Downhill skiing injuries and their cost at a Finnish skiing area Asikainen P, Liithje P, J W e n M, Avikainen V, Koskinen I. Downhill skiing injuries and their cost at a Finnish skiing area. Scand J Med sci Sports 1991: 1: 228-231.

During the 1987-1990 ski seasons. 325 consecutive patients sustained downhill skiing injuries at a skiing area in central Finland. The calcu- lated injury rate was 0.94 per lo00 skier-days (0.9%) and 0.56 per lo00 skiers (0.06%). Forty-one percent of the injuries were located in the lower limbs and 37% in the upper limbs. Sprain was the most common type of injury (34%), followed by fractures (22%) and contusions (17%). Only 7% of the patients needed surgery. The estimated mean cost of medical treatment and sick leave was FIM 5500 (USD 1400) per

I patient.

The most common serious downhill skiing injuries are anterior cruciate ligament ruptures of the knee, tibial fractures, shoulder dislocations, acro- mioclavicular separations and ruptures of the ulnar collateral ligament of the 1st metacarpophalangeal joint (14). This study analyzed injuries and estimated the

cost of medical treatment and sick leave for the downhill skiing injury patients in Jiimsii, Finland during the 1987-1990 ski seasons.

Material and methods This prospective study included everyone injured while skiing in the Jiimsg downhill skiing area and treated at the emergency department in JWszi Hospital, at the University Hospital in Tampere and at the Central Hospital in Jyvaskylii. The re- gional hospital in J h i i is the only acute hospital in the skiing area and all downhill skiers with sig- nificant injuries were brought to this hospital for medical care. The staff of the downhill area and of the district ambulances knew about this study and actively tried to deliver all the injured skiers to JWsl Hospital. The injured skiers were not treated by general practitioners. The Central Hos- pital in Jyvaskyli is located about 45 min from the skiing area by car and the University Hospital of Tampere about 60 min away.

The age, sex, time of injury, types of injury, injury mechanism and length of stay in hospital were recorded for each patient. The central hospi- tals in Tampere and Jyviiskyla knew about this study and the staff of the emergency room filled in the same questionnaire if the patient was injured at the downhill area in Jiimsa. Afterwards, all pa-

P. Adbinen', P. Wj, M. JPMnen', V. Avikainen', 1. Koskinen6 Regional Hospitsl, J l d , Department of Surgary, Regional Hospital, Kuusankoski, Universily Hospital, T a m p , Central Hospital, JyvWyIi, Department of General Practice and Primary Health Care, University of Helsinki, Finland

Key words: downhill skiing eccident; cost Peter Liithjj M.D., Regional Hospital, SF4R50 Kuusanltosiri, Finland

kapted for p u b l i o n September 25,1991

tients got a questionnaire to obtain specific in- formation regarding after-treatment, stay in hospi- tal, sick leavedd costs.

Fromdhe questionnaire, the following data were analyzed: outpatient fee, cost per treatment day, cost of sick leave and ambulatory care fee. The costs for loss of income from sick leave were calcu- lated using the mean industrial wage per hour in Finland in the first 4 months of 1988, 1989 and 1990.

Missing data were also received from the home- town hospitals at which the injured skiers were treated after emergency care in Jam&.

The number of skiers and skiing days was based on the number of lift tickets (season pass, day ticket, %hour ticket, &hour ticket and evening ticket) sold per season. The staff of the downhill area kept a daily count of the number of skiers.

Results The number of skiers from 1987-1990 was 580,OOO. The number of skiing days was estimated to be 345,000. Many skiers skied for part of a day. The material consists of 325 patients; 197 (61%) were male (mean age 22 years; range 3-80) and 128 (39%) female (mean age 24 years; range 5-60) (Table 1). The injury rate was 0.94 per loo0 skier- days (0.09Y0) and 0.56 per 10oO skiers (0.06%). Some of the patients (< 5%) with minor injuries went directly to the central hospitals in Tmpere or Jyviiskylii, where they lived.

Thirty-three percent of the patients were youn- ger than 15 years and half of the patients were younger than 20 years.

Downhiu skiing injuries

Table 1. Age and sex distribution in downhill skiing injuries

Age Women Men Total (Years)

( t 4 5 - 9

10-14 15-19 20-29 30-39 40-49 250

0 9

28 28 26 14 19 4

1 17 53 31 41 30 21 3

Seventy-nine percent of the patients answered the questionnaire. The main injury mechanism was falling (84%). Only 11% were collisions and 5% lift accidents. Fifty-four percent of all injuries oc- curred on weekends and half of the injuries be- tween 1200 and 1700 on weekdays.

Forty-one percent of the injuries involved the lower limbs; more than half of these involved the knee (23%). In 37% of the injuries, the upper limbs were involved (thumb, 15%; shoulder, 9%), and in 14% the head and face. The distribution of injuries to the upper and lower extremities was the same in children ( 4 5 years) as in adults; the chil- dren, however, had more head and face injuries

Sprains, the most frequent injuries, accounted for 34% of the total injuries, fractures accounted for 22% and contusions for 17% (Bble 2). The distribution of fractures is shown in Table 3. Of all fractures, 44% were located in an upper extremity and 39% in a lower extremity.

Children ( 4 5 years) sustained 64% (14/22) of the tibia1 fractures, which accounted for 13% (14/108) of all the injuries in children.

In this study, only 7% of all patients needed surgery (Table 4). Most of the injuries treated op- eratively were rupture of the ulnar collateral liga- ment in the metacarpophalangeal joint of the thumb or anterior cruciate + medial collateral liga- ment ruptures of the knee.

(20%).

Table 2. Distribution of injury types

Type of injury n %

Sprain 112 34 Fracture 70 22 Contusion 56 17 Wound 43 13 Dislocation 19 6 Ligament rupture 16 5 Brain concussion 6 2 Meniscus tear 3 1

Table 3. Distribution of fractures

Bone n

Tibia Radius Thumb Tibia + fibula Clavicle Humerus Finger Metacarpal Rib Fibula Malleolus Nose Radius t ulna Navicular Skull Cervical vertebra Metatarsal

15 13 a 7 6 4 3 2 2 2 2 1 1 1 1 1 1

Total 70 (22%)

The average stay in hospital (14.8 d) and sick leave (40 d) were the longest for those with knee injuries (lkble 5). -0-thirds of the total costs were caused by injuries of the knee, shoulder and thumb (Table 5) .

The estimated total costs in the first season amounted to FIM 650,000 (USD 16O,OOO), in the second season FIM 580,000 (USD 140,000) and in the third season FIM 550,000 (USD 140,000) (Ta- ble 6). The costs were lower during the second and third seasons because there were more children among those injured than in the first season. The estimated total costs of these 325 patients amounted to FIM 1.8 million (USD 450,000) and

Table 4. Patients treated surgically

Tvpe of injury n

Rupture Thumb

Knee ulnar collateral ligament MCP

ACL t MCL medial meniscus lateral meniscus ACL MCL PCL

Dislocation of patella Fracture

patella tibia t fibula medial epicondyle of humerus skull finger

6

Total 24 (7% of total injuries)

229

Asikainen et al.

Table 5. Total treatment days in hospital, number of visits at the casualty department or private units, sick leave days and proportion of total costs of patients with knee, thumb or shoulder injuries

Location Number of Treatment Visits in outpatient Sick leave Propottion of of injury patients days in hospal departmentlprivate units davs total costs

(%I

Knee 74 110 120 61 1398 36 Thumb 49 13 64 34 604 13 Shoulder 29 17 55 15 61 7 13

the mean costs per patient were FIM 5500 (USD 1400).

Diswssion The incidence of skiing injuries in the 1960s was about 2-10 per lo00 skier-days (5, 6). The most common injuries were ankle and tibia fractures. With the development of better skiing boots and bindings, the incidence of these injuries has clearly declined. Several studies from the early 1980s re- port 2-4 injuries per lo00 skier-days (4, 7, 8). In recent years the indicence of skiing injuries has declined further (8). In our study there were few skiing injuries (0.94/1000 skiing days or 0.56/1000 skiers), apparently because Finns are skilled and experienced skiers. The skiing slopes are also rela- tively flat and in good condition at this particular skiing area. Some Japanese studies also report a low injury rate (0.1%) (10).

The decline of skiing injuries during recent years is especially accounted for by a decrease in lower limb injuries, whereas the injuries of the upper limbs have relatively increased (3). In the 196Os, for example, a Swedish study reported that injuries of the lower limbs comprised 79% of total injuries and upper limbs 14% (11). In the winter of 1978- 1979, the corresponding values were 47% and 37% (12). Similar change has generally been reported elsewhere (3,7,8,'13). In this study the incidence of injuries was nearly equal in lower limbs and

upper limbs. Similar results were also reported from Australia (7).

Today knee ligament injuries are the most com- mon lower limb injury in downhill skiing, ranging between 20% and 28% (14-16). Injuries of ante- rior cruciate ligament have especially increased in recent years (15). In this study knee injuries were reported to comprise 23% of total injuries (74325). Fourteen of the knee-injury patients needed surgery (4% of all injuries). The relative excess of knee injuries and few tibial fractures may be due to outward rotation and valgus force affect- ing the knee when falling. The increasing rate of anterior cruciate ligament injuries is partly caused by a very high load on the ligament in a deep knee flexion during high compression. Even with mod- em downhill skiing boots and release bindings, this force cannot entirely be prevented and eliminated. Because of improvements in skiing equipment, the number of tibial fractures has decreased' (17). An exception is the group of young downhill skiers (11-15 years). In this group the proportion of tibial fractures has not altered since the 1960s (17). This study reported 22 (7%) tibial fractures Only one patient had surgery. Children sustained most of the tibial fractures (14/22), as children have softer tibia than adults, and children often use inferior and improper skiing equipment (18, 19).

Shoulder and thumb injuries are the most com- mon upper limb injuries in downhill skiing, com- prising 7-1070 of all injuries (3, 4, 7). The most common shoulder injuries are anterior dislocation,

Table 6. Estimated total costs in winter seasons 1987-1988,1988-1989 and 1989-1990

1987-1 988 1988-1989 1989-1990

n RM total n RM total n RM total perunit RM perunit RM perunit RM

Outpatient at health center 152x la'= 20,216 166x la'= 23m 167X 160'= 26,720

Treatment in hospital (days) 76Xt219= 92,644 89 x 1328'~ 118,192 110 X 14983 = 164,780 Sick leave (days) 1671 X N3'= 504,642 1275 X 31#= 400,3!iO 876X 360'= 315,360

Outpatient at hospital 77 X 41Z2 = 31,724 86x # = 38,700 74x 5 4 6 2 = 4oAo4

Total 649226 581,146 547264

'Outpatient fee, health center, Yms8 1987,1988 and 1989. zOutpatiem fee, Finnish Hospital League, 1988,1989 and 1990. 'Cost per treatment day, Finnish Hospital League, 1988,1989 and 1990. 4Calwlated mean wagdday, Central Federation of Finnish Employers, 1988,1989 and 1990.

230

Downhill skiing injuries

References 1. Feagin JA, Lambert KL, Cunningham RR et al. Consid-

eration of the anterior cruciate ligament injury in skiing. Clin Orthop 1987: 216: 13-18.

2. Freeman JR, Weaver JK, Oden RR, Kirk RE. Changing patterns in tibial fractures resulting from skiing. Clin Or- thop 1987: 216: 19-23.

3. Weaver JK. Skiing-related injuries to the shoulder. Clin Orthop 1987: 216 24-28.

4. Derkash RS, Matyas JR, Weaver JK et al. Acute surgical repair of the skier's thumb. Clin Orthop 1987: 216: 29-33.

5. Haddon W Jr, Ellison AE, Carrol RE. Skiing injuries: epidemiologic study. Public Health Rep 1962: 77: 975- 986.

6. Earle A, Monty J, Saviers G, Ball J. Ski injuries. JAMA 1962: 180: 99.

7. Sherry E. Skiing injuries in Australia. Med J Aust 1984: 140: 53G531.

8. Blankenstein A, Salai M, Israeli A, Gauel A, Horoszow- ski H, Farine I. Ski injuries in 1976-1982: Ybrig Region Switzerland. Int J Sport 1985: 6: 298-300.

9. Ekeland A, Holtmoen A, Lystad H. Alpine skiing injuries in Scandinavian skiers. 8th International Symposium on Ski Trauma and Skiing Safety. Riksgriinsen, Sweden, May 15-21, 1989, abstract 1.

10. Kuriyama S, Fujimaki E, Katagin T, Uemura S. Anterior dislocation of the shoulder joint sustained through skiing. Am J Sports Med 1984: 12: 339-346.

11. Westlin NE. Skiskador - orsak, uppkomstmekanism, pro- fylax. martidningen 1986: 83: -962.

12. Lorentzon R, Perssan 0, Bjornstig U. Utforsiikningsska- dor dyra f6r samhiiller. Liikartidningen 1986: 83: 960-%2.

13. Matter P, Ziegler WJ, Holzach P. Skiing accidents in past 15 years. J Sports Sci 1987: 5: 319-326.

14. Johnson RJ, Ettlinger CF. Alpine ski injuries. Changes through the years. Clin Sports Med 1982: 1: 181.

15. Howe J, Johnson RJ. Knee injuries in skiing. Orthop Clin North Am 1985: 16: 303-314.

16. Blitzer CM, Johnson RJ, Ettlinger CF, Aggeborn K. Downhill skiing injuries in children. Am J Sports Med

17. Suckert K, Genelin A, Horbst W. 25 Jahre alpiner Schi- sport. Akt ltaumatoll986: 16: 213-220.

18. Asang E. Injury threshold of the leg: ten years research on safety in skiing. Int Series Sports Sci 1978: 5: 103-129.

19. Lange J, Asang E. Comparison of the shinbone loading capacities of children and adults. Int Series Sports Sci 1978 5: 209-218.

20. Massart P, Bezes H. Severe metacarpophalangeal sprain of the thumb in ski accidents. Ann Chir Main 1984: 3: 101-112.

21. Danielsson K, Eriksson E, Jonsson E, Lind E, Lundqvist S. Attempts to reduce the incidence of skiing injuries in Sweden. In: Johnson RJ, Moten CD Jr, ed. Skiing Trauma and Safety: 5th International Symposium ASTM STP 860. Philadelphia: American Society for Testing and Materials, 1985: 326-337.

1984: 12: 142-144.

rotator cuff ruptures and acromioclavicular sep- arations (3). This study reports an injury rate of 9% in the shoulder and 15% in the thumb. Four percent of the patients had a glenohumeral ante- rior luxation.

The typical thumb injury is rupture of the ulnar collateral ligament of the first metacarpophalan- geal joint. The complete rupture should be treated surgically, as for 6 patients (2%) in this study.

Thus, the incidence of this type of injury corre- sponds to other reports: in the United States, 3% of all downhill skiing injuries (4); in France, 1% of all skiing injuries, of which 88% were downhill skiing injuries (20).

The cost of downhill skiing injuries has not been studied widely. According to Swiss insurance com- panies, skiing injuries comprised 21% of the total cost of sports injuries from 1978 to 1982 (13). Cross-country skiing injuries amounted to 6% of all winter sport injuries (13). The average cost of medical treatment and sick leave per injured downhill skier was CHF 1073 (USD 740) (13). In Sweden the cost per patient in the Umei district from 1978 to 1979 (outpatient fee, cost per treat- ment day and cost of sick leave) was SKK 2900 (USD 480).

The corresponding cost in this study was F'IM 5500 (USD 1400) per patient. The real cost is even higher because the estimate does not include the cost of travel, physiotherapy care and drugs.

More attention should be focused on the correct choice and proper use of skiing equipment and the correct adjustment of downhill ski bindings to min- imize knee injuries in falls. In this study, knee injuries comprised 36% of the total cost of skiing injury. The prevention of thumb injuries should be intensified as well. Children and adolescents should wear a helmet because they have relatively many head and face injuries. More attention should be focused on preventing injuries by in- formation and education and teaching skiers. Par- ticipation in a skiing school should be recom- mended before starting downhill skiing. According to a study in Sweden, the money invested in dis- seminating information on preventing skiing in- juries is returned fivefold as prevention reduces injuries (21).

231