In-Line Skating Injuries
Patterns and Protective Equipment Use
Renata J. Frankovich, MD; Robert J. Petrella, MD, PhD; Chastity N. Lattanzio, MSc
THE PHYSICIAN AND SPORTSMEDICINE - VOL 29 - NO.4 - APRIL 2001
BACKGROUND: The incidence of in-line skating injuries has increased with the rapid growth in the sport's popularity, but few studies have examined patterns of injuries.
OBJECTIVE: This study sought to determine the demographics of at-risk in-line skaters, document protective equipment use, identify contributing or precipitating factors associated with injuries, and obtain a profile of the injuries sustained.
DESIGN: This prospective, descriptive study examined injuries among in-line skaters seen in emergency departments from three hospitals in Canada from August 23, 1995, to November 19, 1996. Patients completed questionnaires about their injuries, and the data were used for the analysis.
RESULTS: A total of 121 skaters completed the study. The mean age of injured skaters was 24 years. The largest age-group of injured skaters (50%) were those between 18 and 35 years old. Although the ratio of male to female skaters was about equal (45% female, 55% male), twice as many males as females were younger than 18. The most common cause of injury was a loss of control with no obstacles (50% of patients), and the most common injury was forearm fracture. Most injured skaters were either experienced recreational (33.2%) or novice (37.5%), and, when injured, most skaters were wearing less protective equipment than usual.
CONCLUSION: Loss of control and inexperience were factors contributing to about half the injuries. Protective equipment among skaters was underused. Future research must identify the overall incidence of injuries, optimal design and efficacy of protective equipment, and effectiveness of preventive strategies such as safety education.
In-line skating is the fastest-growing recreational sport in the United States and Canada, with approximately 22.5 million US participants in 1995 (1). The sporting goods industry predicted that by the fall of 1995, the last year detailed statistics were available, the number of in-line skates would have exceeded the number of ice skates in Canada (2). Accompanying this rise in popularity has been an increase in in-line skating injuries. The Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP), a database of childhood injuries of any type seen in the emergency department, has documented the following rise in in-line skating injuries from participating hospitals: 33 in 1991, 154 in 1992, 326 in 1993, 756 in 1994, and 893 in 1995 (3). In the United States, the estimated number of in-line skaters requiring emergency care in 1995 was 99,500 (4). In-line skating injuries and protective equipment efficacy have become increasing areas of interest as researchers and clinicians begin to appreciate the burden of injury in this sport.
The scientific literature regarding in-line skating is limited. Studies documenting protective equipment use include observational studies of in-line skaters (5,6) and reports from injured populations (7-10) (table 1). Helmet use in the observational studies has been reported to be less than 10%, while wrist guard use by in-line skaters was approximately 65%. Retrospective reviews (7,11-13) of types and sites of injuries have shown that fractures of the distal radius and wrist were the most common injuries, accounting for 37% to 68.8% of all injuries. When in-line skating injuries were compared with other sports-related injuries in children who presented to the emergency department, in-line skating was associated with a significantly greater number of fractures and upper-extremity injuries. In addition, in-line skating injuries required more extensive treatment than other sports-related injuries noted in the database (8).
We present descriptive information about in-line skaters who sought emergency department assistance. This study had four goals: (1) to obtain demographic characteristics to identify an at-risk group, (2) to document protective equipment use, (3) to identify contributing or precipitating factors, and (4) to obtain a profile of the injuries sustained. This would allow us to identify the nature of the medical problems and the relationship to protective equipment use.
This prospective, descriptive study was conducted from August 23, 1995, to November 19, 1996. The triage staffs at three emergency departments (University Hospital; Victoria Hospital, South Street Campus; and St Joseph's Hospital) in London, Ontario, Canada, provided a questionnaire to all patients who entered the emergency room with an in-line skating injury.
Researchers used the questionnaire to obtain information about patient demographics, protective equipment worn at the time of injury and equipment usually worn, a profile of the frequency and the type of skating (eg, aggressive, recreational, or novice), the physical location of the accident (eg, park, sidewalk, street) and any precipitating factors (eg, a vehicle or wet conditions) associated with the injury sustained. The patient's medical record was subsequently reviewed by one of the researchers (RJF) to obtain the diagnosis, extent of injury, and the treatment required.
The patients who chose to participate completed the questionnaire in the emergency department before being seen by a physician. Patients who were in unstable condition or could not remain in the waiting room for medical reasons were treated immediately and were asked to participate once they were stable. Patients younger than 16 years old could be assisted by a parent or accompanying adult. Participation in the study was voluntary, and subsequent treatment was independent of participation status. The study was approved by The University of Western Ontario Review Board for Health Sciences Research Involving Human Subjects.
Demographics. A total of 121 patients completed the study. The mean age was 24 years (range, 6 to 62). Thirty-one percent of the subjects were younger than 18, 50% were between 18 and 35, and 18% were older than 35. Forty-five percent were female, and 55% were male. There were twice as many males as females under 18.
Skating type and experience. Patients were asked to select the type of skating performed from a checklist that included trick skating, racing, commuting, recreational skating, novice skating, and roller hockey (table 2). All of the trick skaters were male. Approximately equal numbers of males and females were in the novice (53.3% female) and experienced recreational (55.0% female) groups. Along with the type of in-line skating, patients listed how long they had been skating (see table 2) and how often they skated. Of the 46.7% of the skaters who had skated for more than 1 year, 60.7% skated more than three times per week, while another 21.4% skated one to three times per week.
Protective equipment use. Patients reported the type of protective equipment worn. Less equipment was reported to have been used at the time of injury than was usually worn while subjects were in-line skating (see table 1).
Factors related to injury and location of injury. Fifty percent of patients reported that a loss of control with no obstacles was the major factor contributing to their injury. Only 2.5% attributed their fall to a collision with a motor vehicle, while 30.5% blamed a road hazard. Other contributing factors were the presence of pedestrians (0.8%), another in-line skater (5.9%), a cyclist (2.5%), and other causes (7.6%). Approximately half (48.7%) of the patients were skating in a park, 21.8% on a sidewalk, 25.2% on a roadway, 2.5% in a roller-rink, and 1.7% in a house.
Injury and type. Table 3 lists the type of injury sustained categorized by the anatomic location. Injuries above the waist accounted for 71.2% of the total. All but two of the forearm fractures were of the radius. Of the 28.2% of the injuries below the waist, the most catastrophic was a fractured femur in a 36-year-old first-time skater who lost control while going downhill; no obstacles were involved.
Treatment required. Surgery for fracture management was required in 5.9% of the cases (femur, tibia, mandible, ankle, thumb, radial head, and distal radius). Forty percent of patients did not require follow-up, while 54.6% were told to follow up with the emergency department physician, a family physician, or an orthopedic surgeon.
Demographics. In-line skating is most popular among young adults 18 to 35 years old, followed by teens and preteens 10 to 17 years old (14). Our study population resembles this demographic profile. Fifty percent of our study population fell within the 18-to-35 age-group, another 31% were younger than 18, and males accounted for 68.4% of the latter group. This finding is in agreement with others. In one study (8) in which the average age of the injured in-line skaters was 11.7 years, males accounted for 80% of the injured in-line skaters presenting to the emergency department. Keeping in mind that adolescent boys and children, along with more advanced skaters, are least likely to be seen wearing protective equipment (6), these groups may be particularly vulnerable to injury. Therefore, injury prevention programs need to be targeted to these at-risk groups within the in-line skater population.
Inexperienced and novice skaters were prevalent in our study, a finding noted in previous studies of injured in-line skaters (8,11). First-time skaters, skaters with less than 3 months' experience, and occasional skaters accounted for 47.5% of the total. These skaters included 88.9% of those who ranked themselves as novice. In addition to lacking experience, these skaters may also lack skate control and stopping skills. The major contributing factors to injury were behavioral factors (loss of control with no obstacles) and were reported by 50.0% of the skaters in this study. Ellis et al (8) also found that behavioral factors were the major cause of injury (falls, 51.0%; loss of control; 27.8%). Environmental factors, including road hazards (30.5%) and motor vehicles (2.5%), may be avoidable. Motor vehicles can be avoided by skating in public parks and designated areas free of traffic. Road hazards or poor conditions including wet pavement and rough or uneven surface conditions can also be avoided. New skaters, at high risk for injury, should be taught not only proper skating and stopping techniques, but also the environmental hazards that may contribute to being injured.
Protective equipment use and injuries. The pattern of protective equipment use found in this study is similar to previous studies of both injured and uninjured populations (see table 1) (5-10). A significant number of skaters (45.8%) were not wearing any protective equipment when they were injured. Helmets, in particular, were underused; only 18.6% of the injured skaters were wearing them. Less equipment was worn at the time of injury than was usually worn, suggesting that skaters who have access to equipment do not always wear it.
Young et al (10) reported that the reasons for not using protective equipment included discomfort (42%), belief that it is unnecessary (34%), dislike of appearance (22%), and cost (15%). Strategies to promote the use of protective equipment must be developed. Furthermore, current protective equipment varies considerably in style, quality, and cost. No published studies have compared the efficacy of different types and styles of protective gear. Similarly, there are no published studies of the safety of different skate designs or braking mechanisms. Therefore, further studies are needed to determine the optimal design of protective gear and of in-line skates to promote safety.
In this study, the wrist, forearm, and elbow accounted for almost half of all injuries. Fractures accounted for 40.2% of all injuries. Wrist guards were worn by only 3 of 32 patients who had wrist, forearm, or elbow fractures. Of the subjects wearing wrist guards, one sustained a Colles' fracture requiring surgical fixation, while the other two subjects experienced radial head fractures. In cases reported by Banas et al (11), none of the 10 patients with wrist injuries wore wrist guards.
The most comprehensive study to date on the efficacy of protective gear involved 161 patients obtained through the National Electronic Injury Surveillance System in the United States (9). The odds ratio for wrist injury in those who did not wear wrist guards compared with those who did, and adjusted for age and sex, was 10.4 (95% confidence interval, 2.9 to 36.9). For elbow injury, the odds ratio was 9.5 (95% confidence interval, 2.6 to 34.4) for those who did not wear elbow pads, adjusted for number of lessons taken and whether or not skaters performed trick skating. This study supports recommendations for wrist guards and elbow pads to reduce injuries.
Head injuries accounted for only 5% of all injuries in our study. None of these involved concussion. Only 18.6% of patients were wearing a helmet at the time of injury. Helmet use has been shown to be protective in cycling (15) but has not been studied thus far in in-line skating. In a study (16) of patients who presented to the emergency room after bicycle accidents, the only variables that were found to be predictive of head injury were lack of helmet use and involvement of a motor vehicle. The risk of injury to an in-line skater is comparable to the risk for a bicyclist with respect to speeds obtainable, exposure to motor vehicles, and road surfaces used. However, helmet design requirements may be quite different because the patterns of injury may differ. For example, falling in the supine position is much more likely for an in-line skater than for a cyclist. No studies have determined the type of helmet best suited for in-line skating. Until such information is available, helmet use in in-line skating should be promoted based on our experience with bicycling.
The Work That Remains
Our study underestimates the true burden of injury for the sport because injured in-line skaters who did not seek medical attention were not accounted for, we did not survey other primary care settings, and some injured in-line skaters may not have received a survey in the emergency room. However, reporting on in-line skating injuries seen in the emergency department does capture the more serious injuries. Future investigations are needed to determine the overall incidence of injuries, optimal design and efficacy of protective equipment, and effectiveness of preventive strategies such as safety education, formal lessons, and promotion of protective equipment. Determining this information is important given the potential for injury and the subsequent burden of disability and economic cost.
The authors thank the Physicians' Services Incorporated Foundation for funding this project; the emergency department staffs of St Joseph's Health Centre, University Hospital, and Victoria Hospital in London, Ontario, for their participation; and Moira Stewart, PhD, for reviewing the manuscript before submission.
Dr Frankovich is a family practice physician in Ottowa, Ontario. Dr Petrella is associate professor of family medicine and kinesiology at The University of Western Ontario and the Centre for Activity and Ageing at St Joseph's Health Centre in London, Ontario. Ms Lattanzio is a doctoral candidate in the faculty of health sciences at The University of Western Ontario. Address correspondence to Robert J. Petrella, MD, PhD, Centre for Activity and Ageing, St Joseph's Health Centre, 1490 Richmond St, London, Ontario, N6G 2M3; e-mail to [email protected].