search text   Advanced Search

This Article Abstract Full Text (PDF) P3Rs: Submit a response Alert me when this article is cited Alert me when P3Rs are posted Alert me if a correction is posted Citation Map Services E-mail this article to a friend Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via CrossRef Citing Articles via ISI Web of Science (6) Citing Articles via Google Scholar Google Scholar Articles by McGeehan, J. Articles by Smith, G. A. Search for Related Content PubMed PubMed Citation Articles by McGeehan, J. Articles by Smith, G. A. Related Collections Office Practice

Children Should Wear Helmets While Ice-Skating: A Comparison of Skating-Related Injuries

Department of Pediatrics, Ohio State University College of Medicine and Public Health, Center for Injury Research and Policy, Columbus Children’s Research Institute, Children’s Hospital, Columbus, Ohio

	ABSTRACT

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
Objective. This study compares injuries, especially head injuries, among ice-skaters with those among skateboarders, rollerskaters, and in-line skaters, to determine the need for helmet use during recreational ice-skating by children.

Design. A comparative study of a consecutive series of patients.

Setting. The emergency department of a large, urban, academic, children’s hospital.

Participants. Children treated for injuries related to recreational ice-skating, skateboarding, rollerskating, and in-line skating.

Results. During a 31-month period, 419 consecutive children were evaluated in the emergency department for skating-related injuries. Children were predominately male (53.9%), with a mean age of 10.0 years (SD: 3.0 years; median: 10.0 years; range: 1–18 years). The most frequent mechanism of injury was a fall. Overall, 76.5% of children (215 of 281 children) were reported to be wearing no protective equipment, such as a helmet or padding on the elbows or knees, at the time of injury. Ice-skaters were more likely to have adult supervision than were skateboarders (relative risk [RR]: 5.16; 95% confidence interval [CI]: 2.13–12.46), rollerskaters (RR: 1.21; 95% CI: 1.09–1.35), and in-line skaters (RR: 2.08; 95% CI: 1.72–2.51). Ice-skaters were at greater risk of injury to the head (20.0%) than were in-line skaters (4.9%) (RR: 4.09; 95% CI: 1.81–9.23); a weak difference was noted between ice-skaters and rollerskaters (9.9%) (RR: 2.18; 95% CI: 1.04–4.57), with no significant difference in head injuries between ice-skaters and skateboarders (15.9%) (RR: 1.60; 95% CI: 0.54–2.93). Ice-skaters demonstrated lacerations to the head in 68.8% of abnormal head examinations, compared with 37.0% for rollerskaters (RR: 1.86; 95% CI: 1.08–3.20) and 50.0% for in-line skaters (RR: 2.06; 95% CI: 1.35–3.16); however, there was no significant difference in lacerations to the head between ice-skaters and skateboarders (53.3%) (RR: 1.29; 95% CI: 0.76–2.19). Injuries to ice-skaters occurred more often in an indoor skating facility (92.9%, 52 of 56 cases), compared with injuries to skateboarders (3.6%, 1 of 28 cases) (RR: 13.96; 95% CI: 2.01–96.76), rollerskaters (63.4%, 59 of 93 cases) (RR: 1.46; 95% CI: 1.23–1.74), and in-line skaters (10.9%, 15 of 137 cases) (RR: 8.48; 95% CI: 5.23–13.75).

Conclusions. The proportion of head injuries among ice-skaters in this study was greater than that observed for participants in other types of skating, for which helmet use is recommended and often required. Children should wear a helmet during recreational ice-skating. Mandatory helmet use by pediatric ice-skaters at indoor rinks should be implemented. Use of other types of protective equipment, such as wrist guards, knee pads, and elbow pads, should be considered for prevention of injuries to the extremities during ice-skating. Caution should be used when allowing young children to participate in recreational ice-skating. Additional research should be conducted in other populations, to corroborate these findings and to evaluate ice-skating safety recommendations for children.

Key Words: skating • injuries • helmet • pediatric • trauma • head injury

Abbreviations: ED, emergency department • RR, relative risk • CI, confidence interval

In 2001, an estimated 56 300 children 5 to 14 years of age were treated in hospital emergency departments (EDs) for injuries related to skateboarding. Rollerskating was associated with 28 400 injuries in 2001, whereas in-line skating injuries totaled 42 800.¹ Most of the injuries were caused by falls, and the majority of injuries involved an upper extremity (specifically, the forearm and wrist).^2–9 The American Academy of Pediatrics released policy statements regarding in-line skating and skateboarding, stipulating that protective gear (helmets, wrist guards, and knee and elbow pads) should be worn during these activities to prevent serious injuries resulting from falls.^2,3

Recreational ice-skating was associated with an estimated 11 100 injuries treated in hospital EDs in 2001.¹ Although ice-skaters experience falls onto hard surfaces, not unlike those that occur among in-line skaters, rollerskaters, and skateboarders, there are currently no formal guidelines or recommendations regarding the use of protective equipment while ice-skating. A study by Freeland¹⁰ recommended that all ice-skaters <16 years of age wear helmets to prevent head injuries. In 2000, Ron Ludington, a member of the World Figure Skating Hall of Fame and director of the Ice Skating Science Development Center, lobbied the International Skating Union to make helmets mandatory for skaters during practice. This action came shortly after Ludington witnessed a fall of one of his skaters that caused a severe brain injury.¹¹ Although there are no data regarding the effectiveness of helmets in ice-skating, helmet use has been shown to prevent up to 74% of severe traumatic brain injuries associated with recreational bicycling.¹²

Little has been reported regarding the epidemiologic features of pediatric injuries associated with recreational ice-skating. Two studies included children in their study populations; however, neither focused specifically on pediatric injuries.^10,13 This study compares injuries, especially head injuries, among ice-skaters with those among skateboarders, rollerskaters, and in-line skaters, to determine the need for helmet use during recreational ice-skating by children.

	METHODS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
Data for this study were obtained from the medical records of a consecutive series of children treated in the ED of a large academic children’s hospital for injuries related to recreational ice-skating, skateboarding, rollerskating, or in-line skating. This hospital is a tertiary care facility and a level 1 pediatric trauma center. Cases were included only if the child was directly involved in skating. For example, children who were hit by skates or run over by a skater but were not personally using skating equipment were excluded from the study. Follow-up information was obtained by contacting the parents of study patients by telephone or mail. Follow-up assessment was completed for 67.1% of patients (281 of 419 patients) (Table 1).

Data were analyzed by using Epi Info software, version 5.01b (Centers for Disease Control and Prevention, Atlanta, GA). Statistical analyses included the ² test with Yates’ correction and the 2-tailed Fisher’s exact test. Results were considered statistically significant for P values of <.05. Relative risks (RRs) and 95% confidence intervals (CIs) were also calculated.

	RESULTS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
Demographic Features and Types of Injuries
A total of 419 consecutive children were evaluated in the ED for skating-related injuries (Table 1). The children were predominately male (53.9%), with a mean age of 10.0 years (SD: 3.0 years; median: 10.0 years; range: 1–18 years). The most frequent mechanism of injury was a fall (91.4%) (Table 2). Six of the 17 injuries (35.3%) sustained through collision with a stationary object were the result of collision with a wall. Other objects included a chair, a mailbox, a stone, and a car bumper. Two of the 3 children hit by a vehicle were hit by a car, and 1 child was struck by a bicycle. Other mechanisms of injury included combinations of colliding with another skater and falling, colliding with a stationary object and falling, falling and being run over by another skater, and striking one’s own foot with a skate blade. Overall, 76.5% of children (215 of 281 children) were reported to be wearing no protective equipment (such as a helmet, wrist guards, or padding on the elbows or knees) at the time of injury. In 79.6% of cases (223 of 280 cases), parents reported being aware of the dangers of the skating activity before the child’s injury. Most children (74.4%, 209 of 281 children) made changes in protective gear use or adopted new safety behaviors after the injury event (Table 3). The most frequent change was to discontinue the skating activity (36.5%, 76 of 208 cases).

Eighty-seven percent of skateboarders (20 of 23 children) reported not using any protective gear. One child reported wearing a helmet only. One child reported wearing some type of padding, and 1 child reported wearing both a helmet and padding. Nineteen percent of children (4 of 21 children) were under adult supervision at the time of the injury. Most skateboarding injuries (92.8%) took place outdoors, on a sidewalk, driveway, or street (Table 5).

Rollerskating
The upper extremity was the most frequently injured body region for rollerskaters evaluated in the ED, accounting for 52% of injuries (68 of 131 cases) (Table 4). Injuries to the forearm were the most common upper-extremity injury (48.5%, 33 of 68 cases). Soft-tissue injuries accounted for 48.1% of rollerskating-related injuries (63 of 131 cases), whereas fractures occurred in 38.2% of cases (50 of 131 cases). Ten children (7.6%) had lacerations, and the remaining 8 children (6.1%) presented with other injuries. Children 6 years of age received injuries to the head and face in 37.5% of cases (9 of 24 cases), compared with 15.9% of cases (17 of 107 cases) among children >6 years of age; however, this difference was not statistically significant (P = .11; RR: 1.99; 95% CI: 0.98–4.05).

Ninety percent of children (71 of 80 children) were reported not to be wearing protective equipment at the time of injury. Only 5.0% (4 of 80 children) reported wearing a helmet, 2.5% (2 of 80 children) reported wearing padding, and 3.8% (3 of 80 children) reported wearing both a helmet and padding. Eighty-one percent of children (72 of 80 children) were reported to be under adult supervision at the time of injury. Rollerskating injuries frequently (63.4%) occurred at an indoor skating facility (Table 5).

In-Line Skating
The majority of in-line skating-related injuries (57.6%, 106 of 184 cases) involved the upper extremities (Table 4). The upper-extremity injuries most commonly involved the forearm (58.1%, 61 of 105 cases). The most common type of injury among in-line skaters was a fracture (45.6%, 84 of 184 cases), followed by soft-tissue injury (34.8%, 64 of 184 cases) and laceration (17.4%, 32 of 184 cases).

Most in-line skating injuries (74.5%, 102 of 137 cases) took place outdoors, on a sidewalk, driveway, or street (Table 5). Eight percent of injuries (11 of 137 cases) took place at other locations, such as a bike path, playground, stairs, or garage. Sixty-seven percent of children (88 of 132 children) reported wearing no protective equipment. Only 13.6% of children (18 of 132 children) reported wearing a helmet and padding, 6.8% (9 of 132 children) reported wearing padding only, and 12.9% (17 of 132 children) reported wearing a helmet only. Forty-seven percent of children (60 of 127 children) were under adult supervision at the time of injury.

Group Comparisons
Ice-skaters were at greater risk of injury to the head (20.0%) than were in-line skaters (4.9%) (P < .001; RR: 4.09; 95% CI: 1.81–9.23); however, a weak difference was noted between ice-skaters and rollerskaters (9.2%) (P = .06; RR: 2.18; 95% CI: 1.04–4.57), with no significant difference in head injuries between ice-skaters and skateboarders (15.9%) (P = .78; RR: 1.60; 95% CI: 0.54–2.93). Ice-skaters demonstrated lacerations to the head in 68.8% of abnormal head examinations, compared with 37.0% for rollerskaters (P = .03; RR: 1.86; 95% CI: 1.08–3.20) and 50.0% for in-line skaters (P = .002; RR: 2.06; 95% CI: 1.35–3.16); however, there was no statistically significant difference in lacerations to the head between ice-skaters and skateboarders (53.3%) (P = .48; RR: 1.29; 95% CI: 0.76–2.19) (Table 6). In-line skaters and rollerskaters were at greater risk for upper-extremity injuries than were skateboarders and ice-skaters (P < .001; RR: 1.98; 95% CI: 1.43–2.74). In-line skating was associated with more fractures, compared with ice-skating (P < .001; RR: 2.49; 95% CI: 1.43–4.35).

	DISCUSSION

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
This study describes injuries related to ice-skating and compares them with injuries associated with skateboarding, rollerskating, and in-line skating. Head injuries are the focus. Several studies have described the epidemiologic features of skating injuries; however, this is the only study, to our knowledge, that incorporates injuries related to ice-skating. Although the mechanisms of injury were similar for all 4 skating activities, the anatomic locations and types of injuries varied. Ice-skaters sustained injury to the head in 20.0% of cases, and the most frequent type of head injury among ice-skaters was a laceration. Injuries to the head were significantly less frequent among skateboarders (15.9%), rollerskaters (9.2%), and in-line skaters (4.9%). The majority of injuries among rollerskaters and in-line skaters were to the upper extremities, especially the forearms. Frequent forearm injuries in these 2 groups are consistent with findings in previous studies.^5,7,8 The large number of forearm injuries among rollerskaters and in-line skaters suggests that these children may be falling in a forward direction and attempting to stop the fall with their arms. Our study results suggest that skateboarders and ice-skaters may fall differently, possibly backward or sideways; this does not allow the children to use their arms to stop their fall and thus causes more injuries to the head and fewer to the upper extremities. Additional studies should be performed to examine the direction in which children fall while using different types of skates.

The proportion of injuries to the head and face among children 6 years of age was greater than that among children >6 years of age for skateboarding, rollerskating, and in-line skating, but this relationship was statistically significant only for skateboarding. This inverse relationship between head and face injuries and age may be attributable to the higher center of gravity of younger children, which causes them to topple headfirst. Also, the arm strength of young children may not be enough to stop a forward fall and prevent them from striking their heads.

The rate of use of protective equipment by children in this study was low. Approximately three-fourths of the study participants reported wearing no protective equipment at the time of injury. In addition, reported use has been demonstrated to overestimate actual protective equipment use.¹⁴ These findings support the need for increased educational efforts and mandatory helmet use laws and local ordinances to increase helmet use and the adoption of other skating safety behaviors.

Some opponents to laws mandating bicycle helmet use claim that such requirements discourage participation in recreational bicycling by individuals who do not want to wear a helmet. Inasmuch as more than one-third of the children in this study discontinued their skating activity after their injury, mandatory helmet use may have the opposite effect on recreational skating. By preventing head injuries, helmet use may promote continued participation in skating.

Almost all ice-skating injuries occurred at an indoor rink, with adult supervision at the time of injury. This provides a contained environment in which prevention strategies can be more readily implemented, monitored, and enforced. Mandatory helmet use by pediatric ice-skaters at indoor rinks should be implemented. Another way to encourage helmet use by children may be to promote helmet use by competitive figure skaters.

The proportion of head injuries among ice-skaters in this study was greater than that observed for other types of skating, for which helmet use is recommended. This supports the recommendation that helmets be worn by children during recreational ice-skating. In 2003, a bill was introduced in the New York State legislature that mandated helmet use while ice-skating for children <14 years of age, with some exceptions for figure skating.¹⁵ It also stipulated that ice-skating facilities require children <14 years of age to wear a helmet and that rental helmets and helmet safety information be made available at these facilities.¹⁵

Caution should be used when allowing young children to participate in recreational ice-skating. The American Academy of Pediatrics recommends that children <5 years of age should not use skateboards, because they may not be developmentally ready, and that children between 6 and 10 years of age should ride only with close supervision.³ Our study findings suggest that these recommendations may apply to ice-skating by children, given the similarity between the injury patterns observed for skateboarders and ice-skaters in our study population.

Limitations of this study include missing data and inconsistent documentation, as typically found in patient medical records. Recall bias or participants’ desire to please the investigators might have affected the information obtained from the parents during follow-up assessments after treatment in the ED. There were different response rates among the skating activities, which might be an additional source of bias. Children who are examined in the ED of our pediatric tertiary care hospital might not be representative of children who are treated for skating-related injuries at other health care facilities or children who do not seek medical attention.

Additional research should be conducted in other populations, to corroborate our findings and evaluate the evidence regarding our recommendations. A prospective case-control study should be considered, to evaluate the effectiveness of helmets in reducing head injuries among children participating in recreational ice-skating.

	CONCLUSIONS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
The proportion of head injuries among ice-skaters in this study was greater than that observed among participants in other types of skating, for which helmet use is recommended and often required. Children should wear helmets during recreational ice-skating. Mandatory helmet use by pediatric ice-skaters at indoor rinks should be implemented. The use of other types of protective equipment, such as wrist guards, knee pads, and elbow pads, should also be considered for prevention of injuries to the extremities during ice-skating. Caution should be used when allowing young children to participate in recreational ice-skating. Additional research, including a prospective case-control study, should be conducted in other populations, to corroborate these findings and evaluate ice-skating safety recommendations for children.

	FOOTNOTES

 
Received for publication Aug 11, 2003; Accepted Jan 9, 2004.

Reprint requests to (J.M.) Center for Injury Research and Policy, Columbus Children’s Research Institute, Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205-2664. E-mail: CIRPinformation{at}chi.osu.edu

	REFERENCES

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 

1. National Safe Kids Campaign. Fact Sheet: Recreational Injury. Washington, DC: National Safe Kids Campaign; 2003. Available at: www.safekids.org/tier3_printable.cfm?content_item_id=9530&frolder_id=540. Accessed January 5, 2004
2. American Academy of Pediatrics, Committee on Injury, Violence and Poison Prevention. In-line skating injuries in children and adolescents. Pediatrics. 1998;101 :720 –722[Abstract/Free Full Text]
3. American Academy of Pediatrics, Committee on Injury and Poison Prevention. Skateboard and scooter injuries. Pediatrics. 2002;109 :542 –543[Abstract/Free Full Text]
4. Forsman L, Eriksson A. Skateboarding injuries of today. Br J Sports Med. 2001;35 :325 –328[Abstract/Free Full Text]
5. Houshian H, Anderson HM. Comparison between in-line and rollerskating injury. Scand J Med Sci Sports. 2000;10 :47 –50[Medline]
6. Schieber RA, Branche-Dorsey CM, Ryan GW, Rutherford GW, Stevens JA, O’Neil J. Risk factors for injuries from in-line skating and the effectiveness of safety gear. N Engl J Med. 1996;335 :1630 –1635[Abstract/Free Full Text]
7. O’Farrell DA, Ridha HM, Keenan P, McManus FW, Stephens M. An epidemic of rollerblade injuries in children. Injury. 1997;28 :377 –379[CrossRef][ISI][Medline]
8. Schieber RA, Branche-Dorsey CM, Ryan GW. Comparison of in-line skating injuries with rollerskating and skateboarding injuries. JAMA. 1994;271 :1856 –1858[Abstract]
9. Frankovich RJ, Petrella RJ, Lattanzio CN. In-line skating injuries: patterns and protective equipment use. Physician Sportsmed. 2001;29(4) . Available at: www.physsportsmed.com/issues/2001/04_01/frankovichhtm. Accessed January 5, 2004
10. Freeland P. Implications of two newly opened ice rinks on an accident and emergency department. BMJ. 1988;296 :96
11. Thomas B. UD coach initiates drive for helmets for ice skaters. UpDate. 2000;19 (20). Available at: www.udel.edu/PR/UpDate/00/20/ud1.html. Accessed January 5, 2004
12. Thompson DC, Rivara FP, Thompson RS. Effectiveness of bicycle safety helmets in preventing head injuries: a case-control study. JAMA. 1996;276 :1968 –1973[Abstract]
13. Lam CK, Leung WY, Wu WC, Lam J, Ip FK. Orthopaedic ice-skating injuries in a regional hospital in Hong Kong. Hong Kong Med J. 1997;3 :131 –134[Medline]
14. Ni H, Sacks JJ, Curtis L, Cieslak PR, Hedberg K. Evaluation of a statewide bicycle helmet law via multiple measures of helmet use. Arch Pediatr Adolesc Med. 1997;151 :59 –65[Abstract]
15. New York Assembly. New York Assembly Bill 7087, 2003-2004 regular sessions. 2003.

This article has been cited by other articles:

				S. Singh, G. A. Smith, S. K. Fields, and L. B. McKenzie Gymnastics-related Injuries to Children Treated in Emergency Departments in the United States, 1990-2005 Pediatrics, April 1, 2008; 121(4): e954 - e960. [Abstract] [Full Text] [PDF]

				C. F. Lauro, R. Goldbach-Mansky, M. Schmidt, and Z. M. N. Quezado The Anesthetic Management of Children with Neonatal-Onset Multi-System Inflammatory Disease Anesth. Analg., August 1, 2007; 105(2): 351 - 357. [Abstract] [Full Text] [PDF]

				C. L. Knox, R. D. Comstock, J. McGeehan, and G. A. Smith Differences in the Risk Associated With Head Injury for Pediatric Ice Skaters, Roller Skaters, and In-Line Skaters Pediatrics, August 1, 2006; 118(2): 549 - 554. [Abstract] [Full Text] [PDF]

				B. J. Shields and G. A. Smith Cheerleading-Related Injuries to Children 5 to 18 Years of Age: United States, 1990-2002 Pediatrics, January 1, 2006; 117(1): 122 - 129. [Abstract] [Full Text] [PDF]

				All Skaters Need Protective Equipment -- Even Those on Ice Journal Watch Pediatrics and Adolescent Medicine, September 13, 2004; 2004(913): 8 - 8. [Full Text]

This Article Abstract Full Text (PDF) P3Rs: Submit a response Alert me when this article is cited Alert me when P3Rs are posted Alert me if a correction is posted Citation Map Services E-mail this article to a friend Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via CrossRef Citing Articles via ISI Web of Science (6) Citing Articles via Google Scholar Google Scholar Articles by McGeehan, J. Articles by Smith, G. A. Search for Related Content PubMed PubMed Citation Articles by McGeehan, J. Articles by Smith, G. A. Related Collections Office Practice

	Home | My Pediatrics | Journal Information | Current Issue | Past Issues | Subscriptions & Services | Contact Us Click here for faster international access © 2004 American Academy of Pediatrics. All rights reserved.