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New Study Finds Helmet Use in Children Reduces Skull Fractures in Skiing/Boarding

Author(s): Rick Curtis
Posted: February 21, 2011

The helmet debate in winter sports has raged on for a long time with some people claiming that wearing a helmet increases accidents because people feel safer with a helmet and therefore ski faster, what’s often referred to as risk homeostasis. While there is some data from other industries that suggest that this can be a factor (for example that people wearing seat belts drive faster than those who don’t)  I’ve never seen any data to support applying that same conclusion to wearing helmets on the slopes. In fact a 2003 study Testing the risk compensation hypothesis for safety helmets in alpine skiing and snowboarding, found that people who wore helmets found that they skied slower than those who did not.

There is a new study out that sidesteps the risk homeostasis argument with data on actual ski injuries in children wearing helmets.

The findings are reported in the March 2011 issue of the Journal of Neurosurgery: Pediatrics in the article Helmet Use and Reduction in Skull Fractures in Skiers and Snowboarders Admitted to the Hospital by Anand I. Rughani, MD, Chih Lin, MD, Michael A. Horgan, MD, Bruce I. Tranmer, MD, Ryan P. Jewell, MD (Division of Neurosurgery, University of Vermont, Burlington, Vt.); William J. Ares, BS (College of Medicine, University of Vermont, Burlington, Vt.); Deborah A. Cushing, MPH, and Jeffrey E. Florman, MD (Neurosciences Institute, Maine Medical Center, Portland, Maine).


Helmet use has been associated with fewer hospital visits among injured skiers and snowboarders, but there remains no evidence that helmets alter the intracranial injury patterns. The authors hypothesized that helmet use among skiers and snowboarders reduces the incidence of head injury as defined by findings on head CT scans.


The authors performed a retrospective review of head-injured skiers and snowboarders at 2 Level I trauma centers in New England over a 6-year period. The primary outcome of interest was intracranial injury evident on CT scans. Secondary outcomes included the following: need for a neurosurgical procedure, presence of spine injury, need for ICU admission, length of stay, discharge


Of the 57 children identified who sustained a head injury while skiing or snowboarding, 33.3% were wearing a helmet at the time of injury. Of the helmeted patients, 5.3% sustained a calvarial fracture compared with 36.8% of the unhelmeted patients (p = 0.009). Although there was a favorable trend, there was no significant difference in the incidence of epidural hematoma, subdural hematoma, intraparenchymal hemorrhage, subarachnoid hemorrhage, or contusion in helmeted and unhelmeted patients. With regard to secondary outcomes, there were no significant differences between the 2 groups in percentage of patients requiring neurosurgical intervention, percentage requiring admission to an ICU, total length of stay, or percentage discharged home. There was no difference in the incidence of cervical spine injury. There was 1 death in an unhelmeted patient, and there were no deaths among helmeted patients.

Noteworthy results culled from this in-depth analysis:

•Helmet usage: 19 helmeted (33.3 percent), 38 unhelmeted (66.7 percent)
•Helmet usage by sport: 30.8 percent skiers, 35.5 percent snowboarders
•Skull Fractures: 5.2 percent of helmeted patients suffered skull fractures versus 36.8 percent of unhelmeted patients.
•Helmeted fracture patterns: 1 non-depressed skull fracture
•Unhelmeted fracture patterns: 14 skull fractures, 8 of which were depressed

The authors cite several studies that attributed a majority of skiing fatalities to head injury:

•Utah study: 88.9 percent of fatal injuries attributed to head injury
•Vermont study: 87.5 percent of fatal injuries attributed to head injury
•Alberta study: 80.0 percent of fatal injuries attributed to head injury
•Switzerland study: 80.0 percent of fatal injuries attributed to head injury


Among hospitalized children who sustained a head injury while skiing or snowboarding, a significantly lower number of patients suffered a skull fracture if they were wearing helmets at the time of the injury.

“We are able to show that helmets are associated with reduced skull fractures in skiers and snowboarders seen at the hospital. Given that skull fractures can be an indication of severe brain injury and sometimes associated with intracranial bleeding, a reduction in skull fractures is a compelling finding. Furthermore, we did not see any increase in the risk of cervical spine injuries as some might predict. Although not a focus of our work, other research has shown that helmet use in skiers and snowboarders does not increase risk-taking behavior. This work supports the protective role of helmets in skiers and snowboarders,” said Dr. Rughani.

While the sample size is small this is a positive statement about the value of helmets. We are learning more and more about head impacts on the brain both in adults like professional football players and in children and teens where the implications of repeated severe head impact on the developing brain seem to be even more serious. Helmet use needs to be researched more and should be a risk management consideration for programs. For those interested in more information on children and head injuries, watch the TED video below.

The full study can be read online for free at https://thejns.org/doi/full/10.3171/2010.12.PEDS10415 

TED Video

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