Geriatric Skiers: Active But Still at Risk, a National Trauma Data Bank Study.

BACKGROUND: Downhill skiing accounts for a large portion of geriatric sport-related trauma. We assessed the national burden of geriatric versus nongeriatric ski trauma. MATERIALS AND METHODS: Adults presenting to level 1/2 trauma centers after ski-associated injuries from 2011 to 2015 were identified from the National Trauma Data Bank by ICD-9 code. We compared demographics, injury patterns, and outcomes between geriatric (age ≥65 y) and nongeriatric adult skiers (age 18-64 y). A multiple regression analysis assessed for risk factors associated with severe injury (Injury Severity Score >15). RESULTS: We identified 3255 adult ski trauma patients, and 16.7% (543) were geriatric. Mean ages for nongeriatric versus geriatric skiers were 40.8 and 72.1 y, respectively. Geriatric skiers more often suffered head (36.7 versus 24.3%, P < 0.0001), severe head (abbreviated injury scale score >3, 49.0 versus 31.5%, P < 0.0001) and thorax injuries (22.2 versus 18.1%, P = 0.03) as compared with nongeriatric skiers. Geriatric skiers were also more often admitted to the ICU (26.5 versus 14.9%, P < 0.0001), discharged to a facility (26.7 versus 11.6%, P < 0.0001), and suffered higher mortality rates (1.3 versus 0.4%, P = 0.004). Independent risk factors for severe injury included being male (OR: 1.68, CI: 1.22-2.31), helmeted (OR: 1.41, CI: 1.07-1.85), and having comorbidities (OR: 1.37, CI: 1.05-1.80). Geriatric age was not independently associated with severe injury. CONCLUSIONS: At level 1/2 trauma centers, geriatric age in ski trauma victims was associated with unique injury patterns, higher acuity, increased rates of facility care at discharge, and higher mortality as compared with nongeriatric skiers. Our findings indicate the need for specialized care after high impact geriatric ski trauma.

Snowboarders' Knowledge of the FIS Rules for Conduct on Ski Slopes.

The objective of the present study is to assess snowboarders' general perceptions of safety and knowledge of existing rules and both active and passive knowledge of the International Ski Federation (FIS) regulations in order to contribute to defining target groups for specific educational interventions in the field of injury prevention. Data were drawn from random interviews conducted with 918 snowboarders during the 2017-2018 winter season at five ski resorts located in the Spanish Pyrenees. To collect the data, a questionnaire assessing personal characteristics (gender, age, origin, and self-reported skill), general perception of safety, general request for rules, and knowledge of existing rules was used. Pearson's Chi-squared tests were performed to compare characteristics between groups. The study revealed, for accident prevention purposes, a concerning lack of general knowledge of existing rules. Risk-inducing situations that could result in severe injuries were largely assessed incorrectly. The appropriate intuitive behavior increases with age and experience: youths and beginners are less able to implement the FIS rules than older and more experienced snowboarders. Stakeholders, such as parents, ski resorts, clubs or schools, should direct educational efforts at high-risk groups. Further research is needed to determine the causal relation between snowboard-related injuries and disregard of FIS rules.

Motives for sports participation as predictions of self-reported outcomes after anterior cruciate ligament injury of the knee.

Aim of the study was to access how individual's motives for participation in sports impact on self-reported outcomes 2 years after an anterior cruciate ligament injury. Based on a longitudinal cohort study, this secondary analysis present data from the Knee Anterior Cruciate Ligament, Nonsurgical versus Surgical Treatment (KANON) study, a randomized controlled trial. At baseline, 121 patients recorded in an initial questionnaire that their motives for sports participation fell into four categories: achievement, health, social integration, or fun and well-being. These four categories were used as variables in the analyses. All 121 subjects completed the 2-year follow-up. The largest improvement was seen in the Knee Injury and Osteoarthritis Outcome Score (KOOS) subscale sports and recreation function, with an effect size of 2.43. KOOS sports and recreation function was also the subscale score best predicted by the motives for sports participation. Baseline motives achievement and fun and well-being predicted worse levels of pain and function 2 years after the injury, even after adjusting for age, gender, treatment and baseline scores. Psychological aspects, such as motives for participation in sport, can be factors in predicting of patient-reported outcomes 2 years after injury. Evaluating motives for sports participation may help predict the outcome 2 years after ACL injury.

Safety assessment of jumps in ski racing.

The influence of important parameters on the flight trajectory for jumps in downhill World Cup races was investigated. To quantify the impact injury risk at landing, the parameter equivalent landing height (ELH) was introduced, which considered a variable slope inclination during the landing movement. Altogether, 145 runs at four different jumps in World Cup races and trainings were recorded and analyzed. A simulation model was developed to predict the flight phase of the skier. Drag and lift areas were selected by parameter identification to fit the simulation trajectory to the two-dimensional data from the video analysis. The maximum values of the ELH which can be absorbed with muscle force was taken from the study of Minetti et al. for elite female and male ski racers. A sensitivity analysis based on the four jumps showed that ELH is mainly influenced by takeoff angle, takeoff speed, and the steepness of the landing surface. With the help of the developed simulation software, it should be possible to predict the ELH for jumps in advance. In case of an excessive ELH, improvements can be made by changing the takeoff inclination or the approach speed.

Editorial. Bicycle injuries and injury prevention.

In 1989, long before this journal added injuries to its title, it published two papers on childhood injuries and I was asked to write an editorial for this occasion. I chose the title "Challenges for Injury Prevention: Two Neglected Aspects" because I thought the papers neglected to mention the inadequacy of injury statistics (at the time there were no emergency department data) and also failed to emphasize the public health importance of childhood injuries. It is instructive, therefore, to compare this issue's offerings with how matters stood nearly 25 years ago and see what progress we've made. Papers in this and the previous issue of this journal discuss bicycle safety in general and helmet use in particular. Although this is a somewhat narrow focus, it serves as one indicator of how the field has evolved and what remains to be done to improve both the science and policy in this domain.

TITRE: Éditorial -- Traumatismes subis par les cyclistes et prévention des traumatismes. INTRODUCTION: En 1989, cette revue, bien avant que le terme « blessures ¼ ne soit ajouté à son titre, publiait deux articles sur les traumatismes chez les enfants, et on m'avait demandé à cette occasion de rédiger un éditorial. J'avais alors choisi le titre « Deux aspects négligés de la prévention des traumatismes ¼, car j'avais l'impression qu'on omettait de souligner que les statistiques sur les traumatismes étaient insuffisantes (il n'y avait pas de données des services des urgences à l'époque) et qu'on ne mettait pas assez l'accent sur l'importance pour la santé publique des traumatismes chez les enfants. Par conséquent, il est intéressant de comparer les statistiques d'aujourd'hui avec celles d'il y a 25 ans et de constater les progrès accomplis. Certains articles de ce numéro et du numéro précédent portent sur la sécurité des cyclistes en général et sur le port du casque en particulier. Bien qu'il s'agisse d'un objet quelque peu restreint, il peut servir d'indicateur sur la manière dont ce champ a évolué et sur ce qui reste à faire pour améliorer la recherche et la politique en la matière.

Injury prevention for ski-area employees: a physiological assessment of lift operators, instructors, and patrollers.

BACKGROUND: Momentary lapses in concentration contribute to workplace accidents. Given that blood glucose (BG) and hydration levels have been shown to affect vigilance, this study proposed to investigate these parameters and functional movement patterns of ski-resort workers and to determine whether an educational program to stabilize BG and hydration and encourage joint stability had an effect in decreasing occupational injuries. METHODS: Seventy-five instructors, patrollers and, lift-operators at five snowsport resorts were evaluated for BG, vigilance, workload, dietary/hydration practices, and functional-movement patterns. Injury rates were tabulated before and after an educational program for nutrition and functional-movement awareness and compared to other resorts. RESULTS: Workers showed poor stability at the lumbar spine, knee, and shoulder. BG levels were normal but variable (%CV = 14 ± 6). Diets were high in sugar and fat and low in water and many nutrients. Medical Aid and Lost Time claims declined significantly by 65.1 ± 20.0% (confidence interval -90.0% ≤ µ ≤ -40.2%) in resorts that used the educational program whereas four control resorts not using the program experienced increases of 33.4 ± 42.9% (confidence interval -19.7% ≤ µ ≤ -86.7%; F[2,12] = 21.35, P < 0.0001 ) over the same season. CONCLUSION: Provision of snowsport resort workers with educational programs encouraging hydration, diet to stabilize BG, and functional-movement awareness was effective in reducing worksite injuries in this population.

Paralympic medical services for the 2010 paralympic winter games.

OBJECTIVE: To present the planning and medical encounters for the 2010 Paralympic Winter Games. DESIGN: Prospective medical encounter study. SETTING: 2010 Paralympic Winter Games. PARTICIPANTS: Athletes, coaches, officials, workforce, volunteers, and media. ASSESSMENT OF RISK FACTORS: Sport type: alpine, Nordic, and sledge hockey and curling. Participant type: athlete, workforce, and spectators. Terrain and speed. MAIN OUTCOME MEASURES: Medical encounters entered in database at competitive (alpine skiing, biathlon, cross-country skiing, sledge hockey, and curling) and noncompetitive (Whistler and Vancouver Polyclinics, presentation centers, opening and closing ceremonies, media center, Paralympic Family Hotel) venues. RESULTS: Forty-two nations participated with 1350 Paralympic athletes, coaches, and officials. There were 2590 accredited medical encounters (657 athletes, 25.4%; 682 International Federation/National Paralympic Committee officials, 26.3%; 57 IPC, 2.2%; 8 media, 0.3%; 1075 workforce, 41.5%; 111 others, 4.3%) and 127 spectator encounters for a total of 2717 encounters. During the preopening period medical services saw 201 accredited personnel. The busiest venues during the Paralympic Games were the Whistler (1633 encounters) and Vancouver (748 encounters) Polyclinics. Alpine, sledge hockey, and curling were the busiest competitive venues. The majority of medical encounters were musculoskeletal (44.6%, n = 1156). Medical services recorded 1657 therapy treatments, 977 pharmaceutical prescriptions dispensed, 204 dental treatments, 353 imaging examinations (more than 50% from alpine skiing), and 390 laboratory tests. There were 24 ambulance transfers with 7 inpatient hospitalizations for a total of 24 inpatient days and 4 outpatient visits. CONCLUSIONS: The mandate to have minimal impact on the health services of Vancouver and the Olympic Corridor while offering excellent medical services to the Games was accomplished. This data will be valuable to future organizing committees.

Spinal injury patterns among skiers and snowboarders.

OBJECT: Skiing and snowboarding injuries have increased with the popularity of these sports. Spinal cord injuries (SCIs) are a rare but serious event, and a major cause of morbidity and mortality for skiers and snowboarders. The purpose of this study is to characterize the patterns of SCI in skiers and snowboarders. METHODS: The authors queried the Nationwide Inpatient Sample for the years 2000-2008 for all patients admitted with skiing or snowboarding as the mechanism of injury, yielding a total of 8634 patients. The injury patterns were characterized by the ICD-9 diagnostic and procedure codes. The codes were searched for those pertaining to vertebral and skull fracture; spinal cord, chest, abdominal, pelvic, and vessel injuries; and fractures and dislocations of the upper and lower extremity. Statistical analysis was performed with ANOVA and Student t-test. RESULTS: Patients were predominantly male (71%) skiers (61%), with the average age of the skiers being older than that of snowboarders (39.5 vs 23.5 years). The average length of stay for patients suffering from spine trauma was 3.8 days and was increased to 8.9 days in those with SCI. Among hospitalized patients, SCI was seen in 0.98% of individuals and was equally likely to occur in snowboarders and skiers (1.07% vs 0.93%, p < 0.509). Cervical spine trauma was associated with the highest likelihood of SCI (19.6% vs. 10.9% of thoracic and 6% of lumbar injuries, p < 0.0001). Patients who were injured skiing were more likely to sustain a cervical spine injury, whereas those injured snowboarding had higher frequencies of injury to the lumbar spine. The most common injury seen in tandem with spine injury was closed head injury, and it was seen in 13.4% of patients. Conversely, a spine injury was seen in 12.9% of patients with a head injury. Isolated spine fractures were seen in 4.6% of patients. CONCLUSIONS: Skiers and snowboarders evaluated at the hospital are equally likely to sustain spine injuries. Additionally, participants in both sports have an increased incidence of SCI with cervical spine trauma.

Serious ski and snowboard injuries in southern New Zealand requiring acute orthopaedic admission and treatment during winter 2009.

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.

Risk assessment in winter backcountry travel.

OBJECTIVE: Risk assessment is an important part of safe backcountry travel in avalanche terrain. The purpose of this study was to determine and compare the ability of backcountry travelers to accurately estimate the avalanche danger for their destination and time of travel. METHODS: We surveyed 353 winter backcountry users, asking them to rate the avalanche danger for their destination that day. We then compared this estimation to the Utah Avalanche Center daily advisory for that specific location, aspect, and elevation. Tendency to underestimate the avalanche danger was then compared across 6 different sports (backcountry skiing, backcountry snowboarding, snowshoeing, snowmobiling, out-of-bounds skiing, and out-of-bounds snowboarding) as well as across age, gender, and subject participation in an avalanche safety course. RESULTS: A comparison across different sports, adjusted for age and gender, showed that snowshoers were 7.11 times more likely than skiers to underestimate the avalanche danger (95% CI, 2.95, 17.11). This difference was maintained after adjusting for past education in an avalanche safety course (odds ratio, 5.74; 95% CI, 2.28, 14.46). Snowmobilers were also significantly more likely to underestimate the avalanche danger when compared to skiers (odds ratio, 3.11; 95% CI, 1.12, 8.24), but these differences ceased to be significant when the data were adjusted for avalanche safety course (odds ratio, 2.39; 95% CI, 0.84, 6.74). While there was a trend for women and older age groups to underestimate the avalanche danger when compared to men, these trends were not significant. CONCLUSIONS: Snowshoers and snowmobilers are groups that tend to underestimate avalanche danger when traveling in the backcountry. These groups may be unknowingly assuming a higher risk and should be targeted for avalanche education and awareness.

Helmets for skiers and snowboarders: an injury prevention program.

The authors' Level I trauma center has advocated the use of ski helmets for several years and in 1998, undertook a social-marketing campaign and a helmet loaner program to increase helmet use among skiers and snowboarders. The loaner program's effect on helmet acceptance was measured by comparing helmet acceptance in participating rental stores with acceptance in nonparticipating stores during 3 years. For the 1998-1999 season, 13.8% of renters in the participating stores accepted a helmet compared to 1.38% in the nonparticipating stores (p < .01); for 2000-2001, 33.5% to 3.93% (p < .01); and for 2001-2002, 30.3% to 4.48% (p < .01). The authors believe that efforts to increase helmet use--by increasing education and public awareness and decreasing barriers, such as through helmet loaner programs or routinely including helmets in rental packages--have significant potential to decrease the incidence and severity of brain injuries from skiing and/or snowboarding accidents in Colorado.

Seasonal variation in orthopedic health services utilization in Switzerland: the impact of winter sport tourism.

BACKGROUND: Climate- or holiday-related seasonality in hospital admission rates is well known for many diseases. However, little research has addressed the impact of tourism on seasonality in admission rates. We therefore investigated the influence of tourism on emergency admission rates in Switzerland, where winter and summer leisure sport activities in large mountain regions can generate orthopedic injuries. METHODS: Using small area analysis, orthopedic hospital service areas (HSAo) were evaluated for seasonality in emergency admission rates. Winter sport areas were defined using guest bed accommodation rate patterns of guest houses and hotels located above 1000 meters altitude that show clear winter and summer peak seasons. Emergency admissions (years 2000-2002, n = 135'460) of local and nonlocal HSAo residents were evaluated. HSAo were grouped according to their area type (regular or winter sport area) and monthly analyses of admission rates were performed. RESULTS: Of HSAo within the defined winter sport areas 70.8% show a seasonal, summer-winter peak hospital admission rate pattern and only 1 HSAo outside the defined winter sport areas shows such a pattern. Seasonal hospital admission rates in HSAo in winter sport areas can be up to 4 times higher in winter than the intermediate seasons, and they are almost entirely due to admissions of nonlocal residents. These nonlocal residents are in general -and especially in winter- younger than local residents, and nonlocal residents have a shorter length of stay in winter sport than in regular areas. The overall geographic distribution of nonlocal residents admitted for emergencies shows highest rates during the winter as well as the summer in the winter sport areas. CONCLUSION: Small area analysis using orthopedic hospital service areas is a reliable method for the evaluation of seasonality in hospital admission rates. In Switzerland, HSAo defined as winter sport areas show a clear seasonal fluctuation in admission rates of only nonlocal residents, whereas HSAo defined as regular, non-winter sport areas do not show such seasonality. We conclude that leisure sport, and especially ski/snowboard tourism demands great flexibility in hospital beds, staff and resource planning in these areas.

Injuries to New Zealanders participating in adventure tourism and adventure sports: an analysis of Accident Compensation Corporation (ACC) claims.

AIMS: The aim of this study was to examine the involvement of adventure tourism and adventure sports activity in injury claims made to the Accident Compensation Corporation (ACC). METHODS: Epidemiological analysis of ACC claims for the period, July 2004 to June 2005, where adventure activities were involved in the injury. RESULTS: 18,697 adventure tourism and adventure sports injury claims were identified from the data, representing 28 activity sectors. Injuries were most common during the summer months, and were most frequently located in the major population centres. The majority of injuries were incurred by claimants in the 20-50 years age groups, although claimants over 50 years of age had highest claims costs. Males incurred 60% of all claims. Four activities (horse riding, mountain biking, tramping/hiking, and surfing) were responsible for approximately 60% of all adventure tourism and adventure sports-related injuries. Slips, trips, and falls were the most common injury initiating events, and injuries were most often to the back/spine, shoulder, and knee. CONCLUSIONS: These findings suggest the need to investigate whether regulatory intervention in the form of codes of practice for high injury count activities such as horse riding and mountain biking may be necessary. Health promotion messages and education programs should focus on these and other high-injury risk areas. Improved risk management practices are required for commercial adventure tourism and adventure sports operators in New Zealand if safety is to be improved across this sector.

Non-resident orthopaedic admissions to Dunedin Hospital, New Zealand: 1997 to 2004.

AIMS: The purpose of this study is to audit the numbers of non-residents requiring orthopaedic admission to our hospital and determine the effect of increasing tourist numbers and changes in Accident ACC regulations on healthcare resources. METHODS: Details of non-resident orthopaedic admissions for fiscal years 1997/8 to 2003/4 were analysed with respect to country of residence, mechanism of injury, case weights consumed, and actual costs. RESULTS: There has been no change in numbers of admissions or cost, averaging 32 cases (50 case weights [CWs]) per year. Most patients came from Asia (59 cases; 26%), then Australia (52 cases; 23%) and UK (40 cases; 18%). Snowsports accounted for 40% of admissions, Motor vehicle accidents (MVA) for 17%, and falls for 29%. Non-resident, non-MVA admissions have averaged 21 CWs per year since the changes in ACC regulations in 1999. DISCUSSION: Despite increasing tourist numbers, there has been no increase in numbers or CW of non-residents requiring orthopaedic admission. Although representing only a small proportion of the orthopaedic budget, they generate many hidden costs. The 50 CWs annually equates to approximately 13 major joint replacements per year. The increase in CWs consumed due to the ACC changes have had no corresponding increase in contracted orthopaedic volumes.

Prevalence of low back pain in alpine ski instructors.

STUDY DESIGN: Mailed survey to random sample of a specific population. OBJECTIVES: To examine the lifetime and point prevalence of low back pain among alpine ski instructors. BACKGROUND: The lifetime prevalence for back pain is up to 60% among some athletes. Published literature documents back pain among athletes participating in many sports. However, the prevalence of low back pain among alpine ski instructors has not been established. METHODS AND MEASURES: Surveys were mailed to 500 randomly selected members of the Professional Ski Instructors of America. The lifetime and point prevalence were determined by respondents' report regarding history of low back pain and current back pain. RESULTS: Two hundred four (75% of the 272 respondents) reported a history of low back pain. Eighty-five of those who responded (31%) reported current back pain. Over 9% of respondents missed 10 or more days of work because of back pain. CONCLUSIONS: The lifetime prevalence of back pain among respondents was similar to the general population. The respondents reported more lifetime prevalence of back pain than athletes of many other sports. The high prevalence of back pain among ski instructors may increase cost and decrease revenue for the employer. Prevention training in this population may decrease the prevalence of back pain and lessen costs to the employer and the alpine ski instructor.

Snowdome, skiers and boarders: accident and emergency experience.

A prospective case series was compiled of all people presenting to the accident and emergency department with an injury caused by snowboarding or skiing, during the first year of opening of the Milton Keynes snowdome. The aim was to analyse the types of injuries associated with recreational snowboarding and to compare these with the injuries seen in skiing. Of the snowboarders, 23 (86%) were males, and the mean age was 24 years. Of the skiers, 13 (81%) were males, and the mean age was 34 years. Forty-three injuries required orthopaedic review, and 12 were admitted for further management. Significant differences were noted between the patterns of injuries in snowboarding and skiing. The snowboarders had a higher incidence of upper limb injuries (96 vs. 62%) and a lower incidence of lower limb injuries (4 vs. 38%) compared to the skiers. This study demonstrates that the opening of a leisure facility has a significant impact on the local accident and emergency department. Snowboarding is associated with a unique pattern of injuries, the knowledge of which should influence education and accident prevention.

Skiing and snowboarding injuries and their impact on the emergency care system in South Tyrol: a restrospective analysis for the winter season 2001--2002.

OBJECTIVES: To evaluate the incidence and the pattern of skiing and snowboarding injuries in South Tyrol and their impact on the emergency medical system in the winter season 2001--2002 in an attempt to rationalize and improve the emergency care and assist in prevention strategies. METHODS: All medical records of patients referred to our emergency department (ED) that sustained a skiing or snow-boarding injury during the study period were retrospectively reviewed. Age, sex, local or non-local residency, type of injury, data and time of accident, type of transport to the hospital, hospital admission or ED discharge, Injury Severity Score, outcome (including mortality) were evaluated. On site mortality data were obtained from the emergency call-center registry. Ski resorts utilization was estimated from the data published by the Regional Office of Cable Transport. RESULTS: For the period analyzed approximately 2,500,000 skier and snowboarder days were recorded in the whole region of which about 500,000 were attributed to the four nearby ski resorts that refer to our hospital. Of the 1087 patients, 794 were skiers and 294 were snowboarders. Snow-boarders were younger than skiers (mean age 20 and 36 respectively, p = 0.001). Females were equally represented in the two groups. Male patients, children, senior skiers and non-local residents suffered from more severe injuries than their corresponding classes (p < 0.01, p = 0.002, p = 0.02, p = 0.000 respectively). Critical injuries (ISS > or = 25) were homogeneously spread in the groups, with the exception of the non-local resident patients that showed a higher incidence (p < 0.02). No difference in severity was found between skiers and snowboarders. The incidence was 2.05 per 1,000 skier-days. Mortality rate was 1.6 per 1,000,000 skier-days. The pattern of injury was different: snowboarders showed more forearm and wrist trauma and skiers more lower extremity injuries. 208 patients were hospitalized and the mean length of stay was 4.5 days. Head trauma and fractures were the most common diagnosis of admission. The lack of field triage led to 12% of unjustified helicopter transfer and 9.6% of avoidable ambulance transport. CONCLUSIONS: Incidence, pattern of injuries and mortality from skiing and snowboarding accidents in South Tyrol resemble those reported in other part of the world. Nevertheless, strategies for prevention are needed. The routine use of helmets should be enforced by law. Dangerous behaviors should be prosecuted. Skiers and snowboarders should be made aware that skiing beyond their technical ability can be life-threatening.