Whilst they are available, the majority of snowboarders still do not wear wrist guards despite very strong evidence to support their use in recent years. More importantly, we now have good evidence to indicate the best type of guard to wear to protect against wrist injury - click here for more information on wrist guards. Most boarders take no professional instruction and prefer to either learn from friends or are self taught. Bad habits learnt early on can be difficult to eradicate later and inhibit the development of new skills.... As the overall skill levels of boarders increases, so more and more boarders are pushing the limits of their ability on half pipes and jumps. Although still relatively rare, the incidence of serious spinal injuries appears to be on the increase - take care if you go for big air. An injury all snowboarders should be aware of is "snowboarder's ankle" - a fracture of the lateral process of the talus bone in the ankle. This important injury can be easily overlooked and lead to long term problems. More information on all these details can be found on the snowboard page
 

Skiboarding (snowblading)

Current injury rate in Scotland  - 1.99 injuries per 1000 skiboarder days (501 MDBI)

Also known as "snowblades", this sport has had a presence on the slopes for a decade or more now. Skiboards are mini-skis, shorter than 1m in length and, most importantly, to date the majority have been fitted with non-release bindings. Having initially looked like it would establish itself as a separate and prominent snow sport., in recent times its popularity has begun to wane. During the 2009/10 season in Scotland for example, only 2.2% of the population on the slopes were using skiboards. At the height of the sports popularity in Scotland (2003/04) almost 10% of the piste population were on skiboards. Perhaps the reason for this has been the emerging injury pattern -  in many ways this resembles the bad old days of skiing before release bindings with an excess of lower limb injuries and lower leg fractures in particular. In addition, the risk of a fracture in particular is higher when using skiboards than any other snow sport. Nevertheless, despite this the risk is still pretty small - statistically you would have to skiboard for about 500 days before you would sustain an injury! Remember though, if you are injured on a skiboard there is a one in four chance you'll break a bone. A very welcome development  since the 2005/06 season was the wider availability of release binding systems as an option on skiboards. Salomon, arguably the market leader, have introduced the option of release bindings on their 90 and 99 models. It adds a bit to the weight and £50 to the price which on the face of it seems a very reasonable price to pay for (hopefully) a greater degree of protection. We have been watching their progression with interest and it would seem that  release bindings on skiboards have simply have not taken off. You can read the some of the possible reasons for this and a whole lot more on my skiboard page which is here.


Nordic/XC/Telemark Ski Injuries

Current injury rate in Scotland  - 1.13 injuries per 1000 skier days (889 MDBI)

Perhaps not surprisingly given (usually) the lower speeds involved, in-track nordic skiing has a lower risk of injury than the other forms of snow sports, although the absolute rate is hard to calculate as it is difficult to know how many people are xc skiing on any particular day. Falls in leather boots are more likely to lead to ankle sprains and fractures. The development of plastic boots has reduced this risk for both mountain touring and downhill telemarking by providing a greater degree of support to the ankle - as happened when plastic alpine ski boots were developed. I recommend the use of release bindings with such boots and elsewhere on this site will present the data to support this. As the speed of telemarkers now equals that of alpine skiing, and its popularity continues to rise, we expect to see a small increase in the number of injuries from this sport but overall the risks associated with this sport remain very small. I should admit that I am a telemark skier and love it! My nordic/telemark page is here.
 

Ski Mountaineering

No accurate rates available for current injury rate 

For obvious reasons, most ski mountaineers are usually very capable skiers and we see very few injuries from this sport - some seasons, none at all. Added to this, because we do not know an accurate figure for how many people are ski mountaineering on any one day or even in any one season, it is impossible to calculate injury rates for the sport. When injuries do occur, the pattern resembles that of alpine skiing. Ski mountaineering has the supreme attraction of leaving behind the noisy busy ski slopes in search of pristine powder and wilderness. But the backcountry does have its dangers...and often no ski patrol on hand to readily get you out either. Before venturing out, it is essential to have adequate equipment, knowledge of the snow and weather conditions and, in particular, awareness of the prevailing avalanche risk. If you're not au fait with the area you plan to ski then investing in a professional guide may well save your life. Portable avalanche transceivers and knowledge of how to use them should be regarded as mandatory! Equipment developments such as the Avalung and air bag systems are also designed to increase your chances of survival in the event of an avalanche. Remember also not to keep your mobile phone in the same pocket as your transceiver...as the latter can be rendered inaccurate as a result.

 



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