410 Br J Sports Med: first published as 10.1136/bjsm.36.6.410 on 1 December 2002. Downloaded from REVIEW The avoidability of head and neck injuries in ice hockey: an historical review N Biasca, S Wirth, Y Tegner ............................................................................................................................. Br J Sports Med 2002;36:410–427 The number of minor traumatic brain injury (mTBI), (mTBI), even called cerebral concussion.7–20 cerebral concussions, is increasing and cannot be Parallel to this, in the period 1982–1996, there was world wide a persistent number of 17 major eliminated by any kind of equipment. Prevention spinal injuries a year.21–26 These epidemiological strategies, such as the introduction of “checking from data are very worrying and need to be analysed. behind” rules have become effective in decreasing the The development of protective equipment re- quires a sound understanding of the injury number of severe spinal injuries. A new “head mechanism, location, and type as well as the checking” rule should reduce mTBI in the same way in tissue response to stress, fatigue, and displace- the following years. Mouthguards should be mandatory ment velocity or acceleration. There is also the necessity to continuously analyse the epidemio- as an effective device for the prevention of dental and logical data with respect to the evolution of orofacial injuries, as well as reducing the incidence and protective devices and ice hockey rules. The use of severity of mTBI. A new internet database system, the a uniform computerised www.ISIS (International Sports Injury System) based database is one way International Sports Injury System (ISIS) should improve of detecting changes in the epidemiological epidemiological analysis of head, face, and spinal pattern early on.27 injuries worldwide. ISIS should provide an HISTORICAL REVIEW internationally compatible system for continuous The beginnings of North American ice hockey monitoring of risk factors, protective effects of have been traced back to 1783 when British equipment, and protective effects of equipment and troops used the natural arena of frozen ponds and rivers to ease the bleakness of winter.2 In the effects of changes in rules through the years. 1920s, padding was minimal and worn as much .......................................................................... to keep warm as to diffuse the blows of sticks and pucks. Players started to wear pants and soccer ce hockey is a fast sport with a risk of injury as shin guards for leg protection. The large open http://bjsm.bmj.com/ an integral part of the game. To reduce the risk areas of ice used for outdoor games facilitated a Iof injuries, various types of protective equip- more open style of play which may account for ment have been developed. However, this equip- the lack of concern about injury. ment should neither be a source of new injuries In 1929 the first facemask with leather was nor compromise the nature of game. In attempt- introduced for use by a goaltender to cover a bro- ing to eliminate one risk, other risks may be cre- ken nose, but, as vision was impaired, it was not ated and the nature of the game may be used.2 Jacques Plante, goaltender of the Montreal influenced. The injury pattern of head and neck Canadians, started wearing a mask during games on September 25, 2021 by guest. Protected copyright. injuries has changed since the introduction of after he was hit on the nose by a slap shot from helmets and full facemasks. To meet the needs of Ranger Andy Bathgate.2 Head protection for goal- an expanding ice hockey population, equipment tenders was met with mixed reviews, and it was manufacturers began to produce more encom- not common in the National Hockey League until passing body protection. Shoulder pads became the North Star Bill Masterson was struck on the large, covering the shoulder, chest, and half of the head by a puck and died.2 back with a hard shell. Elbow pads became In the late 1930s shoulder protections with a sizeable, and their hard shell became a new leather cap added began to appear.2 Elbow pads weapon in the player’s arsenal. Parallel to the bet- were fashioned from leather tubes filled with ter design and resilience of elbow and shoulder horsehair.2 pads, the increased aggressiveness and the feeling In the late 1940s, hard plastic shoulder pads for of invincibility of the players paradoxically football were covered with foam rubber and contributed to increase the risk of head and neck sometimes used in ice hockey.2 Hard caps with See end of article for 2 authors’ affiliations injuries. Catastrophic injuries, such as subdural foam covering also served as elbow pads. Hockey ....................... haematoma and blinding, were reduced in the gauntlets with leather palms and a cloth covered period 1963–1991 as a result of the compulsory wrist guard made of bamboo strips formed the Dr Biasca, Head of 1–6 2 Orthopaedic Surgery, wearing of helmets and full facemasks. Despite wrist-hand protection. The first head protection Co-Head of Trauma this, the incidence of head injuries is now appeared in the 1950s. It had squares of leather Surgery, Spital increasing.7–20 Head and face currently represent with thin felt backing for comfort and was worn Oberengadin, CH-7503 the most common location of ice hockey on the forehead and back of the head2 (fig 1). Samedan, Switzerland injuries.7–10 World wide, there is also an increasing When the game moved indoors, after the Accepted 26 March 2002 incidence of minor traumatic brain injuries second world war, the play was more constricted www.bjsportmed.com Ice hockey injuries 411 Br J Sports Med: first published as 10.1136/bjsm.36.6.410 on 1 December 2002. Downloaded from Figure 2 Adjustable helmet with a liner of the cradle type, certified in 1963.3 2 Figure 1 Helmet of the late 1950s. of the United States (AHAUS) established a new rule requir- ing players to wear other head protection as well.24 In 1968 30 and the extra clothing and padding were hot and Fekete et al reported on two teenage ice hockey players in cumbersome.2 The first artificial ice surface for indoor hockey Canada who died after closed head injuries while wearing opened 5 January 1912 in Vancouver with a series of rinks and helmets. This led to a request by the CAHA to form a technical leagues operating that year both in the West and East. The committee for approving helmets. A Canadian Standards Association (CSA) technical committee was charged with this introduction of the slap shot in the 1950s created new 4 2 in 1969. In 1975 all CAHA players were required to wear these challenges for the goaltender and changed the game. Up to 4 this point, raising the stick above the shoulder drew a two CSA approved helmets. minute penalty. Players started to heat the stick blade in hot water forming the first curved blade.2 Whipping the puck Face protectors rather then shooting it made the puck dip and drop unexpect- The first face protectors developed in 1972 were an excellent edly, which was a new challenge for the defence. Although start toward ensuring adequate eye protection for hockey written injury information is not available, it appears that players, including goaltenders. Many goaltenders wore when hockey was played outdoors on the large ice sheets with moulded plastic face protectors, and other players wore wire 2 limited boundary materials, injuries were not a great grid face protectors. Unfortunately the blade of a hockey stick concern.2 As the game moved to the enclosed indoor arena, could still penetrate many of the face protectors and could 4 play was more interactive between players and the environ- result in a serious eye injury. In 1973, forwards and defence- ment. High flying pucks and sticks resulted in a high risk of men wore no eye protection, although some goaltenders were above the shoulder injuries.2 wearing moulded masks introduced by Jacques Plante. In a The first catastrophic injury—the loss of an eye—occurred retrospective questionnaire study involving 600 Canadian http://bjsm.bmj.com/ in 1929.2 After this, the NHL rules did not permit players to ophthalmologists, 287 eye injuries were found, including 20 4 play with only one eye.2 The same rule was applied in the blinded eyes. Three quarters of these injuries were stick Canadian Amateur Hockey Association (CAHA) at the end of induced. The consequence of this survey was that in 1975 the 1920s, when a player from Ontario, named Trushinski, CAHA introduced high sticking penalties, which prohibited 4 4 suffered an injury to one eye and later to his other eye, leaving the carrying of sticks above shoulder level. In 1974 Pashby him legally blind.4 One eyed players were no longer permitted began a prospective study on this topic. In the season to play in the CAHA. The list of players who were blinded, 1974–1975, there were 43 blinded eyes, and the puck caused ending promising careers, is extensive.428 The incidence of 38% of these injuries. It was evident that some type of eye above the shoulder injuries was high not only in the protection was necessary. The eye and face protectors available on September 25, 2021 by guest. Protected copyright. professional leagues but also in the amateur ones.29 Eyes were were unsuitable because the hockey stick blade could permanently damaged, teeth were knocked out, and many penetrate them immediately over the eye area. The CSA tech- players had scarred faces from lacerations.2 Missing teeth and nical committee was charged with investigating standards for facial scars were the mark of a hockey player.2 ice hockey visor and face protectors.