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ORIGINAL ARTICLE
Safety knowledge and risk behaviour
of injured and uninjured young skiers
and snowboarders
Andrew J Macnab MD FRCPC, Robert E Cadman MEd PhD, Julia V Greenlaw BA
Division of Critical Care, British Columbia’s Children’s Hospital, Vancouver, British Columbia
AJ Macnab, RE Cadman, JV Greenlaw. Safety knowledge and risk behaviour of injured and uninjured young skiers and snowboarders.
Paediatr Child Health 1998;3(5):321-324.
Les connaissances de la sécurité et les
comportements à risque des jeunes skieurs et des
adeptes de planche à neige blessés et non blessés
BACKGROUND: Earlier studies of ski injury indicated that youths were at
increased risk of injury, that males were most likely to injure the head or
face, and that females were most likely to injure the knee.
OBJECTIVE:To obtain information about safety knowledge and risk behaviour that might contribute to injury among young skiers and snowboarders.
DESIGN: Survey of knowledge and behaviour in injured and noninjured
cohorts.
SETTING: Blackcomb Mountain, Whistler, British Columbia.
PARTICIPANTS: A total of 863 noninjured and 118 injured skiers and
snowboarders aged five to 17 years using Blackcomb during 1993/94.
INTERVENTION: Skier Knowledge Inventory Questionnaire.
RESULTS: The injured cohort had less knowledge of the Skiers Responsibility Code. In both groups, almost half had had no lessons, 31% had had
bindings adjusted by nonprofessionals and chair lift safety bars were used
one ride in four by children age 13 to 17 years. The injuried cohort wore
helmets slightly less often. Both groups regularly skied through the trees
(60% to 70%), and one-thirds had skied on closed runs. Excessive speed
was identified as the major cause of injury. Skiers did not recognize jumping as contributing to injury.
CONCLUSIONS: Lack of knowledge of safety rules was more prevalent
among the injured cohort. Skiing without due care – including skiing
through tress, skiing on closed runs, skiing with excessive speed and jumping, particularly by snowboarders – were identified as potential causes of
injury.
HISTORIQUE : Des études antérieures sur les blessures en ski révèlent que
les jeunes courent un risque accru de blessures et que les garçons sont plus
susceptibles de se blesser à la tête ou au visage tandis que les filles risquent
davantage de se blesser aux genoux.
OBJECTIF : Obtenir des renseignements sur les connaissances de la
sécurité et les comportements à risque qui peuvent contribuer aux
blessures chez les jeunes skieurs et planchistes.
MÉTHODOLOGIE : Sondage des connaissances et des comportements
d’une cohorte blessée et non blessée.
LIEU : Blackcomb Mountain, Whistler, Colombie-Britannique.
PARTICIPANTS : Un total de 863 skieurs et planchistes non blessés et de
118 skieurs et planchistes blessés âgés de 5 à 17 ans qui se sont rendus à
Blackcomb en 1993-1994.
INTERVENTION : Questionnaire de l’inventaire des connaissances des
skieurs.
RÉSULTATS : La cohorte blessée connaissait moins le code de
responsabilité des skieurs. Dans les deux groupes, presque la moitié n’avait
pas suivi de cours, 31 % d’entre eux avaient fait ajuster leurs fixations par
des non-professionnels et s’ils avaient de 13 à 17 ans, ils utilisaient les
barres de sécurité des télésièges une fois sur quatre. Ils portaient des
casques un peu moins souvent. Les deux groupes skiaient régulièrement
dans les sous-bois, et 20 % avaient skié sur des pistes fermées. Une vitesse
excessive était identifiée comme la principale cause de blessures. Les
skieurs ne considéraient pas les sauts comme facteur contributif des
blessures.
CONCLUSIONS : Le manque de connaissance des règles de sécurité était
plus prévalent chez la cohorte blessée. La pratique du ski sans les
précautions nécessaires, dont le ski dans les sous-bois, le ski sur des pistes
fermées, le ski à une vitesse excessive et les sauts, surtout chez les
planchistes, ont été identifiés comme des causes possibles de blessures.
Key Words: Behaviour, Head injury, Helmet, Knee injury, Risk, Skier
Responsibility Code, Spinal injury, Youth
D
ownhill skiing and snowboarding are popular outdoor recreational activities. Unfortunately, as with
all sporting activities, injuries occur and, in some instances, cause long term disability or death. While skiing
and snowboarding are not considered to be activities with
particularly high rates of injury, data collected from
Blackcomb Mountain, Whistler, British Columbia (1), indicate:
Correspondence: Dr AJ Macnab, Division of Critical Care, British Columbia’s Children’s Hospital, 4480 Oak Street, Vancouver,
British Columbia V6H 3V4. Telephone 604-875-2729, fax 604-875-2728, se-mail [email protected]
Paediatr Child Health Vol 3 No 5 September/October 1998
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Macnab et al
TABLE 1: Incidence of significant injury (those requiring
treatment by a physician) based on computer-generated
lift use data for a complete season at Blackcomb Mountain
Age (years)
Population
(% of total)
Significant
injuries
(% of total)
Significant
injuries per
1000 skier days
Birth to 6
7 to 12
13 to 17
18 to 64
9182 (1)
46,487 (6)
86,429 (12)
569,423 (79)
16 (1)
148 (10)
289 (19)
1062 (69)
1.74
3.18
3.34
1.87
65 and older
Total
8545 (1)
720,066 (100)
15 (1)
1530 (100)
1.75
2.12
· that there is a disproportionately high risk of
injury in young people (Table 1)
(relative risk = 1.7);
· that youths skiing during school organized
activities have a much higher incidence of injury
requiring medical treatment than those skiing
independently (4.2/1000 day visits versus
2.3/1000 day visits, P<0.003, c2 test);
· that for males the head is at particular risk in
these sports (Figures 1a, 1b);
· that 22% of head injuries are severe enough to
cause loss of consciousness or clinical signs of
concussion (4.4% of all injuries among those
under 18 years of age); and
· that 60% of young injured skiers identified personal
error as the cause of their injury (Table 2).
These figures are particularly relevant because they
are based on data from an entire ski season and actual
denominator/population data obtained from the computerized lift-ticket data maintained by Blackcomb Mountain. Other investigators have estimated the number of
skiers using the hill, have based injury rates on a partial
season or upon patients seen at nearby clinics or hospitals, rather than ski patrol reports of all injuries on the
mountain.
Because these data raise concerns about the number
of injuries, their nature and the population at risk, we
conducted a study to obtain information about the knowledge and behaviour of young skiers and snowboarders
that might contribute to injury and to identify factors that
physicians could use in injury prevention initiatives.
Figure 1) Sites of injury as a percentage of total injuries by age group. Top
Males; Bottom Females
PARTICIPANTS AND METHODS
This study was approved by the Clinical Research
Screening Committee for Human Subjects at the University of British Columbia. Because there was no preexisting instrument, a questionnaire assessing ski behaviour and ski knowledge (Skier’s Knowledge Inventory or
[SKI] Questionnaire) was developed. Appropriate questions and multiple choice answers were developed by a
panel that included ski patrollers, physicians, ski instructors, skiers, parents and youth. The SKI question-
TABLE 2: Main age-specific, self-reported causes of injury (% of number injured)
Age (years)
Birth to six
7 to 12
13 to 17
18 to 64
65 and older
All
Personal error
Change in snow conditions
Object collision
Jumping
Human collision
43
57
59
62
58
60
0
8
9
8
16
8
17
7
6
7
16
7
9
8
12
5
0
7
9
8
2
6
5
5
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Safety knowledge and of young skiiers and snowboarders
naire was tested with children of staff members and then
with 25 recreational and competitive skiers at a local ski
club to ensure construct validity. Based on feedback
from these people, questions were modified for clarification, and at parent’s request, questions concerning drug
and alcohol use were deleted. The final questionnaire incorporated 43 multiple choice questions and four openended questions. Reliability and validity testing were not
completed because the data were used as individual responses rather than scored to arrive at scales or single
values. The SKI questionnaire was administered to two
groups, injured skiers and a noninjured cohort, all under
the age of 18 years.
The injured cohort was identified through injury reports maintained by the Blackcomb Ski Patrol. Injury reports are used for injuries that require referral to a
physician for treatment. Treatment for most of these injuries is provided at a family physician-run clinic at the base
of the mountain. Data fields on the injury reports include
age, sex, skier ability (self-report), equipment status
(owned, rented or borrowed), snow conditions, weather
conditions, time of day, self-reported cause of the incident (from a list of options) and a description of the injury
as determined by the ski patroller at the time. The quality
of the medical data collected by the ski patrol is highly reliable because all of the members have industrial first aid
certification, many have paramedic training and some are
physicians.
Packages containing the consent form and questionnaire were mailed at the end of the season to parents of a
convenience sample of 200 injured youth aged five to 17
years who had been referred by the ski patrol for physician care. Nonresponders were reminded via a telephone
call, and, if requested, a second package was sent.
A cohort of noninjured youth aged five to 17 years was
recruited by one investigator on 30 skiing days at various
times (weekends, weekdays, spring break) during March
and April. A letter containing a consent form was given to
parents of families using the restaurant at mid-mountain at
lunch times on a series of weekends, weekdays and school
holidays chosen at random. Children whose families consented completed the questionnaire immediately, and content was checked at the time to avoid incomplete data.
Analysis of the data was conducted using Systat 5.2
(Systat, Illinois) and QuattroPro (Corel Corporation Ltd).
Questionnaire items were content coded and expressed
as percentages.
TABLE 3: The Skier’s Responsibility Code
The Skier’s Responsibility Code defines the basic safety and
behavioural expectations of skiers.
1. Ski under control and in such a manner that you can stop at
any time or avoid other skiers or objects.
2. When skiing or overtaking another skier, you must avoid the
skier below you.
3. You should not stop where you obstruct a trail or are not
visible from above.
4. When entering a trail or starting a descent, yield to other skiers.
5. All skiers shall use devices to help prevent runaway skis.
6. You shall keep off closed trails and posted areas and observe all
posted signs.
Officially endorsed by the National Ski Areas Association
sample had 64 males (54%) and the uninjured cohort had
489 male respondents (57%).
The uninjured and injured groups had similar perceptions of their ability, style of skiing, speed (20% described
themselves as fast skiers), degree of control (47% and
38%, respectively, felt they skied “in control”) and incidence of skiing recklessly (0% versus 1.5%) or when
scared (2% versus 4%). About 16% of each group described
themselves as “daring”. Excessive speed was viewed by
both groups as likely being the major cause of ski injuries
(50% in each group), with skiing terrain above one’s ability as the second most frequent cause (18%), followed by
collision (12% in the uninjured and 8% in the injured cohorts). Blind jumping was not seen to be a significant
problem by either group (4% and 2%).
Knowledge: The Skier’s Responsibility Code (Table 3) is a
set of six ‘rules of the road’ for skiers derived from the Alpine Responsibility Code. Among the injured group, 25%
had never heard of the code, compared with 31% of the
uninjured group. Of those who had heard of the code, 50%
of both groups could not list the six main points. Twenty
per cent of both cohorts did not know who had the right of
way when skiing down a slope. Six per cent of the uninjured and 10% of the injured cohort incorrectly identified
the meaning of a blue square as the designation of the difficulty of a run (P<0.0001, binomial distribution).
Twenty-seven per cent of the uninjured group and
20.5% of those injured had had two to nine lessons in the
previous year; 44% of the uninjured and 56% of the injured had had no lessons. In the uninjured group, parents were identified as the primary providers of ski safety
instruction by those age 12 years or under, and ski instructors were cited by those age 13 to 17 years. In the injured group, ski instructors were seen as the primary
providers of information in all age groups except age birth
to six years. Ski instructors and ski patrollers were identified as the individuals who would be listened to most regarding safety. The injured group were half as likely as
the uninjured group to take this information from parents, and neither group indicated that they would listen to
school teachers regarding ski safety.
RESULTS
Responses were received from 118 in the injured cohort (59%), and 863 uninjured subjects were recruited
from 900 approached (more than 95% participation).
The age distributions of the injured and uninjured cohorts were similar, although there was a higher percentage of 16- and 17-year-olds in the injured cohort
compared with the uninjured cohort (r2=0.60 for percentages among those under age 16 years). The injured
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Macnab et al
TABLE 4: Frequency of helmet use, reported by age group, via questionnaire (1993)
Injured population
Uninjured population
Age (years)
Never
Sometimes
Always
Never
Sometimes
Always
Birth to 6
7 to 12
13 to 17
All
20%
55%
92%
76%
20%
12%
8%
10%
60%
32%
0%
14%
21%
55%
86%
64%
16%
15%
13%
14%
63%
30%
1%
22%
Behaviour: Some common skiing practices can be
deemed ‘unsafe’, including skiing through trees, skiing
closed areas, failing to use the safety bar on chair lifts, failure to wear a helmet, jumping and having bindings adjusted by people other than trained technicians. Among
both cohorts, 60% to 70% skied through the trees at least
one run daily, and one-third had skied on closed runs.
Among those over 13 years of age, chair lift safety bars
were used about half as often as by those under age 12
years (25% versus 50%), and helmets were rarely worn
regularly. Injured children in the 13- to 17-year-old age
group reported less helmet use than those in the uninjured sample (Table 4). Jumping contributes to injury,
particularly spinal injury, but as reported above, is not
considered by young people to be a significant problem.
Thirty-one per cent of both groups had had binding adjustments made by individuals other than ski shop technicians.
to the uninjured cohort. For this reason, we have not
called this group a control group.
We do not have denominator data for the distribution
of skiers by sex or for skiers versus snowboarders from
the lift-ticket data, and, therefore, cannot comment on the
injury incidence by sex or by activity.
We do not have data on helmet use among those who
sustained head injuries. This is a question is currently
being addressed in another study.
The 59% return rate from the injured cohort may have
resulted from the decision to mail all the questionnaires at
the end of the season rather than closer to the time of injury.
Our data indicate that important elements of knowledge are lacking, including knowledge of the safety code,
colour coding of run severity and potential risks associated with jumping. In addition, behaviours (skiing out of
bounds, skiing through trees, not wearing a helmet, not
using lift safety bars and binding adjustment by amateurs) that increase the chance or potential severity of injury are common.
DISCUSSION
The overall incidence of injury in our population was
consistent with previous reports, as is the high incidence
of injury found in young people (2) and the fact that the
head/face, knee and shoulder are the most frequent sites
of injury (2-5).
The results of this survey of skier knowledge and behaviour provide important information for physicians
trying to identify strategies to influence behaviour among
young skiers and snowboarders. However, we recognize
the limitation of these data and that our results are likely
affected by several factors that we were unable to control
including the following. The uninjured cohort was skiing
with their parents (unavoidable because of the ethical requirement to obtain parental informed consent on the
mountain at recruitment). In contrast, the injured cohort
may not have been skiing with their parents (this information was not elicited), although the parent may have been
involved in completing the mailed questionnaire. The
presence of parents may have affected the child’s responses or had an influence on the type of youth recruited
ACKNOWLEDGEMENTS: The authors are grateful for the assistance given by Blackcomb Mountain throughout the period of
data collection, and for financial support for aspects of this research provided by SafeStart, the Injury Prevention Program at
British Columbia’s Children’s Hospital, sponsored by the Royal
Bank.
REFERENCES
1. Macnab AJ, Cadman RE, Gagnon F. Demographics of alpine skiing
and snowboarding injury: Lessons for prevention programs. Inj Prev
1996;2:286-9.
2. Blitzer C, Johnson R, Ettlinger C, Aggeborn K. Downhill skiing
injuries in children. Am J Sports Med 1984;12:142-7.
3. Ekeland A, Nordsletten L, Lystad H, Holtmoen A. Alpine skiing
injuries in children. In: Johnson RJ, Mote CD Jr, Zelcer J, eds.
Skiing Trauma and Safety: Ninth International Symposium.
Philadelphia: American Society for Testing and Materials,
1993:43-9.
4. Matter P, Ziegler WJ, Holzach P. Skiing accidents in the past 15
years. J Sports Sci 1987;5:319-26.
5. Oliver B, Allman F. Alpine skiing injuries: An epidemiological study.
In: Mote CD Jr, Johnson RJ, eds. Skiing Trauma and Safety: Eighth
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