Skiing is an enormously popular winter sport for children, teenagers, and families. Here's a review of winter sports injuries and how to provide the best care.
Skiing is an enormously popular winter sport for children, teenagers, and families both in the United States and internationally. Estimates put the number of skiers globally at more than 200 million, with children accounting for 13% to 27% of these skiers.1 According to the National Ski Areas Association, an estimated 10 million skiers and snowboarders made 53.6 million daily visits to US ski areas during the 2014-2015 US ski season.2,3 According to a national survey, there are 471 ski areas currently operating in the United States.2
The authors are 2 pediatricians who have practiced over the last decade in Eagle County, Colorado, home of both Vail Mountain and Beaver Creek, 2 of the most visited ski areas in the United States. Approximately 20% of all the annual ski visits in the United States occur in Colorado, and Vail is the busiest ski area of the many in the state. Thus, the authors have considerable experience with pediatric skiing-related injuries and emergencies in their pediatric hospitalist and general pediatrics practices.
At the authors’ local Vail Valley Medical Center (VVMC), hospital billing data from the VVMC Emergency Department (ED) during the 2014-2015 ski season show there were nearly 4800 patient encounters with a diagnostic accident code E003.2 (activities involving snow; skiing, boarding, sledding). Twenty percent of these VVMC ED visits (nearly 1000) were for children and teenagers. Of the 4800 patients who visited the ED, approximately 500 were admitted to the hospital, and 15% of these admissions (about 75 total admissions) were for children and adolescents injured while skiing and snowboarding. Fifty percent of these admissions were orthopedic injuries (type unspecified) and 12% were for a traumatic brain injury.
Clearly, skiing is a sport with a significant risk of injury and, rarely but tragically, death. During the 2012-2013 Colorado ski season, there were 25 skiing-related deaths. Twenty-three of the fatalities occurred while skiing and 2 while snowboarding. In general, there is a consistent 4:1, male-to-female ratio in skier deaths. According to the Colorado Department of Public Health and Environment, 88% of Colorado skier deaths occurred on the slopes, 11% in terrain parks, and 4% were chair-lift associated. Perhaps surprisingly, despite ski helmets’ critical role in injury prevention, about 60% of deaths were sustained by skiers who were wearing a ski helmet.
Epidemiologists estimate that 600,000 people are injured annually in the United States as a result of skiing and snowboarding.4 Whereas some of these injuries are treated without pursuing medical care, many of the injured will seek care in an ED, acute care facility, or pediatrician’s or primary care provider’s office.
Skiers are prone to sustain lacerations, boot-top contusions, thumb injuries, and complex knee injuries. In contrast, snowboarders tend to experience distal radius fractures and foot and ankle injuries. Skiers are typically prone to severe injuries sustained from collisions on the slopes, while snowboarders tend to suffer injuries from falls and jumps, not uncommon in terrain parks. Snowboarders are 6 times more likely than skiers to sustain a splenic injury from abdominal trauma (so-called “boarder belly”), with males 21 times more likely to sustain this injury than females.5
In a recent study published by colleagues at VVMC, snowfall and mechanism of injury were reviewed in 644 ski-related hospitalizations.6 The majority of these injuries occurred when there was less than 1 inch of new snowfall, and snowfall of less than 2 inches was associated with increased injury severity. This corroborates the long-held ski patroller observation that, with low snowfall, the slopes are icier and faster and skiers are at increased risk of all injuries under such conditions-particularly severe injuries. In the VVMC study, collisions were associated with the most severe injuries: renal injuries and severe thoracic injuries. Consequently, the authors recommend caution and a thorough evaluation of patients with any injury sustained in a collision.
When caring for pediatric and adolescent patients with skiing-related injuries, it is important to remember the mantra long articulated by pediatricians: “Kids are not little adults.” In regard to any cold weather injuries, keep in mind that children have a larger surface area and thinner skin for their weight. Therefore, they can have more difficulty maintaining body temperature compared with adults. They are also at increased risk of both dehydration and hypothermia when compared with adult skiers and snowboarders.
The implications of these realities are clear: When caring for a child on the slopes, think warmth and hydration. Provide warmth by getting them inside as soon as possible, covering them with blankets and/or additional outdoor ski clothing, supplying hand warmers, and offering warm beverages. Water is the preferred first fluid to start with in caring for children. Avoid sports drinks because of their glucose and electrolyte content.7
Regarding energy needs, kids have faster metabolisms than adults and consequently deplete their glucose stores more quickly. Therefore, it is a good idea to quickly get some simple sugars such as chocolates, energy bars, juices, and so on into a child suffering a winter sports-related injury.
Children typically have much healthier hearts than adults, so, provided they have no underlying congenital or other heart disease, an injured child is not likely to have a cardiac problem such as a myocardial infarction or a dysrhythmia. Thus, when coming upon an incapacitated pediatric skier, one should consider a respiratory etiology and not a cardiac problem. Keep in mind, too, when assessing a child for a ski-related injury, that children have higher respiratory rates than adults. Anatomically, children also have relatively small noses, mouths, and tongues and larger tonsils, narrower glottises, and shorter tracheas compared with adults. As a result, children are more predisposed than adults to obstructive-type respiratory problems.
Further, because children have smaller blood volume for body weight relative to adults, they can be prone to hypovolemia even with a relatively small blood loss. Fortunately, children’s bones, joints, and ligaments are more flexible than adults, which enables better absorption of orthopedic trauma. In winter sports mishaps, this results in fewer severe fractures, but more greenstick fractures. However, because children have open growth plates, one must carefully evaluate for possible growth plate fractures (Salter-Harris fractures), as the ramifications of a fracture through a growth plate are significant and need to be carefully managed. Additionally, although, in general, children are at low risk for pelvic fractures, these should not be discounted or overlooked because the consequences can be serious.
Younger children have a relatively larger head for body size versus adults. This relatively large head weight for body size makes children at greater risk for neck injuries including cervical strains, soft tissue injuries, and spinal cord injury, and necessitates careful evaluation of the neck in the event of a ski-related neck injury.
When evaluating the chest following a ski-related injury, keep in mind that children have more compliant chests than adults. A fall to the chest may result in a contusion to the lungs or heart while not injuring the chest wall. Further, while a fall involving the chest may not have resulted in a chest injury per se, the child may have sustained an internal organ injury. Liver, kidney, and splenic trauma can cause profuse internal bleeding leading to hypovolemia and shock.
Finally, when caring for any child or teenager with a skiing-related injury, it is also vital to inquire about any chronic medical problems they have. A history of type 1 diabetes, asthma, seizure disorder, or any other disorder should heighten the provider’s awareness of potential complications related to these underlying medical conditions.
Acute mountain sickness (AMS) is the effect on the body of being in a high altitude environment above 8000 feet. Three-quarters of all skiers experience mild symptoms of AMS over 10,000 feet. Common AMS symptoms include difficulty sleeping, fatigue, headache, nausea or vomiting, tachycardia, and shortness of breath. These symptoms typically peak on the first night of arrival to altitude. In general, children are at less risk for AMS and there is no role for pharmacological AMS prophylaxis for children and adolescents.8 In a recent study, when skiing at altitude, children experienced AMS only about 35% of the time compared with nearly 80% of adult skiers.9 Most pediatric skiers with AMS symptoms do not seek medical care and are treated in the hotel, condominium, resort, and home with rest, over-the-counter medication (acetaminophen, ibuprofen), and hydration.
One of the chief ski-related injuries of concern affecting children or teenagers is a head or brain injury. Skiers experiencing a fall affecting the head can sustain concussions and other brain injuries, skull fractures, scalp injuries, lacerations, or nose and ear injuries. Any child or adolescent who has sustained a fall impacting the head should be thoroughly evaluated for head or brain injury.
Concussions can present with a wide range of physical, cognitive, emotional, and sleep signs and symptoms (Table 1). The decision by the primary care provider regarding concussion management, including neuroimaging, hospitalization, referral to subspecialist/pediatric neurologist, concussion management clinic, and so on can be difficult and challenging.10 Therefore, a healthcare professional initially evaluating a child or teenaged skier with a head injury should have a low threshold to seek a higher level of care at a hospital, ED, or acute care clinic/facility for a thorough evaluation of the injury. For a complete discussion of concussions and concussion management, the reader is referred to the American Academy of Pediatrics (AAP) Clinical Report-Sport-Related Concussion in Children and Adolescents.10
If a child or teenager does sustain a concussion, in addition to seeking acute care, it is important to be cognizant of the second impact syndrome (SIS).11 This syndrome, first identified in the literature in 1973, describes the consequences of a patient sustaining a second blow or concussion before the first concussion has healed and resolved. This second impact, even if less severe than the first injury, can have a devastating outcome with the injured child/teenager falling to the ground, rapidly showing signs and symptoms of increased intracranial pressure. This syndrome has been the cause of death for a number of high school contact sport athletes.
The parents/family of a child or adolescent who sustains a head injury/concussion at a destination resort should be made aware of the risk of SIS and be advised to promptly consult with their pediatrician/primary care provider when home regarding further concussion evaluation, management, and return to school and play. Further, the child or teenager having sustained the head injury should not resume skiing during his or her vacation unless it is clear that the concussion has resolved.
Ski helmets have become an indispensable part of equipment for kids and adolescents who are skiing and/or snowboarding. In skiing and snowboarding, head injuries account for 9% to 19% of all ski-related pediatric injuries reported by ski patrols and EDs.12-15 In recently published literature including a meta-analysis, ski helmet use was found to reduce head injury risk by as much as 35% and did not increase the risk for a neck injury while skiing or snowboarding.16-18 This evidence-based data has helped to further successful advocacy for ski helmet use for children and teenagers.
At Vail Mountain, resort policy is that all children and teenagers in a ski school lesson or program must wear a ski helmet. Recent observational studies performed by VVMC staff at the resort have found ski helmet use rates overall to be 80% for all participants and consistently over 95% for the kids and adolescents skiing there (according to Kim Greene, VVMC Think First Program). Additional studies have demonstrated that ski helmet wearing has minimal effect on hearing,19 does not diminish vision,20 and, in fact, leads to a higher safety awareness on the slopes.21 Both education and helmet laws have been shown to increase ski helmet use among children and teenagers.22
A final key point to remember is that if a child has a marked fall on the head with a ski helmet, that helmet has done its job and should be replaced by a new helmet.
Pediatricians can be invaluable sources of information, support, and advocacy on the slopes, in the office, and in the community to promote the use of ski helmets for children and adolescents and to be aware of the management of other winter sports risks and injuries.
The authors advocate that pediatricians who see patients and families who ski and snowboard provide anticipatory guidance to parents regarding helmet use for themselves and all skiing or snowboarding members of the family. As with the successful advocacy of bicycle helmet use, the pediatrician can be a welcome source of information and support to help prevent winter sports head and brain injuries by promoting ski helmet use among the patients and families in their practices.
A summary of the important considerations for the pediatrician/medical provider caring for a child or adolescent with a skiing-related injury or emergency is in Table 2.
Skiing and snowboarding can be immensely fun and enjoyable activities and good exercise for kids, teenagers, and families. However, when caring for a child or adolescent on the slopes, or in the lodge, ski patrol station, acute care setting, or office, it is vital to remember that, as in other areas of pediatrics, kids are not little adults. Remembering their unique anatomical and physiological differences can help the pediatrician provide optimal medical care and advice that can lead to good outcomes in the event of injuries or emergencies sustained on the slopes.
Hunter RE. Skiing injuries. Am J Sports Med. 1999;27(3):381-389.
National Ski Areas Association. Skier visits dip slightly to 53.6 million in 2014-15. Published May 4, 2015. Available at: http://www.nsaa.org/media/242270/Kottke_press_release.pdf.
Flørenes TW, Bere T, Nordsletten L, Heir S, Bahr R. Injuries among male and female World Cup alpine skiers. Br J Sports Med. 2009;43(13):973-978.
Mueller BA, Cummings P, Rivara FP, Brooks MA, Terasaki RD. Injuries of the head, face, and neck in relation to ski helmet use. Epidemiology. 2008;19(2):270-276.
Kim S, Endres NK, Johnson RJ, Ettinger CF, Shealy JE. Am J Sports Med. 2012;40(4);770-776.
Moore SJ, Knerl D. Let it snow: how snowfall and injury mechanism affect ski and snowboard injuries in Vail, Colorado, 2011-2012. J Trauma Acute Care Surg. 2013;75(2);334-338.
Committee on Nutrition and the Council on Sports Medicine and Fitness. Sports drinks and energy drinks for children and adolescents: are they appropriate? Pediatrics. 2011;127(6):1182-1189.
Bloch J, Duplain H, Rimoldi S, et al. Prevalence and time course of acute mountain sickness in older children and adolescents after rapid ascent to 3450 meters. Pediatrics. 2009;123(1);1-5.
Rexhaj E, Garcin S, Rimnoldi SF, et al. Reproducibility of acute mountain sickness in children and adults: a prospective study. Pediatrics. 2011;127(6);e1445-e1448.
Halstead ME, Walter KD; Council on Sports Medicine and Fitness. American Academy of Pediatrics. Clinical report-sport-related concussion in children and adolescents. Pediatrics. 2010;126(3):597-615.
Wetjen NM, Pichelmann MA, Atkinson JL. Second impact syndrome: concussion and second injury brain complications. J Am Coll Surg. 2010;211(4):553-557.
Ruedl G, Sommersacher R, Woldrich T, Kopp M, Nachbauer W, Martin B. Risk factors of head injuries on Austrian ski slopes [article in German]. Deutsch Z Sportmed. 2010;61(4);97-102.
Hagel BE, Meeuwisse WH, Mohtadi NG, Fick GH. Skiing and snowboarding injuries in the children and adolescents of Southern Alberta. Clin J Sport Med. 1999;9(1):9-17.
Xiang H, Kelleher K, Shields BJ, Brown KJ, Smith GA. Skiing- and snowboarding-related injuries treated in US emergency departments, 2002. J Trauma. 2005;58(1):112-118.
Hagel BE, Pless B, Platt RW. Trends in emergency department reported head and neck injuries among skiers and snowboarders. Can J Public Health. 2003;94(6):458-462.
Russell K, Christie J, Hagel BE. The effects of helmets on the risk of head and neck injuries among skiers and snowboarders: a meta-analysis. CMAJ. 2010;182(4);333-340.
Cuismano MD, Kwok J. The effectiveness of helmet wear in skiers and snowboarders: a systematic review. Br J Sports Med. 2010;44(11);781-786.
Haider A, Saleem T, Bilaniuk JW, Barraco RD; Eastern Association for the Surgery of Trauma Injury Control Violence Prevention Committee. An evidence-based review: efficacy of safety helmets in reduction of head injuries in recreational skiers and snowboarders. J Trauma Acute Care Surg. 2012;73(5):1340-1347.
Ruedl G, Kopp M, Burtscher M, et al. Effect of wearing a ski helmet on perception and localization of sounds. Int J Sports Med. 2014;35(8):645-650.
Ruedl G, Herzog S, Schöpf S, et al. Do ski helmets affect reaction time to peripheral stimuli? Wilderness Environ Med. 2011;22(2):148-150.
Ruedl G, Kopp M, Rumpold G, Holzner B, Ledochowski L, Burtscher M. Attitudes regarding ski helmet use among helmet wearers and non-wearers. Inj Prev. 2012;18(3);182-186.
Burtscher M, Ruedl G, Nachbauer W. Effects of helmet laws and education campaigns on helmet use in young skiers. Paediatr Child Health. 2013;18(9);471-472.
Dr Brown is clinical professor, Department of Pediatrics, Colorado School of Medicine, Aurora, Colorado. Dr Fishman is a general pediatrician, Colorado Mountain Medical, Edwards, Colorado. The authors have nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.