Published online: 02 Feb 2010.

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1 This article was downloaded by: [Azienda Sanitaria di Bolzano] On: 08 May 2013, At: 08:37 Publisher: Taylor & Francis Informa Ltd Registered in England and Wales Registered Number: Registered office: Mortimer House, Mortimer Street, London W1T 3JH, UK Injury Control and Safety Promotion Publication details, including instructions for authors and subscription information: Skiing and snowboarding injuries and their impact on the emergency care system in South Tyrol: a restrospective analysis for the winter season Stefano Corra MD a, Alessandro Conci MD a, Giorgio Conforti MD a, Giuseppe Sacco MD a & Franco De Giorgi MD a a Emergency Department, Regional Hospital of Bolzano-Bozen, Italy Published online: 02 Feb To cite this article: Stefano Corra MD, Alessandro Conci MD, Giorgio Conforti MD, Giuseppe Sacco MD & Franco De Giorgi MD (2004): Skiing and snowboarding injuries and their impact on the emergency care system in South Tyrol: a restrospective analysis for the winter season , Injury Control and Safety Promotion, 11:4, To link to this article: PLEASE SCROLL DOWN FOR ARTICLE Full terms and conditions of use: This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae, and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand, or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material.

2 Injury Control and Safety Promotion 2004, Vol. 11, No. 4, pp Skiing and snowboarding injuries and their impact on the emergency care system in South Tyrol: a restrospective analysis for the winter season Stefano Corra, MD, Alessandro Conci, MD, Giorgio Conforti, MD, Giuseppe Sacco, MD and Franco De Giorgi, MD. Emergency Department, Regional Hospital of Bolzano-Bozen, Italy Abstract Objectives. To evaluate the incidence and the pattern of skiing and snowboarding injuries in South Tyrol and their impact on the emergency medical system in the winter season in an attempt to rationalize and improve the emergency care and assist in prevention strategies. Methods. All medical records of patients referred to our emergency department (ED) that sustained a skiing or snowboarding injury during the study period were retrospectively reviewed. Age, sex, local or non-local residency, type of injury, data and time of accident, type of transport to the hospital, hospital admission or ED discharge, Injury Severity Score, outcome (including mortality) were evaluated. On site mortality data were obtained from the emergency callcenter registry. Ski resorts utilization was estimated from the data published by the Regional Office of Cable Transport. Results. For the period analyzed approximately 2,500,000 skier and snowboarder days were recorded in the whole region of which about 500,000 were attributed to the four nearby ski resorts that refer to our hospital. Of the 1087 patients, 794 were skiers and 294 were snowboarders. Snowboarders were younger than skiers (mean age 20 and 36 respectively, p = 0.001). Females were equally represented in the two groups. Male patients, children, senior skiers and non-local residents suffered from more severe injuries than their corresponding classes (p < 0.01, p = 0.002, p = 0.02, p = respectively). Critical injuries (ISS 25) were homogeneously spread in the groups, with the exception of the non-local resident patients that showed a higher incidence (p < 0.02). No difference in severity was found between skiers and snowboarders. The incidence was 2.05 per 1,000 skierdays. Mortality rate was 1.6 per 1,000,000 skier-days. The pattern of injury was different: snowboarders showed more forearm and wrist trauma and skiers more lower extremity injuries. 208 patients were hospitalized and the mean length of stay was 4.5 days. Head trauma and fractures were the most common diagnosis of admission. The lack of field triage led to 12% of unjustified helicopter transfer and 9.6% of avoidable ambulance transport. Conclusions. Incidence, pattern of injuries and mortality from skiing and snowboarding accidents in South Tyrol resemble those reported in other part of the world. Nevertheless, strategies for prevention are needed. The routine use of helmets should be enforced by law. Dangerous behaviors should be prosecuted. Skiers and snowboarders should be made aware that skiing beyond their technical ability can be life-threatening. Keywords: injury severity score; ski injury; snowboard injury. Introduction Modern skiing started in Norway in the late 1700s, and within 100 years it was an established activity in the Scandinavian countries and in the Alps. In the USA skiing was introduced in the mid 1800s to the western mining camps. In the last decades the number of skiers has progressively increased, reaching a plateau in the late 1980s. Today it is estimated that there are approximately 200 million skiers worldwide. Snowboarding started in the USA in the early 1970s and gained increasing popularity, especially among Received 7 May 2003; In final form 20 November Correspondence: Stefano Corra, Emergency Department Regional Hospital Bolzano-Bozen L. Böhler Str., Bolzano-Bozen, Italy. Tel.: , Fax , stefano.corra@asbz.it DOI: / /233/ Taylor & Francis Ltd.

3 282 S. Corra et al. young people. Today snowboarders represent approximately 20% to 25% of those using the slopes. The purpose of the present study is to evaluate the pattern of snowboarding and skiing injuries in a single winter season (8 December 2001 to 7 April 2002) and their impact on the emergency medical system in South Tyrol, in an attempt to improve and rationalize the out-of-hospital and the in-hospital emergency treatment and assist in prevention strategy. Methods The province of Bolzano-Bozen, better known as South Tyrol, encompasses a large mountain area in the northern part of Italy. This area, with its 16 ski resorts and 372 lift facilities, attracts skiers and snowboarders from all over the world. The regional Hospital of Bolzano-Bozen is the only second level trauma centre of the region, but it also works as a primary facility for four nearby ski resorts. The out-of hospital emergency system is based upon three helicopters, each with an emergency physician who is permanently part of the crew, that operate during daylight time and 32 ambulance bases with paramedic crew scattered throughout the region, coordinated by a single emergency call-centre. By a regional law, ski patrolling must be organized by the owner of the ski facilities, but no specific basic medical training or knowledge is required and it is normally carried out either by local policemen and or by alpine military corps. Field triage is done by ski patrollers, who alert the emergency call-centre and if the patient cannot be safely transported downhill by toboggan or appears unstable a helicopter is sent to the scene. In the other cases, the patient is transported downhill by toboggan and eventually transferred by ambulance. Virtually all head trauma and all patients with multiple injuries rescued by helicopter are referred directly by protocol to our emergency department (ED), whereas patients transported by ambulance are referred to the nearest community hospital. We retrospectively reviewed all the records of patients who sustained a skiing or snowboarding injury from 8 December 2001 to 7 April During this period, 1087 patients visited our ED because of a downhill skiing or snowboarding accident. Cross-country and off-track ski touring injuries were not considered Age, gender, local or non-local residency, type of injury, date and time of accident, type of transport to the hospital, hospital admission or ED discharge were obtained from the ED charts. An injury severity score (ISS) was assigned to each patient, based on criteria from Baker et al. 1 Length of stay and outcome of admitted patients were obtained from the ward charts. On site mortality data were obtained from the registry of the emergency call-centre. The number of skier-days was estimated on the basis of the cable transport statistics published by the provincial office of cabletransport ( which report the total number of people transported in the whole region and from ticket sales, available only for some resorts. Rescue and hospital costs were calculated from the provincial reimbursement tables, based upon the ICD-9-CM classification. Data were entered onto a spreadsheet, and c2 tests were performed to evaluate differences between the populations. Statistical differences among age classes were also confirmed by calculating the odds ratio. Results For the period of the study, an estimate of 2.5 million skierdays were recorded in the whole region. Of these, about 500,000 were attributed to the four resorts referring directly to our ED. Of the 1087 patients examined (4% of all the ED visits in the same period), 794 were skiers and 293 were snowboarders. A total of 1334 lesions were detected in these patients. A total of 1025 patients were referred from the four local ski resorts, whereas the remaining 63 were transported by helicopter from farther resorts. Total incidence of skiing and snowboarding injuries was 2.05 per 1000 skier-days. No data about skier:snowboarder-days ratio was available to calculate their respective incidence. Snowboarders were younger than skiers (mean age 20 and 36 respectively, p = 0.001). The female population was equally represented in the two groups (41% of snowboarders and 42% of skiers). Injuries with an ISS of less than 4 were considered as minor trauma, whereas patients with an ISS of 25 or more were considered as critical. No difference in severity was found among snowboarders and skiers (Table 1). Children and senior skiers suffered from more severe injuries than other age groups, as well as non-local resident patients rather than locals. Males showed more severe lesions than females. With the exception of the non-local resident group, critical injuries were homogeneously distributed in all groups. No difference was found among accidents occurring in the morning compared to those that occurred in the afternoon, as well as those during working days as compared to holidays. The pattern of injury showed some differences between skiers and snowboarders (Table 2). Head and spine trauma were equally represented in the two groups, as well as abdominal and pelvic injuries. Skiers suffered more from chest trauma with rib fractures, shoulder dislocations and lower extremity injuries than snowboarders. Forearm fractures and wrist sprains were more frequent in snowboarders. Of the 82 patients transported by helicopter, 14 were discharged from the ED the same day. Two of these patients (head trauma) refused hospital admission, two suffered from blunt abdominal trauma without internal lesions, but with clinical symptoms that could mimic a severe injury, and the remaining 10 (12%) were affected by minor extremity injuries that, if correctly triaged on the scene, would not have required helicopter transfer. In the same way, of the 290 patients transported by ambulance, 135 were discharged the same day from the ED. Of these, 28 (9.6%) suffered from minor upper extremity injuries that did not require any kind of immobilization and hence ambulance transport. A total of 208 patients (165 skiers, 43 snowboarders) were hospitalized and the mean length of stay was 4.5 days. No

4 Skiing and snowboarding injuries 283 Table 1. Severity of injuries (p = n.s. where not otherwise specified). ISS < 4 ISS 4 < 25 ISS 25 TOTAL No. of patients (%) No. of patients (%) No. of patients (%) No. of patients (%) Place of residency Local residents 306 (66.2) 153 (33.2) 3 (0.6) 462 Non residents 301 (48.2) 308 (49.3) (p = 0.000) 16 (2.5) (p < 0.02) 625 Age class (years) (47.5) 104 (52.5) (p = 0.002) (62.1) 91 (34.9) 8 (3) (59.5) 74 (37.9) 5 (2.6) (57.3) 91 (41.8) 2 (0.9) (51.2) 101 (47) (p < 0.02) 4 (1.8) 215 Gender Male 333 (52.5) 288 (45.4) 13 (2.1) 634 Female 274 (60.5) 173 (38.2) (p < 0.01) 6 (1.3) 453 Type of sport Ski 442 (55.7) 336 (42.3) 16 (2) 794 Snowboard 165 (56.3) 125 (42.7) 3 (1) 293 ISS = injury severity score. difference in the length of stay was found between skiers and snowboarders. Head trauma and fractures of the extremities were the most common diagnosis of admission, respectively 44% and 31%. The overall incidence of head injuries requiring hospitalization was per 1000 skier-days. Eleven patients were discharged or transferred to other hospitals with permanent neurological lesions (four spinal cord injuries and seven severe head trauma) and their incidence was 4.4 per 1,000,000 skier-days. One patient died on the second day (a 17 year old local resident boy, snowboarder). Eight patients were declared dead at the scene. Five of them did not show evidence of trauma, and death was attributed to non-traumatic cardiac arrest. The remaining three patients were all male. No data about the type of sport practised were available. Mortality rate was 1.6 per 1,000,000 skier-days. The average cost for the emergency treatment of each patient was about 290. Helicopter transport accounted for about 49% of the total costs, whereas ED procedures, radiological examinations and ambulance transport accounted for about 17% respectively. Cost for hospitalized patients was estimated to be about 591,000. Discussion Snowboarding and skiing are very popular winter sports practised by a heterogeneous and growing group of participants. Skiing injury statistics are extremely difficult to ascertain, both because of incomplete incident reporting (many minor injuries are treated by family physicians often far away from ski resorts) and because of the approximation in the calculation of skier-days, based upon the ticket sales. 2 Previous studies showed an overall incidence rate of skiing and snowboarding injuries ranging from 2 to 6/1000 skier-days 3 and incidences found in our study are in that range. In the same fashion, the incidence of injuries requiring hospitalization (0.036 per 1000 skier-days) and mortality are consistent with those found in previous reports. 2 The pattern of injury differed in the two populations (Table 2). Skiers suffered more from lower extremity injuries (femur and leg-ankle fractures and knee sprains), whereas wrist fractures and sprains were more common in snowboarders. Shoulder dislocations and rib fractures were more common in skiers. Head injuries were equally represented in the two groups. The different pattern of injury between skiers and snowboarders has already been reported in other studies and it is well established that equipment plays a crucial role in these differences. 3 While extremity injuries have been widely reported and their incidence in the last decade seems to be constant, less is known about head trauma. From previous studies head and spine injuries account for approximately 7% of alpine trauma and the frequency of these injuries has not changed significantly in the last few decades. 4 This is probably true concerning skiing, but data about the incidence of head trauma in snowboarders are still very contrasting. Fukuda et al. 5 found an incidence of head injuries 6.1 times more frequent in snowboarders than in skiers, with a growing number of snowboarder injuries over the study period, whereas other studies did not confirm this data. 2 In our report, head injuries and their severity were equally represented in the two groups. The great number of head injuries implies a need for the ski industry to focus more attention on upper body protection, especially the head. In particular,

5 284 S. Corra et al. Table 2. Pattern of injuries in snowboarders and skiers (p = n.s. where not otherwise specified) SNOWBOARD (%) SKI (%) HEAD AND SPINE Head contusion (without neurological signs) 24 (7.3) 67 (6.7) Head trauma (with neurological signs and negative CT) 30 (9.1) 74 (7.4) Cranial fracture 0 3 (0.3) Intracranial haemorrhagia 1 (0.3) 11 (1.1) Facial fracture 0 12 (1.2) Nose fracture 3 (0.9) 7 (0.7) Cervical sprain/vertebral contusion (without fracture) 52 (15.7) 108 (10.7) Vertebral fracture (without neurological injury) 3 (0.9) 20 (2) Spinal cord injury 1 (0.3) 3 (0.3) ABDOMEN-PELVIS Blunt abdominal/pelvic trauma (without internal lesion or fracture) 5 (1.5) 27 (2.7) Pelvis fracture 0 9 (0.9) Blunt abdominal trauma (with internal lesion) 1 (0.3) 3 (0.3) CHEST Contusion (without fracture) 6 (1.8) 29 (2.9) Rib fracture 0 27 (2.7) p = Pneumothorax and/or hemothorax 0 9 (0.9) UPPER EXTREMITY Shoulder contusion 10 (3) 34 (3.4) Shoulder dislocation 1 (0.3) 25 (2.5) p < 0.01 Acromion-clavicular dislocation 2 (0.6) 9 (0.9) Clavicular fracture 5 (1.5) 19 (1.9) Scapular fracture 0 2 (0.2) Humerus fracture 8 (2.4) 35 (3.5) Forearm/wrist fracture 66 (20) 41 (4.1) p = Metacarpal/finger fracture 6 (1.8) 21 (2.1) Elbow dislocation 1 (0.3) 0 Wrist sprain 41 (12.5) 14 (1.4) p = 0.01 Finger sprain 5 (1.5) 36 (3.6) LOWER EXTREMITY Femur fracture 0 15 (1.5) p = 0.02 Leg/ankle fracture 6 (1.8) 45 (4.5) p = 0.01 Foot fracture 3 (0.9) 1 (0.1) Hip dislocation 0 2 (0.2) Knee sprain (without ligaments involvement) 17 (5.1) 130 (12.9) p = Knee sprain (with ligaments and/or meniscus involvement and/or 6 (1.8) 52 (5.2) p < hemarthro) Ankle sprain 14 (4.2) 21 (2.1) Muscle contusion 10 (3) 49 (4.8) Post traumatic calf deep vein thrombosis 0 1 (0.1) OPEN SKIN WOUNDS 4 (1.2) 42 (4.2) Total number of lesions 331 (100) 1003 (100) the protection of the occipital region seems to be crucial in snowboarders, who tend to fall backward with no defending action. 5 To date, there is little data that would suggest that routine use of helmets would reduce the injury rate in skiers. In a recent repot, Macnab et al. 6 showed that the use of a helmet reduces the incidence of head injuries requiring investigation and/or treatment and does not increase the incidence of cervical spine injuries in young skiers and snowboarders. Our finding that non-local residents have a higher incidence of severe lesions indicates that training and technical ability of the skier is an extremely important factor influ-

6 Skiing and snowboarding injuries 285 encing these injuries. Local residents generally start practising winter sports at a very young age, they are better acquainted with the slopes and snow conditions and they ski throughout the whole season, maintaining a good training level. Tourists, on the other hand, come here only for a short period of time and often ski eagerly regardless of slope difficulty, snow and weather conditions and their physical capabilities. This data should lead to the implementation of an adequate information programme about the life-threatening risks of skiing and snowboarding beyond technical ability and physical conditions. The organization of the out-ofhospital and in-hospital emergency care of this kind of injuries can pose difficult problems in those areas with a high density of ski resorts. Slopes are often in remote locations and ground transport to the appropriate trauma centre can take hours. Helicopter is certainly the best means of transport for unstable and critical patients, but it is burdened with extremely high costs. The lack of field triage that we found in our study led to unnecessary expenses in the emergency transport of some patients. In conclusion we can state that the incidence, pattern of lesions and mortality of skiing and snowboarding injuries in South Tyrol resembles those reported in other parts of the world. These winter sports are basically safe. However, because of the extremely large number of participants, strategies for prevention of serious injuries are undoubtedly needed. Since head trauma accounts for the majority of life-threatening injuries and leads to a high number of hospital admissions, and the protective effect of helmets in high-speed activities such as motorcycling has been widely demonstrated, we believe the routine use of this device in these winter sports should be enforced by law to all participants, regardless of age and technical ability. Dangerous behaviours such as excessive speed, jumping where not permitted or skiing under the effect of alcohol or drugs should be strictly prosecuted. Skiers and snowboarders should be made aware that skiing beyond their technical ability can be life-threatening. Ski patrollers should receive basic medical training, especially concerning field triage, in order to optimize the out-of-hospital phase of the emergency care of these patients. 2 Sacco DE, Sartorelli DH, Vane DW. Evaluation of alpine skiing and snowboarding injury in a Northeastern State. J Trauma. 1998;44(4): Hunter RE. Skiing injuries. Am J Sports Med. 1999;27(3): Johnson RJ, Ettlinger CF, Shealy JE. Skier injury trends 1972 to In Johnson RJ, Mote CD Jr, Ekeleand A (eds): Skiing Trauma and Safety. Volume 11. ASTM STP West Conshohocken, PA: American Society for Testing Materials, 1997; Fukuda O, Takaba M, Saito T, Endo S. head injuries in snowboarders compared with head injuries in skiers. Am J Sports Med. 2001;29(4): Macnab AJ, Smith T, Gagnon FA, Macnab M. Effect of helmet wear on the incidence of head/face and cervical spine injuries in young skiers and snowboarders. Inj Prev. 2002;8(4): Acknowledgements We wish to thank Dr. Antonio Fanolla from the Provincial Office of Epidemiology for statistical analysis and our secretary Mrs. Edith Chimetto for her precious help in collecting patient data. References 1 Baker SP, O Neill B, Haddon W, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974;14:

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