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