Original article Risk factors for injuries in alpine skiing, telemark skiing and snowboarding – case-control study Steinar Sulheim,1,2 Ingar Holme,2 Andreas Rødven,3 Arne Ekeland,4 Roald Bahr2 1 Orthopaedic department, ABSTRACT risk factors for specifi c injury types, and whether SIHF, Gjoevik, Norway 2Oslo Sports Trauma Research Background Alpine skiing and snowboarding have these differ between the disciplines of alpine ski- Center, Department of Sports a substantial risk of injuries, but precise risk factor ing, telemark skiing and snowboarding. Medicine, Norwegian School estimates are limited. The authors therefore conducted a case- of Sport Sciences, Oslo, Objective To determine the risk factors among skiers control study to explore the effects of a number Norway and snowboarders. of assumed risk factors for injury, including age, 3Norwegian Ski Lift Association, Oslo, Norway Study design Case-control study. gender and ability, on overall injury risk as well 4Martina Hansens Hospital, Methods Ski patrols reported cases (N=3277) in as the risk for knee injuries, shoulder injuries and Baerum, Norway eight major Norwegian alpine resorts. Injury type and lower leg fractures. risk factors (age, gender, nationality, skill level, equip- Correspondence to ment, helmet use, ski school attendance, rented or own Steinar Sulheim, Orthopaedic MATERIALS AND METHODS department, SIHF, Gjoevik, equipment) were recorded. An uninjured control group Ski patrols at eight major Norwegian ski resorts Norway; (N=2992) was obtained at the same resorts. A multi- registered injuries during the 2002 winter season steinar.sulheim@ variate logistic regression analysis was used to assess (Geilo, Hafjell, Trysil, Norefjell, Hovden, Oppdal, sykehuset-innlandet.no the relationship between individual risk factors and risk Hemsedal and Ålsheia). These eight ski resorts Received 13 July 2011 of injury. account for about 55% of the ski lift transports Accepted 15 October 2011 Results The overall injury risk was increased among in Norway, based on the number of tickets sold beginners (OR 2.72; 2.12 to 3.47), children (OR 1.72; (personal communication, Andreas Rødven, 1.41 to 2.13), adolescents (OR 2.16; 1.72 to 2.66) and Norwegian Ski Lift Association). non-Nordic skiers (OR 1.80; 1.37 to 2.36). Snowboarders An injury was recorded when a skier or snow- had a higher overall injury risk than skiers (OR 2.11; 1.81 boarder was treated by or consulted with the ski to 2.46). Alpine skiers (OR 2.65; 1.47 to 4.80), beginners patrol or fi rst aid room staff after an accident in (OR 2.50; 1.61 to 3.85), children (OR 11.1; 6.7 to 20.0) the skiing area during skiing or lift transport. and adolescents (OR 4.17; 2.44 to 7.14) were prone To qualify for the ski patrol, the personnel are to lower leg fractures. Knee injuries occurred more required to go through a structured programme frequently among alpine skiers (OR 1.82; 1.39 to 2.38), of fi rst aid education. A standard form was used females (OR 1.67; 1.38 to 2.03) and beginners (OR 3.13; to record personal data (age, gender, nationality), 2.50 to 3.85). Males (OR 1.85; 1.45 to 2.38), telemark as well as information on the type of equipment skiers (OR 1.70; 1.30 to 2.23), children (OR 2.22; 1.37 to (alpine skis, telemark skis (which permit a turn- 3.57) and adults (OR 1.64; 1.11 to 2.37) had an increased ing technique with free heel lift), snowboard, risk for shoulder injuries. sleigh or other), use of helmet (yes/no), previous Conclusions Snowboarders, beginners, children and ski school attendance (yes/no), rented or own adolescents had an increased injury risk. equipment (yes/no) and skiing ability. Skiing ability was classifi ed into four categories (begin- ner, intermediate, good or expert) based on self- INTRODUCTION reported performance of turns.12 In addition, the Skiing and snowboarding are winter sports ski patrol recorded whether the injury occurred in enjoyed by several hundred million people world- prepared runs, in the snowboard park, off-piste wide, and they are increasingly popular. However, (outside groomed runs), while taking the ski lift they also represent activities with high potential or getting on/off. The anatomical location (head, for traumatic injury.1 2 Alpine skiing has been the neck, shoulder, etc.) and injury type was recorded dominant discipline in Norwegian ski resorts. (classifi ed as fracture, dislocation, sprain, contu- However, during the 1990s, telemark skiing and, sion, skin wound or illness), as well as whether in particular, snowboarding gained popularity.3 the patient needed transportation to a physician The injury risk is high,2 and serious injuries are or hospital for further evaluation and treatment. common in both skiers and snowboarders.4–6 Such patients were defi ned as potentially severe Thus, downhill winter sports injuries represent cases. For patients with multiple injuries (less than a signifi cant concern. Safety initiatives should be 1%), each injury was recorded as a separate case. developed to target this population. As a control group, uninjured skiers and snow- Several risk factors for injuries in these disci- boarders were interviewed in the same eight ski plines have been suggested, such as age, gender resorts during the same season (N=2992). The and skill level,1–10 but the results are equivocal target number interviewed corresponded to the and there are few studies which include a repre- expected injury count from each resort, estimated sentative control group of uninjured skiers and from injury surveillance data from the previous snowboarders.1 7–9 11 Even less is known about the years.3 The interviews were conducted at the Sulheim S, Holme I, Rødven A, et al. Br J Sports Med (2011). doi:10.1136/bjsports-2011-090407 1 of 7 e. Downloaded from bjsm.bmj.com on November 15, 2011 - Published by group.bmj.com Original article Table 1 Distribution of injury cases in number and percentage by age, gender, nationality, skiing ability, equipment, used rented equipment, attained skiing instruction and helmet wear. Controls Injuries p Values, injuries Potentially severe p Values, potentially severe Characteristic (N=2992) (N=3277) versus controls injuries (N=1752) injuries versus other injuries Age <0.001 0.99 <13 years 295 (9.9) 453 (13.8) 87 (13.3) 13–20 years 766 (25.6) 1392 (42.5) 27 (41.4) >20 years 1919 (64.1) 1393 (42.5) 269 (41.3) Missing 12 (0.4) 39 (1.2) 5 (0.8) Sex 0.88 0.75 Males 1801 (60.2) 1965 (60.0) 391 (62.0) Females 1185 (39.6) 1281 (39.1) 234 (37.0) Missing 6 (0.2) 31 (0.9) 6 (1.0) Nationality <0.0001 <0.001 Norwegian 1639 (54.8) 1717 (52.4) 373 (59.1) Swedish 569 (19.0) 634 (19.4) 92 (14.6) Danish 615 (20.6) 661 (20.2) 96 (15.2) Others 162 (5.4) 260 (7.9) 70 (11.1) Missing 7 (0.2) 5 (0.1) 0 Skiing ability <0.0001 0.63 Expert 570 (19.1) 448 (13.7) 85 (13.5) Good 1055 (35.3) 946 (28.9) 195 (30.9) Intermediate 1005 (33.6) 963 (29.4) 182 (28.8) Beginner 348 (11.6) 846 (25.8) 156 (24.7) Missing 14 (0.4) 74 (2.2) 13 (2.0) Equipment <0.0001 <0.001 Alpine skiers 1827 (61.1) 1607 (49.1) 267 (42.3) Snowboarders 757 (25.3) 1391 (42.5) 326 (51.7) Telemark 303 (10.1) 179 (5.5) 30 (4.8) Others 21 (0.7) 6 (0.2) 6 (1.0) Missing 84 (2.8) 94 (2.8) 2 (0.3) Used rented <0.0001 0.18 equipment Yes 829 (27.7) 1058 (32.3) 189 (30.0) No 2157 (72.1) 2143 (65.4) 427 (67.7) Missing 6 (0.2) 76 (2.3) 15 (2.4) Skiing instruction 0.13 <0.001 Yes 993 (33.2) 1018 (31.1) 161 (25.5) No 1990 (66.5) 2053 (62.7) 444 (70.4) Missing 9 (0.3) 33 (5.5) 26 (4.1) Helmet wear 0.09 0.35 Yes 656 (21.9) 780 (23.8) 159 (25.2) No 2330 (77.9) 2443 (74.6) 461 (73.1) Missing 5 (0.2) 54 (1.6) 11 (1.7) Values are number (percentages) within the relevant group. entry of the bottom main ski lift at each resort. Every tenth gender, ability, nationality, used rented equipment, attended skier or snowboarder waiting in line was interviewed, to skiing instruction and helmet use as the adjustment factors. achieve a representative sample of the skiing population. The The adjusted ORs were then compared with the crude ORs, interviews were done every Wednesday and Saturday during and if the difference exceeded 20%, major confounding could the four winter months of 2002 by personnel, who were not be involved. The authors used SPSS (PASW Statistics 18) for told the purpose of the study. The registration was done when the analyses. lifts opened in the morning and after lunch (ie, 10am–11am Interaction between two risk factors on injury was tested and 1pm–2pm). This is when most users enter the area, and on the relative scale by creating a product term between them the main lifts serve to feed a number of other lifts, which take as an added factor, which was tested for signifi cance by the the skiers further into the mountain area to ski the runs avail- likelihood ratio method. None were found, and data are there- able.