title: Helmet use and injury severity among pediatric skiers and snowboarders in Colorado.
abstract: BACKGROUND
  Skiing and snowboarding are popular winter recreational activities that are commonly associated with orthopedic type injuries. Unbeknownst to most parents, however, are the significant but poorly described risks for head, cervical spine and solid organ injuries. Although helmet use is not mandated for skiers and snowboarders outside of resort sponsored activities, we hypothesized that helmet use is associated with a lower risk of severe head injury, shorter ICU stay and shorter hospital length of stay.
  
  
  METHODS
  The trauma registry at a level I pediatric trauma center in the state of Colorado was queried for children ages 3-17years, who sustained an injury while skiing or snowboarding from 1/1/1999 to 12/31/2014. Injury severity was assessed by Abbreviated Injury Severity (AIS) score, injury severity score (ISS) and admission location. Head injury was broadly defined as any trauma to the body above the lower border of the mandible. Regression analysis was used to test associations of variables with injury severity.
  
  
  RESULTS
  549 children sustained snow sport related injuries during the 16year study period. The mean patient age was11±3years, most were male (74%) and the majority were Colorado residents (54%). The overall median ISS was 9 (IQR 4-9) and 78 children (14%) were admitted to the ICU. Colorado residents were nearly twice as likely to be wearing a helmet at the time of injury, compared to visitors from out-of-state (adjusted OR 1.86, 95% CI 1.24-2.76, p=0.002). In a multivariate analysis injury severity was significantly associated with injury while skiing (p=0.026), helmet use (p=0.0416), and sustaining a head injury (p<0.0001). In a separate multivariate analysis ICU admission was associated with head injury (p<0.0001) and wearing a helmet (p=0.0257); however, those wearing a helmet and admitted to the ICU had significantly lower ISS (p=0.007) and head AIS (p=0.011) scores than those who were not wearing a helmet at the time of injury.
  
  
  CONCLUSIONS
  Visitors from out of state were less likely to be wearing a helmet when injured and more likely to be severely injured, suggesting Colorado residents have a better understanding of the benefits of helmet usage. Helmeted skiers and snowboarders who were admitted to the ICU had significantly lower ISS and head AIS scores than those who were not helmeted. Pediatric skiers, snowboarders and their parents should be educated on the significant risks associated with these activities and the benefits of helmet usage.
  
  
  METHODS
  III.
authors.affiliation: Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO; Department of Surgery, University Colorado School of Medicine, Aurora, CO. Electronic address: melissamilan@me.com.
authors.forename: Melissa
authors.initials: M
authors.lastname: Milan
authors.affiliation: Department of Surgery, University Colorado School of Medicine, Aurora, CO. Electronic address: jhajjss2009@gmail.com.
authors.forename: Sandeep
authors.initials: S
authors.lastname: Jhajj
authors.affiliation: Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO; Department of Surgery, University Colorado School of Medicine, Aurora, CO. Electronic address: camille.stewart@ucdenver.edu.
authors.forename: Camille
authors.initials: C
authors.lastname: Stewart
authors.affiliation: Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO 80045; Department of Biostatistics & Informatics, University of Colorado School of Public Health, Aurora, CO 80045. Electronic address: laura.pyle@ucdenver.edu.
authors.forename: Laura
authors.initials: L
authors.lastname: Pyle
authors.affiliation: Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO; Department of Surgery, University Colorado School of Medicine, Aurora, CO. Electronic address: steven.moulton@childrenscolorado.org.
authors.forename: Steven
authors.initials: S
authors.lastname: Moulton
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D003120:Colorado; D006259:Craniocerebral Trauma / Q000175:diagnosis / Q000209:etiology* / Q000517:prevention & control; D005260:Female; D006260:Head Protective Devices / Q000706:statistics & numerical data*; D006776:Hospitals, Pediatric; D006801:Humans; D015601:Injury Severity Score; D007362:Intensive Care Units / Q000706:statistics & numerical data; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D015999:Multivariate Analysis; D012042:Registries; D012306:Risk; D012865:Skiing / Q000293:injuries*; D014193:Trauma Centers
keywords: Helmet use; Injury severity; Pediatric trauma; Skiing injury; Snowboarding injury