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Head Injuries on the Slopes
10/9/2010 11:57:38 AM


An injury to the head, wherever and however it occurs, always causes anxiety one way or another - to the casualty, their relatives/friends and also those of us who have to provide medical assistance. Fortunately, most look worse than they actually are, but if you asked me about some of the most challenging injuries I have had to deal with over the years, many of them have involved injury to the head. When the injury is severe, the casualty is usually rendered unconscious. As a result, not only can they not tell you anything about their accident or where they are hurt, but they can also struggle to protect their own airway. Individuals who have sustained serious head injuries often need advanced airway procedures such as intubation and ventilation in order to maintain adequate levels of oxygenation. Additional complications can include respiratory depression, seizures (fits) and associated spinal injury. If the brain has been badly damaged, bleeding both in and around the brain can occur and the brain itself can swell. This is a real problem, because the brain is encased in a solid case (the skull) which has no vent for this increased pressure. The brain therefore gets squeezed by this increasing pressure which damages it still further. All in all, not good. Unfortunately, as a result, serious head injuries, even with appropriate management, frequently result in death or permanent and significant disability.

From a snow sports prospective, the high profile deaths of Sonny Bono and Michael Kennedy in 1998 first heightened public awareness of the risks of head injury on the slopes. Most recently, the debate was reignited after the tragic death of actress Natasha Richardson (Liam Neeson's wife) whilst skiing in Canada in March 2009. The first two high profile deaths in quick succession in 1998 lead to the controversial CPSC report on helmets in snow sports. Certainly the wearing of a helmet seems to have gone from "geek" to "cool" in recent years. Helmet sales in the USA rose from 290,000 in 1998/99 to 629,000 in 2000/01. The latest worldwide data indicates that about 30% of skiers and boarders now wear a helmet. This figure varies from country to country of course and also between age groups. In France, for example, almost 90% of children under 12 now wear a helmet - the result of a long PR campaign by Medicins de Montagne - the association of French ski area doctors. So far during the 2008/09 season, my data indicates about 35-40% of Scottish skiers are now wearing a helmet (levels are even higher amongst children).

Unfortunately, there is still a lot of nonsense both written and spoken about head injuries and helmets on the slopes. So what are the true facts? What are the statistical risks? Are the risks high enough and the protection from helmets good enough to warrant mandatory helmets for everyone? Or should we just concentrate on putting lids on more kids? Or should it remain a matter of personal choice whether to wear a helmet or not?

This topic has become so big that I have now split it into two separate pages on this website - this page covers head injuries per se, whilst the second page looks specifically at the issues regarding helmets and the evidence for their use. As ever, I greatly appreciate any feedback that you may wish to pass on to me - use the contact page.
Incidence of head injuries on the slopes
If you look at the incidence of head injuries on the slopes, most studies show that they constitute about 10-20% of all injuries. Given that overall a ski or snowboard injury occurs once every 300 days or so, we can extrapolate and say that for every 10,000 people on the slopes on any particular day, no more than three people will sustain a head injury requiring medical attention. Fortunately, out of all these people with head injuries, the majority (90%) of the injuries are minor - i.e. cuts, abrasions, and minor bumps. That leaves the remaining 10% having what's known in the business as a Potentially Serious Head Injury - hereafter known as a PSHI. This class of injury includes all episodes of loss of unconsciousness, (suspected) skull fractures, bleeds in and around the brain as well as major open head wounds (including penetrating injuries). All in all rather nasty stuff.
Mechanisms of head injuries whilst skiing or snowboarding
There are three main mechanisms of head injury on the slopes. These are (in descending order of severity) :-

► Collisions - either with another person or an object (e.g. tree, rock, fence, pylon, snow surface)
Collisions cause the majority of PSHI. Given that skiers and boarders regularly reach speeds of 30-40mph even on intermediate slopes (this has been shown in studies using radar guns on the slopes), you can see that the impact forces can be quite high. If you do hit another person, at least their body has a bit of "give" in it, not so a static object like a tree. Hitting a tree or a pylon full on at 30-40mph is not much fun. The available data indicates that most traumatic deaths on the slopes occur as a result of a collision with a tree. So while it is undoubtedly a beautiful experience winding your way in and out between those trees, just take care. Even those nice trees at the side of the piste pose a potential danger - one error such as a missed turn and you could end up a serious injury. Whilst they are designed to absorb impact, even the padding around pylon bases can only do so much. The take home message is one that is repeated throughout this website and its quite simple, if in doubt SLOW DOWN and don't ski or board on slopes or at speeds beyond your ability level!
► Impacts with snow surface (e.g falls onto a hard snow/ice surface or jumps that go wrong)

Whilst this particular kind of fall can affect anyone on the slopes, they tend to be most common amongst beginner snowboarders and skiers who, losing their balance quickly, are unable to recover or compensate in time. Usually this results in either a backwards fall with a quite heavy impact to the back of the head (snowboaders) or a sideways fall and impact to the side of the head(skiers). In fact, scientific study has indicated that helmets do have a role to play in falls onto a hard snow surface - here they can convert a potentially serious injury into a minor one.
Additionally, more and more skiers and snowboarders are pushing the limits of their skills in terrain parks attempting ever more ambitious jumps and tricks. A paper from America published in Autumn 2009  reported a higher incidence of head injuries in terrain parks, even allowing for helmet use. Whilst terrain park antics are spectacular when they work well, they can be disastrous or fatal if they go wrong. Landing inverted in particular is not good for your health. The (limited) evidence to date not surprisngly perhaps indicates that those at highest risk are those who probably don't have sufficient skill to be attempting tricks in terrain parks. Please take heed - don't try and attempt jumps or tricks beyond the level of your abilities.
► Lift accidents (e.g hits on the head from swinging T-bars, chairs or poma buttons)

This is quite a common accident scenario in Scotland as we have a large percentage of T-bar lifts and not enough room on many slopes to allow enough space for the T-bar, once dropped, to travel a safe distance to the turn wheel. This means that the T-bar is still recoiling when it goes around the turn wheel and, if swinging wildly, can pose a danger to anyone near by. I speak from personal experience when I say that a helmet is also invaluable here. Fortunately, the worst injuries to date have been a few really nasty lacerations, but the weight and inertia of a T-bar is certainly enough to knock someone out cold. See the contrasting pictures below.

T-bar in Scotland - minimal distance between the get-off point at the turn wheel. A returning T-bar can swing round the turn wheel and hit someone who is standing around the dismount

T-bar lift in St.Moritz. Note the ample and safe distance from the turn wheel. In addition, there is room for a wooden "funnel" system to safely guide the discarded T-bar away from the dismount area and up to the turn wheel.


Minor head Injuries
Minor head injuries include superficial abrasions, lacerations (cuts) and low impact bumps to the head. As I have already mentioned, thankfully the vast majority of head injuries seen on the slopes fall into this category. Abrasions usually result from a sliding contact between the skin of the head and the snow surface. They can be fairly painful but usuallly require very little medical attention apart from perhaps a clean up and a supply of pain killers. Generally, they are best left open to the air so that they can dry out and scab over. They'll get soggy if you leave a dressing on for too long. Because the scalp has a good blood supply, secondary infection is fairly rare and shows itself with increasing redness, pain and perhaps pus around the site of the abrasion. Minor lacerations tend to bleed impressively initially (thanks to that good blood supply) but once this has stopped (by applying a pressure dressing) can often be treated in the ski patrol room and the skier/boarder can often continue on. Very small cuts can be steri-stripped with adhesive strips, larger cuts we now tend to seal with medical superglue, which is great stuff and saves many a casualty from the pain and inconvenience of stitches. It also allows you to get back out on he slopes quickly if you feel up to it. Low impact bumps may produce a relatively impressive bump/bruise (known in the trade as a haematoma) but otherwise no major harm is usually done. We run through a general check list when examining such patients (see below) and if all is well, nothing more need to be done. Although strictly speaking there's no reason why not, most casualties decide to call it a day at this point and either head home or to the bar.....

Serious head injuries
PSHI include all episodes of unconsciousness, suspected skull fractures, large wounds to the scalp and penetrating injuries to the head. There is often associated multi-trauma to other parts of the body and the medical response needs to be coordinated, skilled and rapid. It goes without saying that all patients in this category need emergency transfer to a trauma centre, often by helicopter ambulance once stabilised. Depending on circumstances a direct transfer to a neurosurgical centre may be the most appropriate course of action. In all cases, the possibility of associated injury to the spine has to be carefully considered and the patient appropriately packaged - see below.
Treatment of head injuries
Treatment of all PSHI (like all serious injuries on the slopes) should follow the established "Safety, A.B.C.D.E." system for major trauma.

   ►  Safety - of the scene, rescuer and casualty
   ►  Airway - with cervical spine control
   ►  Breathing - with assessment and control of ventilation
   ►  Circulation - with control of haemorrhage
   ►  Disability - neurological assessment
   ►  Exposure - secondary survey for associated conditions

It is beyond the scope of this website to go into the precise medical details of this system which can be found in any standard trauma management textbook or online resource. One such resource is the NICE guidance.
Deaths from head injuries on the slopes
Accurate data on traumatic deaths on the slopes is not easy to come by for many of the main ski countries in the world. The most complete publically available data that I am aware of on deaths on the slopes comes from the USA. On average over the last ten years, there have been about 39 deaths per year from snow sports (Source, NSAA March 2009). There is some year on year variation - for example, during the 2006/07 season there were 22 deaths from 55.1 million skier/snowboarder days. This gives a death rate of one for every 2.5 million skier days. (Source - NSAA, USA). This compares to 37 skier and snowboarder deaths in the U.S. in 2002/03. With 57.6 million visits in 2002/2003, the death rate translates to 0.64 deaths per million visits (or one death every 1.6 million skier visits). In 2001/02 there were 45 deaths.
How does the death rate from snow sports compare to other sports?
The number of skiing or snowboarding fatalities (per million participants) is  in fact less than the number of fatalities from swimming or bicycling. According to the most recently available data from 2006, there were 2.07 skiing/snowboarding fatalities per million participants, whereas there were 29.4 bicycling fatalities per million participants, and 72.7 swimming fatalities per million participants (Source - National Sporting Goods Association (Sports Participation, 2007 edition), National Safety Council (Injury Facts, 2008 edition)

In fact, twice as many people die from being struck by lightning than suffer a fatality from skiing or snowboarding in the US (Source - “Injury Facts,” National Safety Council, 2008 edition)
Modes of death on the slopes
In a published research study of the traumatic death rates from skiing and snowboarding in US resorts from 1991/2 to 1998/9 Shealy, Ettlinger and Johnson  reported 285 deaths from a total of 426.2 million participant visits (MPVs). This equates to an overall rate of 0.67 deaths per MPVs - put another way, statistically a death occured every 1.49 million visits to a ski area. Interestingly, the death rate for snowboarding (0.46 per MPV) was 34% lower than that for alpine skiing (0.70 per MPV).

The causes of death and the fatality rate associated with them are given in the table below (adapted from Shealy et al) :-
Modality of death Fatality rate per PMV Ratio of skiing to snowboarding death rates
 Snowboarding Skiing 
Overall 0.455 0.702 1.54 to1
Impact -object or person 0.195 0.563 2.89 to 1
NARSID* 0.081 0.016 0.19 to 1
Impact with snow 0.081 0.085 1.05 to 1
Jump 0.065 0.022 0.34 to 1
Other 0.033 0.016 0.48 to 1
 (* NARSID - Non avalanche related snow immersion death - click here for more information)
So the leading mechanism of traumatic death in both sports is (as I have already mentioned) a collision with either a static object (tree, for example) or another person. This is particularly so for skiers. This aside, snowboarders are most likely to die from a NARSID or as the result of a jump.

In the 1998/99 part of the study, Shealy and colleagues followed the deaths as they happened and found that, where the information was available, 35% of individuals who died were wearing a helmet. This is much higher than the rate of helmet use amongst the general population on the piste. Two of the deaths amongst snowboarders resulted from them being struck by young skiers wearing helmets who had jumped without being able to see where they would land.

Shealy et al conclude "...the findings are not particularly supportive of the notion that wearing helmets will significantly reduce the number of fatalities in winter snow sports". This was supported by a presentation at an ISSS meeting by the Chief Medical Examiner for the state of Vermont, USA - Dr Paul L. Morrow. Dr Morrow was of the opinion that of 54 deaths at commercial ski areas in Vermont from 1979/80 to 1997/98, helmets would not have been of any particular value in saving any of the lives lost - as the degree of trauma simply overwhelmed any benefits that the helmet might convey in an impact. To quote Shealy et al again - a team of highly respected ski injury researchers - "On the basis of results to date, there is no clear evidence that helmets have been shown to be an effective means of reducing fatalities in alpine sports". Some people find their conclusions contentious (to say the least!). You will find my detailed discussion on the topic of helmets on my helmet page.
Who needs to see a ski patroller and/or doctor after a head injury?
This can be tricky one and will often depend on exact circumstances. We certainly don't need to see every tiny bump and scrape but the golden rule is "if in doubt, you should be seen". Obviously, all PSHI need to be seen. The following characteristics also indicate that a medical assessment would be sensible (this list is not exhaustive and I'm bound to forget a few) :

    ► Any episode where the casualty may have lost consciousness, even if they seem to be ok now
    ► Any episode where the casualty cannot remember what has happened, is confused, has a severe
         headache or vomits more than
    ► Any episode where the casualty is complaining of or demonstrating problems with walking,
         talking, coordination or responding normally
    ► Children - personally, I have a very low threshold for seeing children in any aspect of my medical
          practice if concern exists, and a bang on the head is no different.
    ►  Any cut that is gaping or won't stop bleeding after 5 mins of pressure
    ►  Bleeding from either ear
    ► Clear or yellow-coloured fluid loss from the nose and/or either ear - may indicate a leak of
          cerebrospinal fluid from around the brain
Head injury instructions

If and when you decide to allow someone home after a head injury, it is sensible clinical practice to provide a head injury advice sheet. 


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