PEDIATRICS Vol. 118 No. 2 August 2006, pp. 549-554 (doi:10.1542/peds.2005-2913)
ARTICLE |
Differences in the Risk Associated With Head Injury for Pediatric Ice Skaters, Roller Skaters, and In-Line Skaters
a Center for Injury Research and Policy, Columbus Children's Research Institute, Children's Hospital, Columbus, Ohio
b Department of Pediatrics, Ohio State University, College of Medicine and Public Health, Columbus, Ohio
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONREFERENCES |
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OBJECTIVE. The goals were to describe the epidemiologic features of pediatric skating-related injuries sustained from 1993 to 2003 and to compare ice skating–related injuries with roller skating–and in-line skating–related injuries.
METHODS. An analysis of pediatric skating-related injury data from the National Electronic Injury Surveillance System of the US Consumer Product Safety Commission was performed.
RESULTS. An estimated 1 235 467 pediatric skating participants presented to hospital emergency departments with injuries between 1993 and 2003. These children had a mean age of 10.9 years (SD: 3.2 years; range: 1–18 years), and 50.0% were male. The most common mechanism of injury was a fall (83.1%). Ice skaters sustained a greater proportion of head injuries (13.3%), compared with roller skaters (4.4%) and in-line skaters (5.0%). Ice skaters also experienced a greater proportion of concussions (4.3%), compared with roller skaters (0.6%) and in-line skaters (0.8%). The proportion of facial injuries among ice skaters was greater than the proportions among roller skaters and in-line skaters. The majority of roller skating–and in-line skating–related injuries were upper-extremity fractures (53.9% and 59.7%, respectively). Children 
6 years of age experienced a greater proportion of head and facial injuries than did older children in each skating activity.
CONCLUSIONS. The epidemiologic features of pediatric ice skating–related injuries differ from those of roller skating–and in-line skating–related injuries. Children should wear helmets during all recreational skating activities, especially ice skating, because of the risk of serious head injuries. Wrist guards should be worn to protect against the common upper-extremity fractures sustained during skating.
Key Words: skating • recreation • pediatric • head injury • helmet
Abbreviations: ED—emergency department • NEISS—National Electronic Injury Surveillance System • CPSC—Consumer Product Safety Commission • RR—relative risk • CI—confidence interval
Although recreational skating can improve the health of children through exercise, participation in skating activities exposes children to a risk of injury. The National Safe Kids Campaign estimated that, from 2001 to 2002, the number of children 5 to14 years of age who were treated in emergency departments (EDs) for ice skating–related injuries increased from 11 100 to 13 700. The number of children treated for roller skating–related injuries remained largely the same, at 
28 400, and the number treated for in-line skating–related injuries declined from 42 800 to 36 300.1
Multiple studies have explored pediatric injuries associated with roller skating and in-line skating2–8 or have compared injuries sustained by participants in these activities.9–11 However, little research has examined the epidemiologic features of pediatric ice skating–related injuries. Studies investigating ice skating–related injuries generally have not focused specifically on pediatric injuries.12,13 The only study that compared ice skating injuries with other skating-related injuries among children was limited to the patient population of one children's hospital ED; that study demonstrated that ice skaters experienced a greater proportion of head injuries than did other types of skaters.14 This study is the first to use a nationally representative sample to describe the epidemiologic features of pediatric skating–related injuries and to compare ice skating–related injuries with roller skating–and in-line skating–related injuries.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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Data were obtained from the National Electronic Injury Surveillance System (NEISS) of the US Consumer Product Safety Commission (CPSC). The NEISS collects data on individuals treated for injuries in a nationally representative, stratified, probability sample of US hospital EDs. The NEISS includes injury data from 100 hospitals, including 8 children's hospitals.15 The NEISS data set, which is updated daily, provides patient demographic information and specific information about the injury and injury event. Statistical weights provided by the CPSC were applied to the NEISS sample data for calculation of national estimates of the number of injuries.
Injuries were included in the analysis if they were identified as ice skating, roller skating, or in-line skating related (NEISS consumer product codes 3255, 3216, and 3297, respectively). Other types of skating activities coded separately by the NEISS, including skating unspecified (product code 3217), ice hockey (product code 1279), roller hockey (product code 5032), and skateboarding (product code 1333), were excluded from this analysis. Nonparticipant victims, such as a child on a bicycle who collided with a roller skater or a child who was dropped by another person who was skating, also were excluded. Only injuries that occurred while the child was participating actively in a skating activity were included in this study. Variables of interest included the child's age and gender, site of injury, injury diagnosis, mechanism of injury, type of skating activity, and use of protective equipment. The 26 sites of injury (ie, body part affected) were categorized into 5 body regions, including head, face, upper extremity, lower extremity, and other. This study was approved by the institutional review board of the Columbus Children's Research Institute.
Data were analyzed with SPSS software, version 13.0 (SPSS, Chicago, IL), and EpiInfo software, version 6 (Centers for Disease Control and Prevention, Atlanta, GA), with adjustment for sample weights and the stratified survey design, as recommended by the CPSC for NEISS data, to yield national injury estimates. National estimates and percentages were calculated for comparisons of body region and type of injury according to skating activity. Statistical analyses included the 
2 test with Yates' correction. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated with weighted data, for assessment of the magnitude and direction of associations. P values of <.05 were considered statistically significant.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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Demographic Characteristics
Nationally, an estimated 1 235 467 children <19 years of age were treated in EDs for skating-related injuries between 1993 and 2003. These children had a mean age of 10.9 years (SD: 3.2 years; range: 1–18 years), and 50.0% were male. More injuries were attributed to in-line skating (48.4%) than roller skating (35.8%) or ice skating (15.7%) (Table 1).
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Overall Injury Epidemiologic Data
Figure 1 shows the trends over time in the number of injuries according to type of skating activity. Ice skating–related injuries ranged from a low of 13 241 in 2003 to a high of 23 287 in 1994. Roller skating–related injuries declined from 61 773 in 1993 to 30 182 in 2003. In-line skating–related injuries increased from 19 941 in 1993 to a peak of 79 749 in 1998, before declining to 32 308 in 2003. Despite the recent decline, more roller skating–and in-line skating–related injuries than ice skating–related injuries were treated in EDs in each year from 1993 to 2003.
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The most common mechanism of injury was a fall (83.1%). Other known mechanisms of injury included collision with an object such as a wall or vehicle (3.3%), collision with another skater (0.8%), and being stepped on or kicked by another person's skate (0.8%). The most common injury diagnoses were fractures (38.1%), sprains/strains (20.5%), contusions/abrasions (19.1%), and lacerations (13.7%) (Table 2). The majority of injuries involved the upper extremities (59.5%) (Table 3). Among upper-extremity injuries, the most common sites were the wrist and lower arm (69.6%). Of the 6.1% of injuries involving the head, the most common injury diagnoses were internal-organ injuries (34.5%), contusions/abrasions (23.1%), and concussions (21.3%). The majority of facial injuries (9.4% of all skating injuries) were lacerations (80.5%) and contusions/abrasions (14.7%). Children
6 years of age experienced a greater proportion of head or facial injuries (31.6%), compared with children >6 years of age (13.9%; RR: 2.27; 95% CI: 2.25–2.29; P < .001). Children 6 years of age also sustained a greater proportion of concussions, compared with children >6 years of age (RR: 1.21; 95% CI: 1.15–1.27; P < .001). Approximately 90% of concussions (89.9%) were related to a fall.
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Although most children (97.5%) were treated and released from the ED, an estimated 22 429 children were admitted to the hospital for treatment of their injuries, and an estimated 50 children died as a result of injuries sustained during participation in a recreational skating activity. Of the 22 429 children who were admitted to the hospital, the most common body regions injured were the upper extremities (61.9%), lower extremities (16.8%), and head (13.3%), and the most common diagnosis was a fracture (80.4%). All of the children who died and more than one half of the children who were admitted to the hospital (59.1%) were injured while in-line skating. Only 1.4% of the injury narratives in the NEISS data set mentioned the absence or presence of protective gear.
Injury According to Type of Skating Activity
Ice Skating
An estimated 194 452 children were injured while ice skating. Lacerations were the most common type of injury experienced during ice skating (35.2%) (Table 2), with 67.7% of lacerations occurring on the face. Other common injuries related to ice skating were fractures (18.1%), sprains/strains (16.4%), and contusions/abrasions (16.2%). More injuries involved the head and face (39.9%) than the upper or lower extremity (Table 3). Nearly 60% percent of children 6 years of age (14 550 of 24 589 children) had injuries involving the head or face, whereas only 37.2% of children >6 years of age (63 148 of 169 863 children) had injuries involving the head or face (RR: 1.59; 95% CI: 1.57–1.61; P < .001).
Roller Skating
An estimated 442 726 children were injured while roller skating. The most common type of injury was a fracture (40.3%) (Table 2), with 70.3% of fractures involving the wrist and lower arm. The majority of roller skating–related injuries involved the upper extremities (64.6%) (Table 3). An estimated 21.9% of children 6 years of age (10770 of 49172 children) sustained injuries of the head or face, compared with 8.0% of children >6 years of age (31 644 of 393 554 children; RR: 2.72; 95% CI: 2.67–2.78; P < .001).
In-Line Skating
In-line skating–related injuries accounted for the largest proportion of skating-related injuries, with an estimated 598 289 children injured. Fractures were the most common type of injury (42.9%) (Table 2), with 72.7% of fractures involving the wrist and lower arm. Like roller-skating-related injuries, the majority of injuries related to in-line skating involved the upper extremities (64.9%) (Table 3). Injuries of the head or face occurred for 25.3% of children 6 years of age (7954 of 31 415 children), whereas only 11.1% of children >6 years of age (62 787 of 566 875 children) sustained injuries of the head or face (RR: 2.29; 95% CI: 2.24–2.33; P < .001).
Group Comparisons
Children who were ice skating experienced a greater proportion of head injuries (13.3%), compared with children who were roller skating (4.4%; RR: 3.05; 95% CI: 3.00–3.11; P < .001) or in-line skating (5.0%; RR: 2.68; 95% CI: 2.64–2.72; P < .001). Ice skaters also experienced a greater proportion of concussions (4.3%) than did roller skaters (0.6%; RR: 5.12; 95% CI: 4.95–5.30; P < .001) and in-line skaters (0.8%; RR: 7.52; 95% CI: 7.20–7.86; P < .001). The proportion of injuries involving the face among ice skaters (26.6%) was greater than that among roller skaters (5.2%; RR: 5.11; 95% CI: 5.04–5.18; P < .001) or in-line skaters (6.8%; RR: 3.89; 95% CI: 3.84–3.94; P < .001). In addition, ice skaters experienced a greater proportion of lacerations (35.2%) than did roller skaters (7.8%; RR: 4.53; 95% CI: 4.47–4.58; P < .001) or in-line skaters (11.2%; RR: 3.15; 95% CI: 3.12–3.18; P < .001).
Conversely, roller skaters (64.6%; RR: 2.08; 95% CI: 2.06–2.09; P < .001) and in-line skaters (64.9%; RR: 2.09; 95% CI: 2.07–2.10; P < .001) sustained greater proportions of injuries involving the upper extremities than did ice skaters (31.1%). Compared with ice skating, roller skating (RR: 2.23; 95% CI: 2.21–2.25; P < .001) and in-line skating (RR: 2.37; 95% CI: 2.35–2.40; P < .001) were associated with greater proportions of fractures.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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This study found important differences in the types of injuries children sustained while ice skating, roller skating, and in-line skating. Although the number of children presenting to US EDs with head injuries related to in-line skating was higher than the number of ice skating–related head injuries, the proportion of head injuries was
3 times greater for pediatric ice skaters than roller skaters and in-line skaters. More specifically, ice skaters experienced a 5 times greater proportion of concussions than did roller skaters and a 7 times greater proportion of concussions than did in-line skaters. Approximately 1 of 4 ice skating–related injuries involved the face, whereas only 1 of 20 roller skating–and in-line skating–related injuries involved the face. Previous studies described skating-related injuries.2–13 However, only one study using data from a single children's hospital ED compared ice skating injuries with other types of skating-related injuries in a strictly pediatric population.14 The results of our study, which is the first to describe and to compare the epidemiologic features of pediatric skating-related injuries with a nationally representative sample, were largely consistent with those of the small previous study. The difference in the body regions injured among ice skaters, compared with roller skaters and in-line skaters, described in this study and the previous study of pediatric skating injuries14 is an interesting finding that deserves additional investigation. Although a fall was the most common mechanism of injury for all 3 types of skating activities, the body regions that were injured differed. Ice skaters sustained a greater proportion of injuries involving the head and face, whereas roller skaters and in-line skaters sustained greater proportions of fractures of the upper extremities, mainly the wrist and lower arm. A recent study of skating-related falls found that most ice skaters, roller skaters, and in-line skaters tended to fall forward and attempted to break the fall with their arms and hands.16 However, because ice is a low-friction surface, ice skaters' attempts to break the fall with their arms and hands were often unsuccessful, resulting in the head or face striking the skating surface. Roller skaters and in-line skaters may break falls successfully with their arms and hands more frequently, thus preventing injuries of the head and face. However, the associated force loading to the upper extremities may be the reason for the increased proportions of arm injuries seen among roller skaters and in-line skaters.
Another interesting finding, consistent with the previous study of pediatric skating injuries,14 is that, in each type of skating activity, children 6 years of age experienced significantly greater proportions of head injuries, compared with older skaters. This may be partly attributable to younger children's higher center of gravity, which causes younger children to fall headfirst. Younger children also have less-developed arm strength and therefore may be unable to catch themselves during a fall. Additional studies are needed to examine skating-related injury differences in body region according to age.
In 1998, the American Academy of Pediatrics issued a recommendation that children and adolescents wear full protective gear, including a helmet, wrist guards, knee pads, and elbow pads, during in-line skating.2 A decrease in injuries related to in-line skating started in 1999 (Fig 1). The trend of decreasing in-line skating–related injuries may reflect more children wearing protective gear and/or the popularity of in-line skating decreasing. Also, as the number of in-line skating–related injuries increased, the number of roller skating–related injuries decreased (Fig 1). This suggests that, as the popularity of in-line skating increased, the popularity of roller skating decreased.
This study has limitations. The NEISS data set has a limited number of variables and has limited narrative comments about injury events. For example, NEISS does not have a variable regarding the use of protective equipment, and the use of protective equipment was documented in the narrative comments for only 1.4% of skating-related injuries collected by NEISS. Furthermore, the injury locale (ie, sidewalk versus outdoor rink) was not reported for almost one half of skating-related injuries. Information about other factors that may influence the risk of injury, such as parental supervision and level of skating experience, is also unavailable in the NEISS data set. In addition, children presenting to EDs may not be representative of all children who are injured during skating-related activities, because less severely injured children may seek other or no medical attention or because care-seeking behaviors may differ among parents on the basis of the child's age, medical insurance coverage, or other social, cultural, or economic factors. In addition, identifying all serious head injuries is challenging because of NEISS coding protocols. For example, if no specific diagnosis is provided for a head injury, then the injury is coded as an internal-organ injury. Despite these limitations, the NEISS data set provides the only nationally representative, stratified, probability sample of pediatric skating injuries in the United States. Although exposure-based risk rates of injury could not be calculated because participant-hours of exposure were unavailable for the skating activities, comparisons of estimated numbers and proportions of injury yielded important information.
On the basis of our findings, we support several safety recommendations for pediatric skating activities.1,2,14,16 Children should wear helmets during all recreational skating activities, especially ice skating, because of the risk of head injuries. However, because of the risk of facial injuries during ice skating, bicycle helmets and multisport helmets, which are typically worn by ice skaters, may not provide the best protection. Even helmets specific to ice skating, such as those required currently in many ice skating rinks in Canada, may not protect adequately the ice skater's face and front of the head from hitting the skating surface. One study recommended that pediatric ice skaters should wear a hockey-style helmet with a facemask for the best protection, although many recreational skaters might be unlikely to do so.16 A new type of protective device now being developed for ice skaters, that is, a wrist guard with a nonslip palm, will need to be tested to determine its effectiveness in preventing head and facial injuries.16
Additional engineering and education strategies aimed at reducing head injuries among ice skaters could include developing a safety skate for younger children to reduce the number of falls, attaching removable padding to the boards around ice skating rinks, and implementing graduated skills-testing programs that require children to demonstrate a certain level of skill before free skating with more advanced skaters. Several studies have found support for the effectiveness of wrist guards in reducing lower-arm injuries.17–19 Wrist guards should be worn by all skaters to help protect against forearm and wrist injuries. Educational interventions to promote the use of protective gear, improved engineering of safety equipment, and mandatory helmet laws should be considered for all types of skating activities.
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ACKNOWLEDGMENTS |
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We thank the US CPSC and the NEISS for providing the data.
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FOOTNOTES |
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Accepted Mar 20, 2006.
Address correspondence to Christy L. Knox, MA, Center for Injury Research and Policy, Columbus Children's Research Institute, Children's Hospital, 700 Children's Dr, Columbus, OH 43205. E-mail: knoxc{at}pediatrics.ohio-state.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
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PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics
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