Abstract
Background
Snow sports (alpine skiing/snowboarding) would benefit from easily implemented and cost-effective injury prevention countermeasures that are effective in reducing injury rate and severity.
Objective
For snow sports, to identify risk factors and to quantify evidence for effectiveness of injury prevention countermeasures.
Methods
Searches of electronic literature databases to February 2014 identified 98 articles focused on snow sports that met the inclusion criteria and were subsequently reviewed. Pooled odds ratios (ORs) with 90 % confidence intervals (CIs) and inferences (percentage likelihood of benefit/harm) were calculated using data from 55 studies using a spreadsheet for combining independent groups with a weighting factor based on quality rating scores for effects.
Results
More experienced skiers and snowboarders are more likely to sustain an injury as a result of jumps, while beginners sustain injuries primarily as a result of falls. Key risk factors that countermeasure interventions should focus on include, beginner skiers (OR 2.72; 90 % CI 2.15–3.44, 99 % most likely harmful), beginner snowboarders (OR 2.66; 90 % CI 2.08–3.40, 99 % harmful), skiers/snowboarders who rent snow equipment (OR 2.58; 90 % CI 1.98–3.37, 99 % harmful) and poor visibility due to inclement weather (OR 2.69; 90 % CI 1.43–5.07, 97 % harmful). Effective countermeasures include helmets for skiers/snowboarders to prevent head injuries (OR 0.58; 90 % CI 0.51–0.66, 99 % most likely beneficial), and wrist guards for snowboarders to prevent wrist injuries (OR 0.33; 90 % CI 0.23–0.47, 99 % beneficial).
Discussion
The review identified key risk factors for snow-sport injuries and evaluated the evidence for the effectiveness of existing injury prevention countermeasures in recreational (general public use of slopes, not racing) snow sports using a Haddon’s matrix conceptual framework for injury causation (host/snow-sport participant, agent/mechanism and environment/community).
Conclusion
Best evidence for the effectiveness of injury prevention countermeasures in recreational snow sports was for the use of helmets and wrist guards and to address low visibility issues via weather reports and signage.
Similar content being viewed by others
Avoid common mistakes on your manuscript.
1 Introduction
Snow sports are a popular recreational activity; however, the incidence of injury can be high for both skiers and snowboarders [1, 2]. Targeted injury prevention countermeasures have the potential to help reduce the incidence and severity of recreational snow-sports injuries if they are based on an understanding of injury mechanisms and associated risk factors. Most research still focuses on the incidence and causes/mechanics of injuries rather than implementing preventive measures. Injuries result from a set of circumstances and pre-existing conditions that can be considered using Haddon’s matrix [3], which provides a conceptual framework for injury causation. The temporal components of pre-event (primary injury prevention), event (secondary injury prevention) and post-event (tertiary injury prevention) phases were considered against human, agent and environmental factors. When considering recreational snow-sport injuries, the key question is “where will injury prevention interventions be most effective within this matrix”? In selecting injury prevention countermeasures there needs to be identification of the key problem hazards and resulting injuries; consideration of design change that ideally will not result in individuals having to take action each time the countermeasure is used; ensuring the countermeasure is accepted for use by the participants; ensuring there is a positive cost to benefit ratio; no unwanted side effects or misuse of the countermeasure; and the effects of the countermeasure can be measured. The effectiveness of common injury prevention countermeasures such as education and behaviour change programmes, environmental/equipment design changes, and regulation/legislation changes need to be evaluated.
2 Objective
This review aimed to identify key risk factors and evaluated the evidence for the effectiveness of injury prevention countermeasures in recreational snow sports using a Haddon’s matrix [3] conceptual framework for injury causation (host/snow-sport participant, agent/mechanism and environment/community).
3 Methods
3.1 Literature Search Methodology
Cochrane Collaboration [4] review methodology (literature search, assessment of study quality, data collection of study characteristics, analysis and interpretation of results, recommendations for practice and further research) was used to evaluate the injury risk factors and effectiveness of injury prevention countermeasures in snow sports.
3.2 Search Parameters and Criteria
A search of the literature was conducted for snow-sport risk factors and mechanisms. The PubMed, CINAHL, Web of Science and SPORTDiscus databases, to February 2014, were searched for terms linked with the Boolean operators (‘AND’, ‘OR’, ‘NOT’): ‘ski*’, ‘snowboard*’, ‘injur*’, ‘risk’, ‘prevention’. Injury and prevention studies prior to the 1990s were considered relevant today as we learn from our historical approaches. However, due to changes in technology, some interventions surrounding equipment (bindings, braces, helmets) would hopefully have better effects the more recent the study. Given the limited number of studies for any risk factor, an inclusive approach was taken for the year of publication. Papers were selected based on title, then abstract and finally text. Manual searching of reference lists and the ‘Cited by’ tool on Google Scholar were used to identify additional articles. From volumes 6–19 of Skiing Trauma and Safety available for review, 324 articles were reviewed. These volumes from the American Society for Testing Materials (ASTM) series of conference proceedings articles were reviewed, given this is a specific conference series containing full papers focused on snow injury issues. Papers were excluded if their content (1) was unavailable in English; (2) was unavailable in full-text format; and (3) did not provide additional information for any of the identified sections and subsections of this review. Inclusion criteria for all articles were (1) reported data for risk factors on snow-sport injury rate or severity; or (2) reported data for interventions to reduce snow-sport injury. For subsequent analysis, exclusion criteria were (1) did not provide odds ratios (OR) or risk ratios (RRs) and/or other statistics allowing assessment of the effect factors on injury (or data to enable their calculation, e.g. cohort studies using only absolute and not relative injury rates); (2) data reported solely for other forms of snow sports, e.g. telemarking, Nordic skiing, ski boarding; (3) data reported only death rather than injury rate; and (4) data only compared injury risk between alpine skiing and snowboarding. In summary, articles were excluded if they were epidemiological studies with no injury risk focus, provided no data allowing risk statistics to be calculated, or were intervention studies without an injury risk factor focus or did not provide enough data for the OR analyses (Fig. 1 shows the flow of information through the systematic review).
A total of 6738 papers were identified, of which 3045 were duplicates. After selection for inclusion criteria and elimination based on exclusion criteria, 98 papers were left for inclusion into the final review (Fig. 1). Of the resulting 98 journal articles, 10 intervention studies (outlined in Table 1) and 88 papers [outlined in Table S1 of the electronic supplementary material (ESM)] detailing injury risk factors were reviewed, with six of the intervention studies and 49 of the other studies summarised for the pooled OR analyses. Although only the aforementioned papers were tabulated and used for pooled OR analyses, additional papers were kept and used for supporting evidence. For example, 23 snow-sport literature reviews were identified via online searching focusing on topics including helmet use [5], wrist-guard use [6], ski bindings [7], and alpine ski strength and conditioning [8]. Other groups of relevant articles included helmet use intervention or analysis [9–13] and injury mechanism analysis [14–16].
3.3 Assessment of Study Quality
Methodological quality evaluation is usually quantified using scales such as Delphi [17] or PEDro [18]; however, many of the criteria were not relevant in the current review. For example, none of the included studies in this review would meet 6/11 criteria of the Pedro Scale: (2) random allocation; (3) concealed allocation; (5) subject blinding; (6) therapist blinding; (7) assessor blinding; and (9) intention-to-treat analysis. Given the studies included would receive poor methodological scores as a reflection of a poor choice in quality scale rather than in the study design, two authors from the current study independently assessed each article using a 6-item custom methodological quality assessment scale, where 0 = clearly no and 1 = clearly yes. The six items included (1) study design (0 = prospective cohort or cross-sectional study, 1 = case control—randomised); (2) study samples (0 = no control or control not greater than 4:1, 1 = adequate); (3) participant characteristics (0 = not given, 1 = sex and age reported); (4) sport details (0 = not detailed, 1 = detailed); (5) outcome variables (0 = not appropriately defined or reported, 1 = appropriate and tabulated); and (6) statistical analyses included adjusted OR and/or RR adjusted for covariates (0 = no, 1 = yes). Covariates included age, sex, type of skier, weather condition, and self-reported experience level. The quality scores based on the paper selection criteria ranged from 1 to 6, and are shown in curved brackets in Table 1.
3.4 Data Extraction
For studies passing the quality criteria, data were extracted, including study name, snow-sport type, aim/focus, study design, participants’ characteristics, methodological quality, interventions, outcome measures and injury risk factor statistics results (Table 1 shows the ten intervention studies [19–28], and Table S1 in the ESM shows 88 injury risk factor studies used in the review—noting that only six of the intervention studies and only 49 of the injury risk factor studies had sufficient data to be included in the pooled OR analyses). There was a large range in sample size, injury risk factors investigated, definition of injury risk factor categories (e.g. such as types of slope conditions of hard and icy, soft and powdery, or slushy) and injury risk factor statistics (e.g. RRs, ORs, Pearson correlations) utilised throughout the risk factor studies. For example, skiing ability was assessed using readiness for risk and speed measured using a self-reported visual analogue scale (1 for minimum speed or minimum risk, and 10 for maximum speed or risk) [29] or by participant self-reported categorical ability (beginner–intermediate, intermediate, intermediate–expert) [30]. This large variation in definition of outcomes and factors between studies made combined analysis difficult for some risk factors. For example, head injury was defined as serious (e.g. severe traumatic brain injury with intracranial bleeding with edema) in some papers, whilst a head/face injury was less severe (e.g. minor facial injury including a fractured nose) in other papers. The diagnosis of injuries in studies may have been provided by a range of medical personnel such as paramedics or physicians. Most studies did not adjust for covariates. A good exception was the conditional inference trees analysis by Hasler et al. [29], who identified non-helmet-wearing snowboarders on icy slopes as being at risk.
3.5 Analysis and Interpretation of Results
For individual studies, the relative frequencies for injury (relative risk, OR) were tabulated with 90 % confidence intervals (CIs). For example, relative risk or RR was calculated as the relative risk of injury for no helmet versus helmet as 25/10 = 2.5 if 10 % of helmet users and 25 % of non-helmet users were injured. The hazard ratio (HR) is similar, but is the instantaneous RR. The OR was calculated as (25/75)/(10/90) = 3.0. RRs and HRs are mostly reported for cohort studies to compare the incidence of injury between groups. ORs are mostly reported for case-control studies to compare the frequency of exposure to the risk factor or countermeasure in injured and non-injured participants. The OR is approximately the same as the RR or HR in value and meaning when frequencies are less than 10 % [31]. Pooled ORs with 90 % CIs and inferences (percentage likelihood of benefit/harm) were calculated using a spreadsheet for combining independent groups with a weighting factor based on quality rating scores for effects. The likelihood that an effect was substantially harmful, trivial or beneficial was given in plain-language terms using the following scale: 0.0–0.5 %, most unlikely; 0.6–5.0 %, very unlikely; 5.1–25.0 %, unlikely; 25.1–75.0 %, possible; 75.1–95.0 %, likely; 95.1–99.5 %, very likely; 99.6–100 %, most likely [31]. Values are reported with 90 % CIs to express the uncertainty in the true effect.
A Haddon matrix approach was used to summarise the identified injury risk factors and injury prevention countermeasures likely to be effective in reducing injury incidence or severity (Table 3).
4 Results
A wide range of risk factors have been investigated in a number of studies, including modifiable factors such as helmet use [10, 30, 32–36], wrist-guard use [6, 37–40], ability [41, 42], alcohol use [43, 44] and terrain conditions [45–48]. Non-modifiable factors such as age [49–51], sex [52–55] and weather [29, 56, 57] have also been examined. In contrast to studies investigating a large number of risk factors with little depth, less frequently studies have gone into more depth focusing on a single factor such as physical condition [58] or ski binding factors [59–61]. Of the ten intervention studies (Table 1), six focused on education programmes [19, 21–23, 26, 28], three on wrist-brace interventions [24, 25, 27], and one on a ski-binding adjustment intervention [20]. Data from six of the intervention studies and 49 of the risk factor studies could be used in the pooled OR analyses.
Table 2 provides a summary of the derived injury ORs and 90 % CIs for host/participant, agent/mechanism, and environment/community risk factors from the 55 studies (note that some studies contributed data to more than one risk factor, therefore the total number of studies does not add up to 55 in Table S2 of the ESM, or Fig. 2). Figure 2 of the pooled ORs (OR = crude OR; LRA OR = linear regression adjusted OR) can be interpreted as clear evidence for the benefit of a countermeasure or factor if the average and CI is below 1.0 (e.g. wrist-brace use for preventing wrist injuries). Conversely, there is a clear negative risk of injury if the countermeasure or risk factor is above 1.0. Table 3 provides a summary of host/snow participant, agent/mechanism and environment/community snow-sport risk factors, the potentially modifiable risk factors and those where there is evidence from the scientific literature for effective injury prevention countermeasures targeted at the risk factors. Key risk factors to focus on for countermeasure interventions include beginner skiers and snowboarders, participants who rent skis and snowboards, female participants, knee injuries in females, snowboarders, and poor visibility. Countermeasures shown to be effective included injury prevention education for all injuries for skiers and snowboarders; helmets for both ski and snowboarding for head and neck injuries; wrist guards for ski and snowboarding for wrist injuries; and knee braces for knee injuries in skiers.
5 Discussion
Many studies detailed snow-sports injury characteristics and injury risk factors from epidemiological studies; however, there was limited evidence for effectiveness of injury prevention countermeasures from randomised controlled trials or studies evaluating the cost-to-benefit ratio of countermeasure interventions. Some important host factors (e.g. age and sex), and environmental factors (e.g. weather) are unalterable. Interventions should focus on affecting modifiable factors such as education, protective equipment (in particular wrist guards and helmets), equipment design/set-up and limiting the snow-sport participant’s exposure to poor run conditions and jump planning.
5.1 Effects of Skiing/Snowboarding Experience
For both snowboarding [50, 55, 62–68] and skiing [41, 50, 55, 62, 64, 67–78], self-rated beginners were far more likely to sustain an injury than individuals who were of self-reported intermediate or advanced ability [55]. More experienced skiers and snowboarders were more likely to sustain an injury as the result of jumps, while beginners sustained injuries primarily as a result of falls [42]. Analysis of two decades of injury data in France showed that injury risk slowly increased up until 2005 when a reversal in injury risk occurred [67]. This reversal in trend was attributed primarily to a decrease in snowboarding injury risk. Beginners contributed to most of the number of recorded injuries, with the first 4 days of exposure being the most precarious.
5.2 Effectiveness of Education Interventions
The effectiveness of education interventions was unclear, based on the CI; however, education interventions were rated as 65 % possibly beneficial, using the classification system of Hopkins [31]. This result is probably due to the diverse nature of the education campaigns and target populations. Due to the limited number of studies, it remains unclear what the best format and content is for the education sessions for particular target groups of participants (e.g. based on age, sex or skiing/snowboarding ability).
Screening of a 45-min educational video on long-haul bus trips specifically to ski slopes was effective in reducing injury risk, collisions and falls, particularly in beginners [23]. Key messages covered in this video were basic skills and safety requirements, including binding checking and helmet use. Screening occurred during an 18- to 24-h bus trip in the afternoon or evening. A 1-h group education workshop was beneficial for more experienced individuals (on-slope employees) and showed a clear benefit in reducing the injury rate [21]. The workshop used video-directed discussions, including identifying and responding to possible hazard situations, and participants developing risk factor identification for anterior cruciate ligament injury. The nature of the education programme and the target audience appear to be keys to the success of the education programme. Injury risk initially decreased following a media campaign, however effectiveness declined with time [19]. Providing past injury information as well as technique and safety tips to ski club members by way of paper handouts and leaflets clearly reduced hospital ski injury admittance [22]. However, a 30-min teaching session with a 20-min educational video ‘A Little Respect: Think First!’ and brochure, followed by a test, were ineffective in reducing the risk of injury in 11- to 12-year-old school children over 4 school-supervised ski days [28]. The video focused on the alpine responsibility code, proper helmet use and clothing attire, trail and terrain sign interpretation, and emergency procedures in the event of an injury. Although there was a trend for a reduction in injury, the ineffective result was probably due to the inadequate sample size [28].
Three studies investigated the effect of taking lessons on injury risk. Two studies produced unclear results; however, Langran and Selvaraj [42] found lessons were associated with an increased risk of injuries not only in those injured on their first day of skiing or snowboarding but also in all individuals injured. Increased risk-taking as a result of confidence after having taken lessons may increase injury risk.
5.3 Effects of Equipment
The use of rented equipment was clearly harmful (OR 2.37; 90 % CI 1.84–3.05); however, it was not clear from the studies whether it was the equipment per se, its maintenance, or the people who used rental equipment that resulted in rental equipment being a risk factor. A number of factors were likely contributing to this result; primarily the age (children) of the skier or snowboarder, skill level (beginner) and knowledge of the equipment. The studies with adjusted ORs were performed on children [79], who usually have less experience and also have reduced coordination when compared with adults [49], or on individuals who were injured on their first day on the slope [42]. Beginners were most likely more at risk of injury, having less specific strength, coordination and skill than more experienced skiers and snowboarders [51, 64].
Pooled ORs for having bindings checked within the last year showed a likely trivial effect. Individual analysis of a study of 572 injured and 576 uninjured control recreational downhill skiers indicated that bindings checked within the last year showed a 63 % possibly beneficial effect and a 35 % trivial effect [60]. Similar results were reported for a randomised intervention where the intervention population had bindings tested and properly adjusted prior to the start of the season (60 % possibly beneficial, 39 % trivial) [20]. Later studies, 1996–1997 season [64] and 2002–2003 season [80], showed binding checks to be possibly harmful. No details about who performed the binding checks were given for the 1996–1997 season [64]. While injuries reported during the 2002–2003 season included time since the last professional binding check, no details were given as to whether calibration machines were used. Boulter et al. [60] distinguished between how binding checks were performed, test apparatus and with skier characteristics or without characteristics, and found the risk increased slightly when the testing method was less specific. In France when the recommended binding settings were lowered using the French Association Francoise de Normalisation (AFNOR) settings for females, knee injuries did reduce.
The evidence supports that helmets were clearly beneficial for reducing the risk of head injuries in skiers and snowboarders [30, 81–85], and possibly useful in the reduction of neck and other injuries [29, 86–88]. A clear effect of sex was found for head injuries, with males more likely to sustain head injuries than females [83, 84, 89]. Whether males have increased risk-taking behaviour or less helmet usage is unclear. Non-helmet users were 2.3 times more likely to die from a head injury than helmet users [90]. Resistance to helmet use includes the perception there is no need to wear one and that they were uncomfortable [91]. Reduced ability to hear and see the surroundings were also given as reasons for non-use of helmets.
Snowboarders sustained upper extremity injuries, particularly wrist fractures [92]. Use of a customised wrist brace in a group of Austrian school children when snowboarding showed a clear effect for reducing wrist fractures [25]. Comfort of the brace was noted as a hindrance to retention of the intervention. Use of a wrist brace showed a definite reduction in wrist injuries for snowboarders in a population of recreational snowboarders; however, presentation of the use of a wrist brace prior to recruitment and randomisation introduced a selection bias only for individuals willing to try using a wrist brace [24]. The design of the wrist guard is important [93, 94]. A compulsory wrist-brace-wearing policy implemented with secondary-school students (12–16 years) in a single-school snow-sport programme showed a possible large effect on reducing wrist fractures [27]; however, the efficacy of implementing such policies outside of a school environment is unknown. Wrist guards may increase the risk of elbow, upper arm and shoulder injuries whilst reducing the risk of hand, wrist and forearm injuries [38]. This is potentially due to impact forces being transmitted up the kinetic chain of the limb.
Females were at greater risk of knee injuries for both skiing and snowboarding [54, 56, 87, 95–97]. Knee braces for skiers were most likely beneficial and use should be encouraged [95, 98]; however, the practical issues of hygiene and fit of braces used in a rental setting need to be addressed.
5.4 Effects of Weather and Terrain
Inclement weather is clearly harmful, increasing the risk of injury substantially. Visibility and condition of the snow appear to be key factors contributing to the increased risk of injury [29, 56, 99]. Increasing the size and frequency of signage to improve visibility during inclement weather periods may help decrease injury incidence. The average reaction time, from the time a sign comes into view to the time needed to respond to avoid an obstacle, is 1056 ms in clear visibility; therefore, during adverse weather conditions there is a need to allow for greater times for reacting to signage before obstacles [100].
Inappropriate trail design and grooming can increase the incidence of injuries at alpine ski areas at certain trail sites [99]. Other risk factors such as jump planning and type of terrain need further investigations using epidemiology risk factor analyses so that ORs can be determined. Experimental studies have indicated that the design of the landing surface is important for reducing injury risk [45, 48].
5.5 Priorities for Countermeasure Interventions
Based on the strength of the evidence from the effect size analysis, priorities for countermeasure interventions could be as follows:
-
Signage. Increase the size and frequency of signage to improve visibility during poor weather periods. The average reaction time from the time a sign comes into view to the time needed to respond to avoid an obstacle is ~1000 ms in clear visibility; therefore, in adverse weather conditions there needs to be allowance for greater times for reacting to signage before obstacles. There is a need for consistent signage, incorporating the science behind what signage influences behaviour.
-
Weather reports. Increase the frequency of mountain reports, including snow conditions, and include how to check mountain reports and how to interpret the reports in educational programmes for beginners. To avoid ski-field operators ‘talking up’ the weather and snow conditions to entice participants onto the field, this information needs to be independent of the ski-field operators.
-
Trail grooming. Increase grooming hours during periods of fresh snowfall, no recent snowfall, or icy conditions. Groom during the day to maintain slope integrity. There is a need for regulation or competency requirements for ski-field groomers.
-
Terrain park design. The design of terrain parks should be considered. Filtering systems could be developed where more challenging obstacles (e.g. a big jump) are placed at the start of a terrain park to filter out those without the necessary skill to use the park.
-
Education. Develop educational videos, targeted at beginners, for screening on tour buses and at key rental locations. Video length should be considered, with short but catchy messages for rental locations and more detailed explanations for bus videos. Key messages to include in videos targeting beginners would be safety rules and key safety protocols (helmets, wrist guards in snowboarders, knee braces for skiers), important skills, hazard awareness (collisions with other people and rocks and trees), understanding the weather and snow conditions and how these can affect speed, stopping ability and visibility issues which change the impact of hazards. Create partnerships with tour companies that transport participants to the ski areas by bus, so that TV messages on snow-sport injury prevention messages can be played on the buses. Develop workshops for more experienced skiers and snowboarders, using videos of injurious or near-injurious events to promote thought and discussion of key things to be aware of and how to respond to different, potentially injurious situations. All on-slope personnel should attend these workshops regularly (i.e. every 2 years, with a first-aid refresher). Lesson instructors should be required to remind beginner skiers not to take risks with their newly acquired skills that exceed their ability. Beginner participants should be encouraged to build up speed and technical aspects slowly. All lessons should be undertaken with helmets worn; this often happens with children but needs to be across the board, with instructors setting the example. The Norwegian expression is “if you don’t wear a helmet you have already had a head injury!”
-
Rental equipment. Target information to equipment renters regarding helmet and wrist-guard use, appropriate equipment fitting, awareness and key injury prevention skills. Possible options could include compulsory reading of information before equipment is provided, free fitting/bindings check and helmet/wrist/knee braces, and educational videos at rental facilities.
-
Digital assets. Use digital assets such as cellphones, websites and TV screens mounted at ski-area facilities to provide information on injury prevention. For example, mount TV screens in rental facilities so that while participants are waiting in line to get their snow equipment, they can view the short key messages on injury prevention regarding the use of helmets and wrist guards, the ski slope rules, and techniques on how to stop safely, etc. Mount TV screens in other areas where queues form, such as in food venues and on chair-lift facilities.
-
Protectors. Helmet use should be a key feature in education campaigns, with a focus on appealing to the male population. Free helmets with all rentals should be considered to ensure that those at higher risk of injury (i.e. beginners) are well protected. Free wrist braces should be available for snowboarders to use. This would encourage those willing to utilise wrist guards to do so. As the design of wrist guards is important, careful selection of guards is needed. Design must consider how to increase user compliance by addressing comfort, ease of cleaning, and effectiveness at reducing injury. Interventions regarding knee brace use should be targeted at females. Written and video information should note the higher risk in females and that the use of knee braces is an effective preventative measure. As the design and type of knee brace is a determinant of its injury prevention effectiveness, education messages about considering the use of professionally fitted knee braces could be provided. The evidence suggests that the more precise and specific the binding adjustments are to the individual, the more likely the binding adjustments will prevent injury. In France when the recommended binding settings were lowered using the French AFNOR settings for females, knee injuries were reduced. The issue of time pressures for technicians in adjusting bindings in rental outlets needs to be addressed so that correct binding adjustments are made rather than reverting to a ‘thump the heel of the boot and if it releases then all is OK’ adjustment. Public education could drive shop practices. The use of the more sensitive and specific torque calibration machines should be considered.
In analysis of the countermeasures reported in the studies from 1981 to 2013, no adjustment was made for the historical and sociocultural context in which these studies occurred. For example, an education campaign that was conducted nearly 20 years ago with a video in a bus may not have the same impact on a cohort carrying their own personal entertainment devices via their phones in 2014. Placing digital information screens on slopes will require these devices to operate at temperatures that can be <30 °C. Consideration of educational or warning signage becoming an object hazard would also be required. Technology and equipment changes may result in different effect sizes for injury risk; therefore, an implementation plan for countermeasure interventions for skiers and snowboarders needs to consider the current sociocultural and technological context.
6 Conclusions
Snow sports would benefit from easily implemented and cost-effective injury prevention countermeasures that are effective in reducing injury rate and severity. The best evidence for effectiveness of injury prevention countermeasures for recreational snow sports was for use of helmets for skiers/snowboarders to prevent head injuries, and wrist guards for snowboarders to prevent wrist injuries. Key risk factors that injury prevention countermeasures should focus on include beginner skiers and snowboarders, skiers/snowboarders who rent snow equipment and poor visibility due to inclement weather.
References
Girardi P, Braggion M, Sacco G, et al. Factors affecting injury severity among recreational skiers and snowboarders: an epidemiology study. Knee Surg Sport Traumatol Arthrosc. 2010;18(12):1804–9.
Rust DA, Gilmore CJ, Treme G. Injury patterns at a large western United States ski resort with and without snowboarders: the Taos experience. Am J Sports Med. 2013;41(3):652–6.
Haddon W. A logical framework for categorizing highway safety phenomena and activity. J Trauma. 1972;12:193–207.
Higgins JPT, Green S, editors. Cochrane handbook for systematic reviews of interventions 4.2.6. The Cochrane Library. Chichester: Wiley; 2006.
Russell K, Christie J, Hagel BE. The effect of helmets on the risk of head and neck injuries among skiers and snowboarders: a meta-analysis. Can Med Assoc J. 2010;182(4):333–40.
Russell K, Hagel B, Francescutti LH. The effect of wrist guards on wrist and arm injuries among snowboarders: a systematic review. Clin J Sport Med. 2007;17(2):145–50.
Natri A, Beynnon BD, Ettlinger CF, et al. Alpine ski bindings and injuries: current findings. Sports Med. 1999;28(1):35–48.
Hydren JR, Volek JS, Maresh CM, et al. Review of strength and conditioning for alpine ski racing. J Strength Cond. 2013;35(1):10–28.
Cundy TP, Systermans BJ, Cundy WJ, Cundy PJ, Briggs NE, Robinson JB. Helmets for snow sports: prevalence, trends, predictors and attitudes to use. J Trauma. 2010;69(6):1486–90.
Fenerty L, Thibault-Halman G, Bruce BS, et al. Helmets for skiing and snowboarding: who is using them and why. J Trauma Acute Care Surg. 2013;74(3):895–900.
Lawrence L, Shaha S, Lillis K. Observational study of helmet use among children skiing and snowboarding. Pediatr Emerg Care. 2008;24(4):219–21.
Levy AS, Hawkes AP, Rossie GV. Helmets for skiers and snowboarders: an injury prevention program. Health Promot Pract. 2007;8(3):257–65.
Andersen PA, Buller DB, Scott MD, et al. Prevalence and diffusion of helmet use at ski areas in Western North America in 2001–02. Inj Prev. 2004;10(6):358–62.
Fischer JF, Leyvraz PF, Bally A. A dynamic analysis of knee ligament injuries in alpine skiing. Acta Orthop Belg. 1994;60(2):194–203.
Bere T, Flørenes TW, Krosshaug T, et al. Mechanisms of anterior cruciate ligament injury in World Cup alpine skiing: a systematic video analysis of 20 cases. Am J Sports Med. 2011;39(7):1421–9.
Johnson SC. Anterior cruciate ligament injury in elite alpine competitors. Med Sci Sports Exerc. 1995;27(3):323–7.
Bizzini M, Childs JD, Piva SR, et al. Systematic review of the quality of randomized controlled trials for patellofemoral pain syndrome. J Orthop Sports Phys Ther. 2003;33(1):4–20.
Maher CG, Sherrington C, Herbert RD, et al. Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther. 2003;83(8):713–21.
Danielsson K, Eriksson E, Jonsson E, et al. Attempts to reduce the incidence of skiing injuries in Sweden. In: Johnson RJ, Mote CD, editors. Skiing trauma and safety, vol. 5. West Conshohocken: ASTM; 1985. p. 326–37.
Hauser W. Experimental prospective skiing injury study. In: Johnson RJ, Mote CD, Binet MH, editors. Skiing trauma and safety, vol. 7. West Conshohocken: ASTM; 1989. p. 18–24.
Ettlinger CF, Johnson RJ, Shealy JE. A method to help reduce the risk of serious knee sprains incurred in alpine skiing. Am J Sports Med. 1995;23(5):531–7.
Ytterstad B. The Harstad injury prevention study: the epidemiology of sports injuries. An 8 year study. Br J Sports Med. 1996;30(1):64–8.
Jorgensen U, Fredensborg T, Haraszuk JP, et al. Reduction of injuries in downhill skiing by use of an instructional ski-video: a prospective randomised intervention study. Knee Surg Sport Traumatol Arthrosc. 1998;6(3):194–200.
Ronning R, Ronning I, Gerner T, et al. The efficacy of wrist protectors in preventing snowboarding injuries. Am J Sports Med. 2001;29(5):581–5.
Machold W, Kwasny O, Eisenhardt P, et al. Reduction of severe wrist injuries in snowboarding by an optimized wrist protection device: a prospective randomized trial. J Trauma. 2002;52(3):517–20.
Laporte JD, Binet MH, Bally A. Why the ski binding international standards have been modified in 2001. In: Johnson RJ, Lamont MK, Shealy J, editors. Skiing trauma and safety, vol. 14. West Conshohocken: ASTM; 2003. p. 64–94.
Slaney GM, Weinstein P. Community-driven intervention to reduce injury rates in school-age snowboarders. Aust J Rural Health. 2009;17(4):218–9.
Cusimano M, Luong WP, Faress A, et al. Evaluation of a ski and snowboard injury prevention program. Int J Inj Control Saf Promot. 2013;20(1):13–8.
Hasler RM, Berov S, Benneker L, et al. Are there risk factors for snowboard injuries? A case-control multicentre study of 559 snowboarders. Br J Sports Med. 2010;44(11):816–21.
Hagel BE, Pless IB, Goulet C, et al. Effectiveness of helmets in skiers and snowboarders: case-control and case crossover study. BMJ. 2005;330(7486):281–3.
Hopkins WG. Linear models and effect magnitudes for research, clinical and practical applications. Sportscience. 2010;14(1):49–57.
Cusimano MD, Kwok J. The effectiveness of helmet wear in skiers and snowboarders: a systematic review. Br J Sports Med. 2010;44(11):781–6.
Haider AH, Saleem T, Bilaniuk JW, et al. An evidence-based review: efficacy of safety helmets in the reduction of head injuries in recreational skiers and snowboarders. J Trauma Acute Care Surg. 2012;73(5):1340–7.
Michael DC. The effectiveness of helmet wear in skiers and snowboarders: a systematic review. Br J Sports Med. 2010;44(11):781–6.
Ruedl G, Kopp M, Burtscher M. The protective effects of helmets in skiers and snowboarders. BMJ. 2011;342(1):d857.
Rughani AI, Lin C-T, Ares WJ, et al. Helmet use and reduction in skull fractures in skiers and snowboarders admitted to the hospital. J Neurosurg Pediatr. 2011;7(3):268–71.
Dickson TJ, Terwiel FA. Snowboarding injuries in Australia: investigating risk factors in wrist fractures to enhance injury prevention strategies. Wilderness Environ Med. 2011;22(3):228–35.
Hagel B, Pless IB, Goulet C. The effect of wrist guard use on upper-extremity injuries in snowboarders. Am J Epidemiol. 2005;162(2):149–56.
MacDermid JC. Do wrist guards decrease injuries among snowboarders? Clin J Sport Med. 2008;18(2):178–9.
Slaney GM, Finn JC, Cook A, et al. Wrist guards and wrist and elbow injury in snowboarders. Med J Aust. 2008;189(7):412–4.
Bouter LM, Knipschild PG, Volovics A. Ability and physical condition in relation to injury risk in downhill skiing. In: Johnson RJ, Mote CD, Binet MH, editors. Skiing trauma and safety, vol. 7. West Conshohocken: ASTM; 1989. p. 94–102.
Langran M, Selvaraj S. Increased injury risk among first-day skiers, snowboarders, and skiboarders. Am J Sports Med. 2004;32(1):96–103.
Made C, Elmqvist LG. Downhill skiing injuries in Lapland, Sweden: survey including alcohol monitoring and one-year follow-up. In: Mote CD, Johnson RJ, Hauser W, Schaff P, editors. Skiing trauma and safety, vol. 10. West Conshohocken: ASTM; 1996. p. 98–103.
Meyers AR, Perrine AR, Caetano R. Alcohol use and downhill ski injuries: a pilot study. In: Johnson RJ, Mote CD, Ekeland A, editors. Skiing trauma and safety, vol. 11. West Conshohocken: ASTM; 1997. p. 14–22.
Hubbard M, Swedberg AD. Design of terrain park jump landing surfaces for constant equivalent fall height is robust to “uncontrollable” factors. In: Johnson R, Shealy J, Greenwald R, Scher I, editors. Skiing trauma and safety, vol. 19. West Conshohocken: ASTM; 2012. p. 75–94.
Russell K, Meeuwisse W, Nettel-Aguirre A, et al. Characteristics of injuries sustained by snowboarders in a terrain park. Clin J Sport Med. 2013;23(3):172–7.
Russell K, Meeuwisse WH, Nettel-Aguirre A, et al. Injuries and terrain park feature use among snowboarders in Alberta. Br J Sports Med. 2011;45(4):311–4.
Swedberg AD, Hubbard M. Modeling terrain park jumps: linear table top geometery may not limit equivalent fall height. In: Johnson R, Shealy J, Greenwald R, Scher I, editors. Skiing trauma and safety, vol. 19. West Conshohocken: ASTM; 2012. p. 75–94.
Blitzer CM, Johnson RJ, Ettlinger CF, et al. Downhill skiing injuries in children. Am J Sports Med. 1984;12(2):142–7.
Greenwald RM, Laporte JD. Effect of age and experience on lower leg fractures in alpine sports. In: Johnson R, Shealy J, Langran M, editors. Skiing trauma and safety, vol. 17. West Conshohocken: ASTM; 2009. pp. 3–10.
Ekeland A, Rodven A. Injury types in alpine skiing and snowboarding related to age groups. Br J Sports Med. 2005;39(6):380–6.
Goulet C, Regnier G, Valois P, et al. Injuries and risk taking in alpine skiing. In: Johnson RJ, Zucco P, Shealy J, editors. Skiing trauma and safety, vol. 13. West Conshohocken: ASTM; 2000. pp. 139–46.
Cadman R, Macnab AJ. Age and gender: two epidemiological factors in skiing and snowboarding injury. In: Mote CD, Johnson RJ, Hauser W, Schaff PS, editors. Skiing trauma and safety, vol. 10. West Conshohocken: ASTM; 1996. pp. 58–65.
Greenwald RM, France PE, Rosenberg TD, et al. Significant gender differences in alpine skiing injuries: a five year study. In: Mote CD, Johnson RJ, Hauser W, Schaff P, editors. Skiing trauma and safety, vol. 10. West Conshohocken: ASTM; 1996. pp. 36–44.
Shealy J, Ettlinger C. Gender-related injury patterns in skiing. In: Mote CD, Johnson RJ, Hauser W, Schaff P, editors. Skiing trauma and safety, vol. 10. West Conshohocken: ASTM; 1996. pp. 45–57.
Ruedl G, Fink C, Schranz A, et al. Impact of environmental factors on knee injuries in male and female recreational skiers. Scand J Med Sci Sports. 2012;22(2):185–9.
Bouter LM, Knipschild PG, Volovics A. Personal and environmental factors in relation to injury risk in downhill skiing. Int J Sports Med. 1989;10(4):298–301.
Raschner C, Platzer HP, Patterson C, et al. The relationship between ACL injuries and physical fitness in junior Austrian alpine ski racers: a 10 year longitudinal study. Br J Sports Med. 2011;45(4):310–1.
Burtscher M, Sommersacher R, Ruedl G, et al. Potential risk factors for knee injuries in alpine skiers. In: Johnson R, Shealy J, Langran M, editors. Skiing trauma and safety, vol. 17. West Conshohocken: ASTM; 2009. pp. 73–6.
Bouter LM, Knipschild PG, Volovics A. Binding function in relation to injury risk in downhill skiing. Am J Sports Med. 1989;17(2):226–33.
Finch CF, Kelsall HL. The effectiveness of ski bindings and their professional adjustment for preventing alpine skiing injuries. Sports Med. 1998;25(6):407–16.
Bissell BT, Johnson RJ, Shafritz AB, et al. Epidemiology and risk factors of humerus fractures among skiers and snowboarders. Am J Sports Med. 2008;36(10):1880–8.
Ishimaru D, Ogawa H, Wakahara K, et al. Hip pads reduce the overall risk of injuries in recreational snowboarders. Br J Sports Med. 2012;46(15):1055–8.
Boldrino C, Furian G. Risk factors in skiing and snowboarding in Austria. In: Johnson RJ, editor. Skiing trauma and safety, vol. 12. West Conshohocken: ASTM; 1999. pp. 166–74.
Ekeland A, Sulheim S, Rodven A. Injury rates and injury types in alpine skiing, telemarking, and snowboarding. In: Johnson RJ, Shealy JE, Ahlbaumer MG, editors. Skiing trauma and safety, vol. 15. West Conshohocken: ASTM; 2005. pp. 31–9.
Idzikowski JR, Janes PC, Abbott PJ. Upper extremity snowboarding injuries. Ten-year results from the Colorado snowboard injury survey. Am J Sports Med. 2000;28(6):825–32.
Laporte JD, Bajolle L, Lamy D, et al. Winter sports injuries in France over two decades. In: Johnson R, Shealy J, Greenwald R, Scher I, editors. Skiing trauma and safety, vol. 19. West Conshohocken: ASTM; 2012: pp. 201–15.
Zacharopoulos AN, Tzanakakis NE, Douka MI. Skiing and snowboarding injuries in Greece: a two-year case-control study. In: Johnson RJ, Shealy J, Langran M, editors. Skiing trauma and safety, vol. 17. West Conshohocken: ASTM; 2009: pp. 23–30.
Bouter LM, Knipschild PG, Feij JA, et al. Sensation seeking and injury risk in downhill skiing. Pers Indiv Diff. 1988;9(3):667–73.
Ekeland A, Holtmoen A, Lystad H. Skiing injuries in alpine recreational skiers. In: Johnson RJ, Mote CD, Binet MH, editors. Skiing trauma and safety, vol. 7. West Conshohocken: ASTM; 1989: pp. 41–50.
Hauser W, Asang E, Mueller B. Injury risk in alpine skiing. In: Johnson RJ, Mote CD, editors. Skiing trauma and safety, vol. 5. West Conshohocken: ASTM; 1985. pp. 338–48.
Jenkins R, Johnson RJ, Pope MH. Collision injuries in downhill skiing. In: Johnson RJ, Mote CD, editors. Skiing trauma and safety, vol. 5. West Conshohocken: ASTM; 1985. pp. 358–66.
Lamont MK. New Zealand ski injury statistics: 1989 and 1990 ski seasons. In: Johnson RJ, Mote CD, Zelcer J, editors. Skiing trauma and safety, vol. 9. West Conshohocken: ASTM; 1993. pp. 33–42.
Lystad H. A one-year study of alpine ski injuries in Hemsedal, Norway. In: Johnson RJ, Mote CD, editors. Skiing trauma and safety, vol. 5. West Conshohocken: ASTM; 1985. pp. 314–25.
Lystad H. A five-year survey of skiing injuries in Hemsedal, Norway. In: Johnson RJ, Mote CD, Binet MH, editors. Skiing trauma and safety, vol. 7. West Conshohocken: ASTM. ASTM; 1989. pp. 32–40.
Oliver BC, Allman FL. Alpine skiing injuries: An epidemiological study. In: Mote CD, Johnson RJ, editors. Skiing trauma and safety, vol. 8. West Conshohocken: ASTM; 1991. pp. 164–9.
Shealy J. Overall analysis of NSAA/ASTM data on skiing injuries for 1978 through 1981. In: Johnson RJ, Mote CD, editors. Skiing trauma and safety, vol. 5. West Conshohocken: ASTM; 1985. pp. 302–13.
Shealy J. Comparison of downhill ski injury patterns: 1978–81 vs. 1988–90. In: Johnson RJ, Mote CD, Zelcer J, editors. Skiing trauma and safety, vol. 9. West Conshohocken: ASTM; 1993. pp. 23–32.
Goulet C, Regnier G, Grimard G, et al. Risk factors associated with alpine skiing injuries in children: a case-control study. Am J Sports Med. 1999;27(5):644–50.
Burtscher M, Gatterer H, Flatz M, et al. Effects of modern ski equipment on the overall injury rate and the pattern of injury location in alpine skiing. Clin J Sport Med. 2008;18(4):355–7.
Hagel B, Pless IB, Goulet C, et al. The effect of helmet use on injury severity and crash circumstances in skiers and snowboarders. Acc Analysis Prev. 2005;37(1):103–8.
Mueller BA, Cummings P, Rivara FP, et al. Injuries of the head, face, and neck in relation to ski helmet use. Epidemiology. 2008;19(2):270–6.
Sulheim S, Holme I, Ekeland A, et al. Helmet use and risk of head injuries in alpine skiers and snowboarders. JAMA. 2006;295(8):919–24.
Fukuda O, Hirashima Y, Origasa H, et al. Characteristics of helmet or knit cap use in head injury of snowboarders: analysis of 1,190 consecutive patients. Neurol Med Chir (Tokyo). 2007;47(11):491–4.
Sandegard J, Eriksson B, Lundkvist S. Nationwide registration of ski injuries in Sweden. In: Mote CD, Johnson RJ, editors. Skiing trauma and safety, vol. 8. West Conshohocken: ASTM; 1991. pp. 170–8.
Hagel BE, Russell K, Goulet C, et al. Helmet use and risk of neck injury in skiers and snowboarders. Am J Epidemiol. 2010;171(10):1134–43.
Sulheim S, Holme I, Rodven A, et al. Risk factors for injuries in alpine skiing, telemark skiing and snowboarding: case-control study. Br J Sports Med. 2011;45(16):1303–9.
Hasler RM, Dubler S, Benneker LM, et al. Are there risk factors in alpine skiing? A controlled multicentre survey of 1278 skiers. Br J Sports Med. 2009;43(13):1020–5.
Hagel BE, Goulet C, Platt RW, et al. Injuries among skiers and snowboarders in Quebec. Epidemiology. 2004;15(3):279–86.
Shealy JE, Johnson RJ, Ettlinger CF. Do helmets reduce fatalities or merely alter the patterns of death? In: Johnson R, Shealy J, Langran M, editors. Skiing trauma and safety, vol. 17. West Conshohocken: ASTM; 2009. pp. 39–42.
Dickson T. Behavious and attitudes towards snowsport safety in Australia. In: Johnson RJ, Shealy J, Langran M, editors. Skiing trauma and safety, vol. 17. West Conshohocken: ASTM; 2009. pp. 65–72.
Sakamoto Y, Sakuraba K. Snowboarding and ski boarding injuries in Niigata. Japan. Am J Sports Med. 2008;36(5):943–8.
Wadsworth P, Binet MH, Rowlands A. Prospective study to compare efficacy of different designs of wrist protection. In: Johnson RJ, Shealy J, Greenwald RM, Scher I, editors. Skiing trauma and safety, vol. 19. West Conshohocken: ASTM; 2012. pp. 17–30.
Kim S, Endres NK, Johnson RJ, et al. Snowboarding injuries trends over time and comparisons with alpine skiing injuries. Am J Sports Med. 2012;40(4):770–6.
Kocher MS, Sterett WI, Briggs KK, et al. Effect of functional bracing on subsequent knee injury in ACL-deficient professional skiers. J Knee Surg. 2003;16(2):87–92.
Laporte JD, Binet MH, Constans D. Evolution of ACL ruptures in French ski resorts 1992–1999. In: Johnson RJ, Zucco P, Shealy J, editors. Skiing trauma and safety, vol. 13. West Conshohocken: ASTM; 2000. pp. 95–107.
Laporte JD, Binet MH, Fenet N, et al. Ski bindings and lower leg injuries. A case control study in Flaine, 2006. In: Johnson R, Shealy J, Langran M, editors. Skiing trauma and safety, vol. 17. West Conshohocken: ASTM; 2009. pp. 77–88.
Sterett WI, Briggs KK, Farley T, et al. Effect of functional bracing on knee injury in skiers with anterior cruciate ligament reconstruction: a prospective cohort study. Am J Sports Med. 2006;34(10):1581–5.
Bergstrom KA, Ekeland A. Effect of trail design and grooming on the incidence of injuries at alpine ski areas. Br J Sports Med. 2004;38(3):264–8.
Harley EM, Scher IS, Stepan L, et al. Reaction times of skiers and snowboarders. In: Johnson RJ, Shealy J, Senner V, editors. Skiing trauma and safety, vol. 18. West Conshohocken: ASTM; 2011. pp. 90–8.
Boldrino C, Klaus D. Risk factors in snowboarding. Int J Consum Prod Saf. 1998;5(1):41–51.
Bouter LM, Knipschild PG. Behavioral risk factors for ski injury: problem analysis as a basis for effective health education. In: Mote CD, Johnson RJ, editors. Skiing trauma and safety, vol. 8. West Conshohocken: ASTM; 1991. pp. 257–64.
Brooks MA, Evans MD, Rivara FP. Evaluation of skiing and snowboarding injuries sustained in terrain parks versus traditional slopes. Inj Prev. 2010;16(2):119–22.
Carr D, Johnson RJ, Pope MH. Upper extremity injuries in skiing. Am J Sports Med. 1981;9(6):278–383.
Diamond PT, Gale SD, Denkhaus HK. Head injuries in skiers: an analysis of injury severity and outcome. Brain Inj. 2001;15(5):429–34.
Ekeland A, Holtmoen A, Lystad H. Lower extremity equipment-related injuries in alpine recreational skiers. Am J Sports Med. 1993;21(2):201–5.
Ekeland A, Nordsletten L, Lystad H, et al. Alpine skiing injuries in children. In: Johnson KN, Mote CD, Zelcer J, editors. Sking trauma and safety: ninth volume. ASTM; 1993. pp. 43–49.
Ekeland A, Rodven A. Skiing and boarding injuries on Norweigan slopes during two winter seasons. In: Johnson RJ, Shealy J, Senner V, editors. Skiing trauma and safety, vol. 18. West Conshohocken: ASTM; 2011. pp. 139–49.
Ettlinger C, Johnson RJ, Shealy J. Functional and release characteristics of alpine ski equipment. In: Johnson RJ, Shealy J, Yamagishi T, editors. Skiing trauma and safety, vol. 16. West Conshohocken: ASTM; 2006. pp. 65–74.
Giddings PH, McCallum IG, Duff PA. Children’s skiing injuries in Victoria, Australia. In: Johnson RD, Mote CD, Zelcer J, editors. Skiing trauma and safety, vol. 9. West Conshohocken: ASTM; 1993. pp. 50–4.
Goulet C, Hagel B, Hamel D, et al. Risk factors associated with serious ski patrol-reported injuries sustained by skiers and snowboarders in snow-parks and on other slopes. Can J Public Health. 2007;98(5):402–6.
Goulet C, Hagel BE, Hamel D, et al. Self-reported skill level and injury severity in skiers and snowboarders. J Sci Med Sport. 2010;13(1):39–41.
Greve MW, Young DJ, Goss AL, et al. Skiing and snowboarding head injuries in 2 areas of the United States. Wilderness Environ Med. 2009;20(3):234–8.
Hansom D, Sutherland A. Injury prevention strategies in skiers and snowboarders. Curr Sports Med Reports. 2010;9(3):169–75.
Langran M, Selvaraj S. Snow sports injuries in Scotland: a case-control study. Br J Sports Med. 2002;36(2):135–40.
Lystad H. Collision injuries in alpine skiing In: Johnson RJ, Mote CD, Binet MH, editors. Skiing trauma and safety, vol. 7. West Conshohocken: ASTM; 1989. pp. 69–74.
Macnab AJ, Cadman R. Demographics of alpine skiing and snowboarding injury: lessons for prevention programs. Inj Prev. 1996;2(4):286–9.
Macnab AJ, Cadman RE, Greenlaw JV. A comparison of knowledge and behavior in young injured and non-injured skiers. In: Johnson RJ, editor. Skiing trauma and safety, vol. 12. West Conshohocken: ASTM; 1999. pp. 3–10.
Macnab AJ, Smith T, Gagnon FA, et al. Effect of helmet wear on the incidence of head/face and cervical spine injuries in young skiers and snowboarders. Inj Prev. 2002;8(4):324–7.
Made C, Elmqvist LG. A 10-year study of snowboard injuries in Lapland Sweden. Scand J Med Sci Sports. 2004;14(2):128–33.
Merkur A, Whelan K, Kuah E, et al. The effect of ski shape on injury occurence in downhill skiing In: Johnson RJ, Lamont MK, Shealy J, editors. Skiing trauma and safety, vol. 14. West Conshohocken: ASTM; 2003. pp. 129–39.
Oates KM, Van Eenenaam P, Briggs K, et al. Comparative injury rates of uninjured, anterior cruciate ligament-deficient, and reconstructed knees in a skiing population. Am J Sports Med. 1999;27(5):606–10.
Ogawa H, Sumi H, Sumi Y, et al. Skill level-specific differences in snowboarding-related injuries. Am J Sports Med. 2010;38(3):532–7.
Ruedl G, Ploner P, Linortner I, et al. Are oral contraceptive use and menstrual cycle phase related to anterior cruciate ligament injury risk in female recreational skiers? Knee Surg Sport Traumatol Arthrosc. 2009;17(9):1065–9.
Ruedl G, Schranz A, Fink C, et al. Are ACL injuries related to perceived fatigue in female skiers? In: Johnson RJ, Shealy J, Senner V, editors. Skiing trauma and safety, vol. 18. West Conshohocken: ASTM; 2011. pp. 119–29.
Ruedl G, Ploner P, Linortner I, et al. Interaction of potential intrinsic and extrinsic risk factors in ACL injured recreational female skiers. Int J Sports Med. 2011;32(8):618–22.
Ruedl G, Webhofer M, Helle K, et al. Leg dominance is a risk factor for noncontact anterior cruciate ligament injuries in female recreational skiers. Am J Sports Med. 2012;40(6):1269–73.
Ruedl G, Kopp M, Sommersacher R, et al. Factors associated with injuries occurred on slope intersections and in snow parks compared to on-slope injuries. Acc Analysis Prev. 2013;50(1):1221–5.
Shealy J, Johnson RJ, Ettlinger C. Femur and tibial plateau fractures in alpine skiing. In: Johnson RJ, Lamont MK, Shealy J, editors. Skiing trauma and safety, vol. 14. West Conshohocken: ASTM; 2003. pp. 140–8.
Stepien-Slodkowska M, Ficek K, Eider J, et al. The +1245g/t polymorphisms in the collagen type I alpha I (col1a1) gene in Polish skiers with anterior cruciate ligament injury. Biol Sport. 2013;30(1):57–60.
Van Dommelen BA, Zvirbulis RA. Upper extremity injuries in snow skiers. Am J Sports Med. 1989;17(6):751–3.
Acknowledgments
Patria Hume, Anna Lorimer, Peter Griffiths, Isaac Carlson, and Mike Lamont declare that there are no competing interests associated with the research contained within this manuscript. The research was funded by the New Zealand Accident Compensation Corporation (ACC) Injury Prevention Group, a service group of ACC, and the Sports Performance Research Institute New Zealand (SPRINZ) of the Auckland University of Technology. According to the definition given by the International Committee of Medical Journal Editors, the authors listed above qualify for authorship based on making one or more substantial contributions to the intellectual content of the manuscript.
The opinions expressed are those solely of the authors and do not necessarily reflect those of the ACC, New Zealand.
Conflict of interest
There is no conflict of interest.
Author information
Authors and Affiliations
Corresponding author
Electronic supplementary material
Below is the link to the electronic supplementary material.
Rights and permissions
About this article
Cite this article
Hume, P.A., Lorimer, A.V., Griffiths, P.C. et al. Recreational Snow-Sports Injury Risk Factors and Countermeasures: A Meta-Analysis Review and Haddon Matrix Evaluation. Sports Med 45, 1175–1190 (2015). https://doi.org/10.1007/s40279-015-0334-7
Published:
Issue Date:
DOI: https://doi.org/10.1007/s40279-015-0334-7