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The New Zealand Medical Journal

 Journal of the New Zealand Medical Association, 21-January-2011, Vol 124 No 1328

Serious ski and snowboard injuries in southern New Zealand requiring acute orthopaedic admission and treatment during winter 2009
A Gordon Burgess, Ridzwan Namazie
Abstract
Aims The aims of this study were to report on ski and snowboard injuries which required in-patient assessment and treatment, by investigating demographics, complexity and cost.
Methods A prospective study investigating the pattern of ski and snowboard injuries admitted to the Orthopaedic Department of Southland Hospital (Invercargill) during 2009. Patient demographics, injury characteristics, treatment and financial implications have all been examined.
Results 88 patients were admitted with 92 injuries over 129 days. Thirty-six skiers sustained 37 injuries compared to 55 injuries in 52 snowboarders. The median age of skiers was 32.5 years compared to 26 years for snowboarders, which represented a statistically significant difference. Thirty-two admissions were visitors from Australia, compared to 29 from New Zealand and 14 from Great Britain and Ireland. Fifty-two patients (59.1%) were transported to Invercargill by ambulance compared to 13 (14.8%) by helicopter. Twenty-five ski-related injuries were treated operatively (67.5%) compared with 37 snowboard-related injuries (67.3%). Twenty-three patients (26%) were admitted with spinal injuries including one C5 burst fracture which was ultimately fatal. A total of 124.46 case weights were generated by all 88 admissions representing a cost of almost $500,000.
Conclusions Ski and snowboard injuries represent a significant workload and financial burden to a typical mid-sized district general hospital in New Zealand. There is little published data on the natural history of serious orthopaedic injuries related to skiing and snowboarding in New Zealand.

Skiing and snowboarding are part of an important adventure tourism industry in New Zealand. Winter sports carry an element of risk. Previous research suggests a risk of injury of 1.74 ski injuries per 1000 ‘skier days’ and 3.55 snowboard injuries per 1000 ‘boarder days’.1 The demographics of ski and snowboarding injuries are well documented in other parts of the world suggesting a predominance of lower limb injuries in skiers and upper limb injuries in snow boarders.1,2
In New Zealand, treatment for accidents and injuries is covered by the Accident Compensation Corporation (ACC) irrespective of nationality or domiciliary status in New Zealand. In 2007, ACC accepted claims for 11,633 snow sports injuries at a cost of around NZ$12 million.3
Queenstown is a major hub for snow sports during winter months. Snowsports injuries sustained in this area are usually managed initially at the ski field or in medical centres in Queenstown. Injures requiring orthopaedic specialist assessment, are referred to the orthopaedic department in Southland Hospital, Invercargill. Severely injured patients can be transferred directly from the ski field to Southland Hospital for rapid assessment and treatment.
The resident population of Queenstown is around 23,000 people.4 An increased population typical during winter months places increased strain on local emergency, medical services and orthopaedic services. Very little published data exists on the demographics of significant ski and snowboard-related injuries, and their acute orthopaedic inpatient assessment and treatment in New Zealand.
The aims of this study were to report on the demographics, complexity and cost of ski and snowboard injuries presenting to a medium sized orthopaedic trauma unit during winter 2009.

Methods

Data collection for this prospective audit was undertaken using a pro forma designed by the author. A literature search for published articles on ski and snowboard injuries was performed prior to the study to help establish appropriate information regarding patient demographics, injury and treatment and to provide data for comparison. Patients admitted to the orthopaedic ward in Southland Hospital with ski or snowboard injuries were included in this study. Patient details were passed to the main author for inclusion in the study and these details were double checked against admission records to ensure all patients were identified for inclusion. Patients admitted in the semi-acute or chronic period, at least two weeks after injury were excluded.
Demographic data, country of origin and injury date were collected. Referral Source and means of transport to Southland Hospital were recorded along with site of injury (spine/pelvis, upper limb or lower limb), including a written description and Radiographic means of acute investigation. Treatment was documented (conservative/operative) including a description. In-patient duration and complications associated with treatment initiated were also recorded.
Cost analysis was calculated in terms of both case weights and actual cost based on hospital coding data. Case weights (CWs) are a financial currency used by District Health Boards in New Zealand to calculate the cost of admissions and are necessary when applying for funding, particularly for elective admissions not covered under ACC bulk funding. One case weight is equal to approximately NZ$4000.
Mean, median and standard deviation have been calculated to allow interpretation of the spread of data and 95% confidence intervals have been calculated to test significance of data when comparing groups. P-values were also calculated using an unpaired t-test, with p<0.01 accepted as significant. There was no conflict of interest between the author and the study and no pecuniary interests. Ethical Approval has been sought for this study from the Southern Regional Ethics Committee.5

Results

Eighty-eight patients were admitted with 92 injuries to Southland Hospital (Invercargill, New Zealand) for orthopaedic assessment and treatment of injuries sustained from skiing and snowboarding over 129 days from 8 June 2009 until 14 October 2009. One injury occurred in one patient heliskiing and all other injuries were sustained on local fields. There were no admissions for injuries sustained during telemark skiing.
Thirty-six skiers and 52 snowboarders were admitted with 37 injuries and 55 injuries respectively over the season. Injured snowboarders were significantly younger than skiers. Injured male snow boarders were also significantly younger than male skiers. No significant difference was found between female skiers and snowboarders or between sexes generally. See Table 1.
Table 1. Demographics of injured skiers/snowboarders
Variables
Ski(range)
95% CI
Snowboard(range)
95% CI
Both(range)
P
Admissions
36

52

88

Injuries
37

55

92

Sex
Female
Male
13
23

14
38

27
61

Median age (range)
Female
Male
Both
29 (5-59)
39 (15-69)
32.5 (5-69)
24.4-40.5
33.7-48.6
32.3-43.6
25.5 (17-49)
26.5 (11-47)
26 (11-49)
23-32
23.7-28.7
24.4-28.7
28 (5-49)
27 (11-69)
27.5 (5-69)
0.249
<0.001a
<0.001a
a significant difference
Thirty-two admissions (37.5%) were Australian comprising 18 skiers and 14 snowboarders, compared to 29 New Zealanders (31.8%) comprising 10 skiers and 19 snowboarders (Table 2).
In total there were 11 different nationalities included in this study. Most admissions were made in July (30 [34%]) compared to the least in October (5 [6%]).
Table 2. Country of origin of injured skiers/snowboarders
Variables
Skiers
Snowboarders
Both
Country of origin
New Zealand
Australia
UK & Ireland
Europe
USA/Canada
Japan
Other
10
18
3
2
2
1
0
19
14
11
4
2
0
2
29
32
14
6
4
1
2
Admission month
June
July
August
September
October
5
9
18
4
0
6
21
10
10
5
11
30
28
14
5
The majority of patients were referred from either a general practice-led medical centre in Queenstown of Lakes District Hospital. Most patients were transported to Invercargill by ambulance. See Table 3.
Eighty-eight admissions spent 292 inpatient days in hospital throughout the study period with a mean stay of 3.3 days and median stay of 2 days. There was no significant difference in in-patient stay between skiers and snowboarders. All patients had an X-ray and more than half had a CT scan. See Table 3.
Table 3. Hospital admission details of injured skiers/snowboarders
Variables
Ski
(95%CI)
Snowboard
(95%CI)
Both
P
Referral source
Ski field (%)
MC
LDH
ED
3 (3.4)
15 (17)
18 (20.4)
0

0
16 (18.2)
35 (39.8)
1 (1.1)

3 (3.4)
31 (35.2)
53 (60.2)
1 (1.1)

Transport to Invercargill
Helicopter (%)
Ambulance
Personal
9 (10.2)
24 (27.3)
3 (3.4)

4 (4.5)
28 (31.8)
20 (22.7)

13 (14.8)
52 (59.1)
23 (26.1)

Inpatient duration
Median (range)
2.5 (1-12)
(1.4-4.9)
2 (1-14)
(2.2-3.8)
2 (1-14)
0.2331
Investigation
X-ray (%)
CT
MRI
Bone scan
36 (40.9)
17 (19.3)
0
1 (1.1)

52 (59.1)
33 (37.5)
0
0

88 (100)
46 (52.3)
0
1 (1.1)

i No significant difference of inpatient duration between groups
MC: medical centre
LDH: Lakes District Hospital
ED: Emergency Department (Southland Hospital)
There was a predominance of lower limb injuries in skiers and upper limb injuries in snowboarders. Spinal injuries were more common in snowboarders than skiers. One death occurred following a cervical burst fracture in a snowboarder (Table 4).
Table 4. Injury type by sport
Variables
Skiing
Snowboarding
Spine
Cervical spine fracture
Cervical spine soft tissue injury
Thoracic spine fracture 1 level
Thoracic spine fracture multiple levels
Lumbar spine fracture 1 level
Lumbar spine fracture multiple levels
Pelvic fracture
Total (%)
1
1

3
1

2
8 (21.6)
2
1
4
2
5
1

15 (27.3)
Upper limb
Clavicle fracture
Complicated shoulder dislocation
Proximal humerus fracture
Mid shaft humerus fracture
Distal/supracondylar humerus fracture
Elbow dislocation
Proximal ulna/radius fracture
Mid shaft ulna/radius fracture
Distal radius/ulna fracture
Carpal dislocation including scaphoid injury
Metacarpal fracture
Phalangeal fracture
Upper limb wound
Total (%)
1

1
1
1
1


2



1
8 (21.6)

2
4
2
4
4

1
3
8
1
1
1
31 (56.4)
Lower limb
Dislocated hip
Neck of femur fracture
Sub-trochanteric fracture
Supra-condylar femoral fracture
Tibial plateau fracture
Tibial shaft fracture
Distal tibial fracture
Ankle fracture
Talus fracture (excluding lateral process)
Lateral talar process fracture
Calcaneal fracture
Wound lower leg
Total (%)
1
2
2
1
3
8
2
1
1



21 (56.7)




5



1
1
1
1
9 (16.4)
Sixty-two primary operations were performed for ninety two injuries (67%). There were four further planned returns to theatre for fasciotomy wound closure in a snowboarder. Four injured skiers chose to their country of origin for surgery when surgery was recommended as treatment of choice for their injury. There were three unplanned returns to theatre for operative complications in three different skiers. One skier was transferred to the regional spinal injuries unit in Christchurch for a single level lumber burst fracture and one snowboarder for an unstable cervical fracture after HALO traction was applied (Table 4).
Table 5. Locations of injuries
Variables
Operation
Ski
Snowboard
Spine
Halo application
1
1

ORIF lumbar spine

2

Total (%)
1 (4)
3 (7.3%)
Upper limb
Clavicle ORIF
1
2

Greater tuberosity ORIF

2

Capsular repair

2

MUA shoulder

2

Proximal humerus ORIF



Humeral Shaft ORIF

1

Humeral IMN

1

Humeral Shaft TENS
1
2

Distal humerus/condylar ORIF
1
3

Olecranon ORIF

1

Shaft radius or ulna ORIF

3

Distal radius MUA

3

Distal radius MUA +K-wires

1

Distal radius ORIF

2

Scaphoid ORIF

1

MUA hand/fingers



MUA +K-wire/ORIF hand/fingers (exc. scaphoid)

2

Wound debridement/washout
2


Total (%)
5 (20)
28 (68.3)
Lower limb
Cannulated or Compression hip screws
2


Cephalo-medullary nail
2


ORIF distal femur
1


Tibial IMN
7


ORIF proximal tibia
1
3

ORIF distal tibia
2


External fixation Tibia

1

ORIF ankle
2


MUA ankle



MUA + K-wires mid-foot
1
1

ORIF foot
1


ORIF lateral process talus

1

Fasciotomy management

4a

Total (%)
19 (76)
10 (24.3.)
a 4 planned returns to theatre for fasciotomy wound closure; ORIF: open reduction and internal fixation; MUA: manipulation under anaesthesia; IMN: intra-medullary nail; K-wire: Kirschner wire.
More case weights were attributed to snowboard injuries than ski injuries, however no significant difference was found for size of case weights between these groups. The total cost in terms of case weights for all 88 admissions was approximately $497,840 or 124.46 case weights. Ski and snowboard injuries in New Zealanders generated the most case weights and therefore costs. See Table 6.
Table 6. Costs associated with the injured skiers/snowboarders
Variables
n
Total CW
Median CW (range)
95% CI
Average cost
NZD
Total cost
NZD
P
Ski
Snowboard
36
52
56.03
68.44
1.88 (0.19–3.97)
1.09 (0.20–7.30)
1.19–1.921
0.99–1.641
6240
5280
224,120
273,760
0.342
New Zealand
Australia
UK &Ireland
USA & Canada
Europe
Japan
Other
29
33
14
4
6
1
2
39.34
33.88
30.98
3.52
13.24
0.54
3.43
1.17 (0.20–3.27)
0.60 (0.19–3.97)
1.88 (0.60–7.30)
0.56 (0.52–1.88)
1.98 (0.60–3.76)
0.54
1.72 (1.55–1.88)

5440
4120
8840
3520
8840
2160
6880
157,360
135,520
123,920
14,080
52,960
2160
13,720

All patients
88
124.46
1.21 (0.19–7.30)

5640
497,840

CW: case weight (approx. $4000); n: number of admitted patients; 1no significant difference found.

Discussion

Eighty-eight patients were admitted with ski and snowboard-related injuries to orthopaedics in Southland Hospital during the 2009 winter season. No data could be found for previous years. Siu et al report on 936 snowsports-related admissions to Canberra Hospital, Australia over an 8-year period, and over a period of 6 years to December 1995 in Vermont, Sacco et al reported on 279 injuries admitted for significant ski and snow board injuries.2,6
Sacco reports on 40 (14.3%) snowboard-related injuries and 238 (85.3%) skier injuries, differing substantially from 59% and 41% of snowboard and ski injuries respectively in this study. This difference may be best explained by the increasing popularity of snowboarding in recent years, although no data on ski field usage was available.
A significant difference was found between the age of skiers and snow boarders with median skier age of 32.5 years compared to 26 years old for snowboarders. This difference was also noted within the subgroup of males, where again snowboarders were significantly younger. Without reliable control data on ski field usage it is impossible to attribute a true increased risk of snowboarding to the younger male.
Australian visitors sustained most injuries amongst tourists, followed by British and Irish visitors. This follows the pattern of visitors to New Zealand by country of residence as outlined by Statistics New Zealand in 2004.7 Admissions to Dunedin Public Hospital from any cause of injury found Asian visitors represented the highest number of admissions (20%), which varies greatly from the two Asian visitors admitted during this study (2.3%).8 The busiest months for admissions were July and August which most likely represents the peak holiday season and most reliable snow conditions.
There were 53 ambulance transfers from Lakes District Hospital to Invercargill, the cost of which is approximately $466.67 (ex. GST).9 Thirteen (14.8%) patients were transported either directly from the ski field or Lakes District Hospital to Southland Hospital by helicopter at a cost of approximately $2494 (ex. GST) per hour for a typical 2½ hour return trip.10 Neither of these costs account for a nurse if required for the transfer.
One skier underwent a bone scan following a pathological distal femoral fracture secondary to metastatic malignant melanoma. No other metastatic lesions were found and this patient was treated with open reduction and internal fixation and adjuvant radiotherapy. No patients required Magnetic Resonance Imaging.
The overall pattern of injuries in this study between skiers and snow boarders follows typical trends seen in other studies, with a higher tendency towards upper limb injuries in snowboarders (56.4%) and lower limb injuries in skiers (78.4%). Six patients with upper limb injuries were found in this study to discharge from hospital with a preference to return to their country of origin for definitive surgical treatment. This practice was less common in lower limb due most likely to the significant restriction to overall mobility. Most injuries were treated with surgery (67.3%) in both skiers and snowboarders.
Twenty-three patients (26%) were admitted with spinal injuries across the study period; 15 snowboarders and 8 skiers. Donald et al reported on 25 spinal injuries from skiing or snowboarding presenting to Dunedin Public Hospital between 1991 and 2002.10
Siu et al report on 66 patients (7%) admitted with spinal trauma over 8-year period from the Snowy Mountains, Australia with a predominance of lumbar spine injuries as found in this study.8 Single level lumbar spine fractures represented the most common area of injury and three required surgical treatment. Two snowboarders with unstable lumbar vertebra level 1 (L1) fractures were treated surgically in Invercargill and one referred to the regional spinal unit in Christchurch.
Halo vest bracing was used as definitive treatment for a cervical spine fracture in an Australian skier, and Aspen bracing for a C2 fracture in a snowboarder. One patient required temporary halo application for transfer to the regional spinal injuries with an unstable C5 burst fracture and associated tetraplegia which eventually proved fatal.
124.46 case weights were generated with the total cost of inpatient admissions for ski and snowboard-related orthopaedic injuries being over $550,000 including patient transfer costs. Acute injury treatment including implant costs is covered by ACC bulk funding and does not directly rely on individual case weights. The actual cost of implants used may exceed the case weight value and will not be caught by generic coding data used for certain injuries.
Without previous data, it is difficult to say if ski and snowboard-related trauma is on the increase in New Zealand. However injury prevention measures may help to reduce the incidence of injuries. The Accident Compensation Corporation is committed to prevention of injuries and measures related to winter sports include posters reminding skiers and snowboarders of the risks involved and advice on codes of conduct for skifield users. An increased use of protective equipment may reduce injury rate and severity. Increased utilisation of other theatres and clinics along with increased staff awareness of ski and snowboard-related trauma may help to deal with the influx of trauma from the skifields during peak season, such as the school holidays.

Conclusion

Skiing and snowboarding-related injuries are at times severe, and as well as major patient morbidity, represent a reasonable drain on hospital resources in terms of cost and time. This is the first study to document the demographics, complexity and costs of orthopaedic ski and snowboard trauma in New Zealand. Low overall numbers are a limitation and data collection over more than one season along with other studies are required to further clarify the impact of snowsports injures on New Zealand.
Competing interests: None.
Author information: A Gordon Burgess and Ridzwan Namazie, Orthopaedic Registrars, Southland Hospital, Invercargill
Acknowledgements: The authors thank Maree Jackson, Elective Services Southland Hospital for case weight data and data on elective and acute services.
Correspondence: Dr Gordon Burgess, Orthopaedic Registrar, Orthopaedic Outpatients, Christchurch Hospital, Private Bag 4710, Christchurch, New Zealand. Email: agburgess@hotmail.com
References:
  1. Langran M, Selvaraj S. Snow sports injuries in Scotland: a case-control study. British Journal of Sports Medicine 2002;36:135-140.
  2. Sacco DE, Sartorelli DH, Vane DW. Evaluation of alpine skiing and snowboarding in a northeastern state. Journal of Trauma-Injury Infection & Critical Care. 1998 Apr;44(4):654-9.
  3. ACC SnowSmart Website: http://www.snowsmart.co.nz/articles/view/150
  4. New Zealand Census 2006. http://www.stats.govt.nz/Census/2006CensusHomePage/QuickStats/AboutAPlace/SnapShot.aspx?id=2000070&type=ta&ParentID=1000014
  5. Lower South Regional Ethics Committee. Application number LRS/09/32/EXP.
  6. Siu TLT, Chandran KN, Newcombe RL, et al. Snow sports related head and spinal injuries: an eight year survey from the neurotrauma centre fro the Snowy Mountains, Australia. J Clin Neuroscience 2004;11(3):236-242.
  7. Statistics New Zealand. Visitor arrivals by country. http://search.stats.govt.nz/search?w=visitor+arrivals+by+country
  8. Gwynne Jones D. Non-resident orthopaedic admissions to Dunedin Hospital New Zealand: 1997 to 2004. 2005 N Z Med J 24 June 2005;118(1217). http://www.nzma.org.nz/journal/118-1217/1531/content.pdf
  9. St John Southern Region. 17 York Place, Po Box 5055, Dunedin, New Zealand (contacted via Frankton base January 2010).
  10. Donald S, Chalmers D, Theis J-C. Are snowboarders more likely to damage their spines than skiers? Lessons learned from a study of spinal injuries from the Otago skifields in New Zealand. N Z Med J 24 June 2005;118(1217). http://www.nzma.org.nz/journal/118-1217/1530/content.pdf
     
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