Abstract
Purpose
The rapid development of winter sports requires investigation on injuries in Chongli district, Zhangjiakou city, one of the ski sites of the 2022 Winter Olympics. Careful evaluation is required to observe which injuries are caused under what circumstances, and then we can make corresponding preventive measures and recommendations based on the results.
Methods
In this retrospective study, the data of injury cases at ski resorts in China (Chongli district) and Japan were analyzed to provide a reference for the ongoing injury prevention at ski resorts. We collected data on injuries at Wanlong and Fulong ski resorts in Chongli district during the 2017–2018 and 2018–2019 ski seasons. We referred to the skiing injury report issued in February 2020 of a nationwide ski safety statistical service – Japan Ski Safety Association. The causes of injury and specific injured body parts were analyzed based on the data of Chinese and Japanese ski resorts. Statistical significance has been calculated using the Chi-square test.
Results
During the 2019–2020 ski season in Japanese ski resorts, the number of reported injuries per 10,000 skiers was 0.93, of which 457 (17.3%) were over 50 years old, accounting for a large proportion of injuries, meanwhile in Chongli ski resort, the injury rate of skiers aged 50 and over was 7.1%. The knee joint (23.7% at Wanlong ski resort and 28.4% in Japanese ski resorts) was the most injured body part among Chongli and Japanese skiers. Among snowboarders, shoulder joint injury (17.7% in Japanese ski resorts) was the most common, and injury on hands and fingers (16.3% in Wanlong ski resorts) was the most common. Head injury rates are similar in Chongli, China and Japanese ski resorts (8.2% and 8.7%, respectively).
Conclusion
Our analysis demonstrated that injury data recorded among young skiers was higher in Chinese ski resorts (Chongli district) than that in Japanese ski resorts, and elderly skiers made up a larger proportion of skiing injuries in Japanese resorts. Thus, according to our research, the protection of knee joints, shoulder joints, and hands and fingers should be taken seriously. It should pay attention to the teaching of ski poles (for finger protection), and use protective devices such as knee pads, helmets, etc.
Keywords: Ski resorts, Skiing, Sports injury, The winter olympics
Introduction
Skiing is one of the most popular winter sports, but the high injury rate limits its development. Studies have reported an average of 0.7–1.37 injuries per 1000 skiers per day,1, 2, 3 indicating that skiing is a relatively dangerous sport for adults.4 Moreover, professional athletes may be at greater risks of injury in competition.
Flørenes et al.5 noted that 86 (45%) of the 191 acute injuries that occurred among 521 skiers were sustained during the International Ski Federation Alpine Ski World Cup. With the successful hosting of the 2022 Winter Olympics, Chongli district, as a skiing hotspot in China, is expected to experience a large influx of skiers, most of whom are beginners. Ogawa et al.6 examined the relationship between snowboard injuries and skill level, and demonstrated that 86.4% of 19,539 injured snowboarders were at an intermediate or low level. Plans have been made for Chongli to recruit more health care personnel, and upgrade essential medical equipment to deal with the increasing number of skiing injuries. However, to date, only few studies specifically investigate skiing injuries in Chongli, and provide little evidence and guidance for local injury prevention. In Japan, skiing as a prevalent sport has developed very well. This may explain why the Japanese literature on skiing injuries dates back longer and is more substantial than the Chinese literature. Therefore, the knowledge on skiing injury prevention in Japan is worthy of reference.
This study analyzed the data on injuries collected from two ski resorts in Chongli during the 2017–2018 and 2018–2019 ski seasons. We also analyzed skiing injury data in Japan of February 2020. Moreover, we referred to data on experiences concerning skiing injury prevention and specific precautions to improve the skiing injury prevention in Chongli.
Methods
The investigation of skiing injuries in China was conducted at the two main ski resorts in Chongli: Fulong ski resort and Wanlong ski resort. The data on skiing injuries in Japan were retrieved from the reports issued by Japan Ski Safety Association (a nationwide ski safety statistical service). During ski seasons, there are two physicians and one nurse in each medical station at the two Chongli ski resorts. The patient information (e.g., name, sex, age, cause and type of injury, and injured body part) were recorded by the nurse, and the emergency and preliminary treatment was provided by the physicians. Patients with relatively serious injuries, such as fractures, concussions, visceral injuries and ligament injuries, are immediately transported to the nearest district hospital by a dedicated ambulance for further treatment.
We sorted the original data from the two ski resorts in Chongli according to the classification criteria of Japan Ski Safety Association presented in the injury reports. Furthermore, we conducted a comparative analysis of the age, injury site, and cause of injury in the Chinese and Japanese ski resorts. We plotted the injuries of skiers in Chongli at different times and compared them with data from Japanese ski resorts (Fig. 1).
Fig. 1.
The number of injuries that occurred during business hours in ski resort.
The data were analyzed using Excel software, with the categorical data presented as the number and percentage of cases. Causes of injury and injured body parts (in both Chinese and Japanese skiers) were subjected to a Chi-squared test using IBM SPSS Statistics for Windows, version 25 (IBM Corp., Armonk, NY, USA). Significance was set at p < 0.05.
Results
Among 2644 cases of skiing injuries in 47 Japanese ski resorts in February 2020, men and women accounted for 1571 and 1073 cases (59.4% and 40.6%), respectively. During the 2017–2018 ski season, at Fulong ski resort, men and women accounted for 191 and 130 (59.5% and 40.5%), respectively. A total of 321 skiing injuries occurred, and the injured persons were between 3 and 60 years old, with a mean age of (27.9 ± 11.3) years. During the 2018–2019 ski season at Fulong ski resort, 432 cases of skiing injuries were reported, of which men and women accounted for 230 and 202 (53.2% and 46.8%), respectively, and the injured individuals were aged from 2 to 58 years, with the mean age of (27.2 ± 11.1) years. During the 2018–2019 ski season, at Wanlong ski resort, of the 755 skiing injuries, 476 were men and 279 women (63.0% and 37.0%), respectively. The injured individuals were aged from 3 to 73 years, with a mean age of (32.6 ± 12.9) years. Ski- and snowboard-related injuries are the major skiing injuries. Of the 2644 people injured at ski resorts in Japan, 1657 were ski-related injuries and 1847 snowboard-related injuries. During 2018–2019 ski season, Wanlong ski resort recorded 755 skiing injuries, 469 ski-related injuries, and 301 snowboard-related injuries.
Of the 2644 injuries at Japanese ski resorts, falls not caused by collisions accounted for 2136 (80.8%). The second most common cause of injury (13.9%) was collisions with other visitors. Falls not caused by collisions accounted for 483 (66.5%) of the 726 injuries at Wanlong ski resort during the 2018–2019 ski seasons. The second most common cause of injury (31.3%) was collisions with other visitors. More visitors at Wanlong ski resort were injured because of collisions with other visitors (p < 0.001, Table 1).
Table 1.
Causes of skiing injury.
| Cause of injury | Wanlong ski resort (n, %) | Japanese ski resorts (n, %) | χ^2 | p value |
|---|---|---|---|---|
| Falls (not caused by collision) | 483 (66.5) | 2136 (80.8) | 124.1 | < 0.001 |
| Collision with other visitors | 227 (31.3) | 368 (13.9) | ||
| Collision with objects | 11 (1.5) | 82 (3.1) | ||
| Other | 5 (0.7) | 58 (2.2) | ||
| Total | 726 (100.0) | 2644 (100.0) |
Among the 2644 injuries at the Japanese ski resorts, 904 cases (34.2%) occurred among individuals aged 21–30 years, and individuals aged 11–50 years accounted for 79.2% of the total injuries. Among the 1146 injuries at two ski resorts in Chongli during the 2017–2018 and the 2018–2019 ski seasons, 409 cases (35.7%) occurred among individuals aged 21–30 years, and individuals aged 11–50 years constituted 88.4% of the total injuries. In Japanese ski resorts, more older visitors sustained injuries, with 227 cases of injury (8.6% of the total) sustained by individuals aged over 60 years (Table 2).
Table 2.
Age stratification.
| Age (year) | Chongli ski resorts, n (%) | Japanese ski resorts, n (%) |
|---|---|---|
| < 10 | 51 (4.5) | 93 (3.5) |
| 11–20 | 151 (13.2) | 479 (18.1) |
| 21–30 | 409 (35.7) | 904 (34.2) |
| 31–40 | 309 (26.9) | 410 (15.5) |
| 41–50 | 145 (12.6) | 301 (11.4) |
| 51–60 | 65 (5.7) | 230 (8.7) |
| 61–70 | 15 (1.3) | 151 (5.7) |
| 71–80 | 1 (0.1) | 63 (2.4) |
| > 80 | 0 (0) | 13 (0.5) |
| Total | 1146 (100.0) | 2644 (100.0) |
The most frequently injured body parts in the 1657 skiing accidents at the Japanese ski resorts were the knee joint (28.4%), shoulder joint (11.0%), head (7.7%), and ankle and toes (7.2%), whereas at Wanlong ski resort, the most frequently injured body parts involved in the 469 skiing accidents were the knee joint (23.7%) and head (7.9%), with a lower likelihood of injury to the shoulder joint (7.7%) and calf (5.0%). Overall, the body parts involved in the accident at Wanlong ski resort significantly differed from those at the Japanese ski resorts (p < 0.001, Table 3).
Table 3.
Body parts commonly involved in skiing injuries.
| Body part | Wanlong ski resort, n (%) | Japanese ski resorts, n (%) | χ^2 | p value |
|---|---|---|---|---|
| Knee joint | 111 (23.7) | 471 (28.4) | 18.68 | < 0.001 |
| Shoulder joint | 36 (7.7) | 182 (11.0) | ||
| lower limbs | 75 (16.0) | 166 (10.0) | ||
| Head | 37 (7.9) | 128 (7.7) | ||
| Ankle and toes | 36 (7.7) | 119 (7.2) | ||
| Total | 295 (62.9) | 1066 (64.3) |
Due to the data mentioned above, most of the 1847 snowboard-related injury at the Japanese ski resorts involved the shoulder joint (17.7%), hands and fingers (15.4%), head (9.6%), elbow (7.0%), and knee joint (6.8%). Concerning the 301 cases of snowboard-related injuries at Wanlong ski resort, the likelihood of injury to the hands and fingers (16.3%) and the shoulder joint (13.6%) was comparable to the results of Japanese ski resorts in the statistical analysis (p = 0.513, Table 4).
Table 4.
Body parts commonly involved in snowboarding injuries.
| Body part | Wanlong ski resort, n (%) | Japanese ski resorts, n (%) | χ^2 | p value |
|---|---|---|---|---|
| Shoulder joint | 41 (13.6) | 327 (17.7) | 3.27 | 0.513 |
| Hands and fingers | 49 (16.3) | 284 (15.4) | ||
| Head | 27 (9.0) | 177 (9.6) | ||
| Elbow | 16 (5.3) | 129 (7.0) | ||
| Knee joint | 23 (7.6) | 126 (6.8) | ||
| Total | 156 (51.8) | 1043 (56.5) |
A total of 1462 accidents in Chongli two ski resorts and 3504 accidents in Japanese resorts were recorded. Knee joint injury (18.2% in Chongli and 17.0% in Japan) is the most common type of injury both in Chongli and Japan ski resorts (Table 5). Head injuries are dangerous and fatal, with 120 head injuries (8.2%) reported at the two ski resorts in Chongli, similar to the rate at ski resorts in Japan (Table 5). In the Japanese ski resorts, the helmet use rate among injured skiers rose from 43.2% in the 2018–2019 ski season to 48.2% in the 2019–2020 ski season, and among injured snowboarders rose from 22.9% to 24.4%. No record of helmet use was found at the two ski resorts in Chongli.
Table 5.
Body parts commonly involved in skiing and snowboarding injuries.
| Body part | Chongli ski resorts, n (%) | Japanese ski resorts, n (%) | χ^2 | p value |
|---|---|---|---|---|
| Knee joint | 266 (18.2) | 597 (17.0) | 10.55 | 0.005 |
| Head | 120 (8.2) | 305 (8.7) | ||
| Shoulder joint | 155 (10.6) | 509 (14.5) | ||
| Total | 541 (36.9) | 1411(40.3) |
Based on the data recorded by Wanlong ski resort from 2018 to 2019, the number of injury accidents was plotted. Generally, the peak of the number of accidents occurs between 11:00 and 14:00 every day, and the lowest is at 13:00, which is similar to the statistical results of Japanese ski resorts. After the opening of the ski resort, the number of accidents has been increasing with the extension of time, which may be related to the increase of fatigue level and the number of people, the diffusion of environmental complexity, and other factors. The peak time for injuries is at 14:00, which may be related to the rest time, ambient temperature, and number of skiers (Fig. 1).
Discussion
Considering the health benefits of skiing and advances in ski equipment, the risk-reward ratio of participating in this sport has been optimized.7 Based on data on the ski patrol accidents at Styrian resorts in Austria during the 2014–2015 ski season, Castellani et al.1 estimated that the average daily number of injuries per 1000 skiers was 0.7, with a slight increase (0.2 per 1000 skiers) over seven years prior. In the two ski seasons of 2017–2018 and 2018–2019, the average daily number of injuries per 10,000 skiers was 27.9 in Chongli ski resorts. The corresponding rate at the Japanese ski resorts during the 2019–2020 ski season was 0.93 per 10, 000 skiers. Overall, the Chongli ski resorts had a higher rate of injuries. However, the popularity of skiing differentiates between the two countries. In Japan, the number of skiing and snowboarding participants peaked at about 18 million in the 1990s, but its domestic market has declined over the last 20 years, and dropped to about five million in recent years, which was published by Ministry of Land, Infrastructure, Transport, and Tourism.8 The number of ski resorts and ski participants in China is increasing, as winter sports gain more attention and the success of the 2022 Beijing Winter Olympics. The number of skiers reached 13.2 million in 2018, about seven million in northern China, where the two Chongli ski resorts are located.9 The rapid development of skiing sport may lead to a temporary shortage of protective facilities and equipment. From 2018 to 2019, leisure lovers of skiing with two-year or less of training experience accounted for 48.9% of the injured people in Wanlong ski resort, of which 17.4% were beginners. Consistent with injury data of Japan, beginners accounted for 10.7% of injuries and the skiers with primary skill certification accounted for 39.3%. In the absence of professional training and qualification registration system, skiers may lack awareness of maintaining a safe distance between skiers and neglect to wear protective gear, leading to increased injury rates.10,11
At Wanlong ski resort (66.5%) and Japanese ski resorts (80.0%), most skiing injuries were caused by falls rather than collisions, but at Wanlong ski resort, 31.3% of skiing injuries were caused by collisions with other skiers, much higher than Japanese ski resorts. This may be related to the high flow of people in Wanlong ski resort. In general, inadequate skill, excessive speed, or loss of balance can all result in falls. Quinlan et al.12 noted that less experienced skiers frequently had wrist fractures, mostly related to falls due to insufficient jumping movements or skills. Similarly, Sakamoto et al.13 suggested that with regard to injury prevention, both skiers and snowboarders should take extra care when performing jumping movement. Another study showed that professional skiers and snowboarders may have a higher risk of serious injury than beginners because they often engage in technically challenging workouts.14
In China and Japan, skiing is mainly a sport for young people. At both ski resorts in China and Japan, the most significant proportion of injuries (35.7% and 34.2%, respectively) occurred among individuals aged 21–30 years. Moreover, significantly more injuries at the Japanese ski resorts were reported among older individuals, with 227 cases (8.6%) aged over 60 years. According to statistical data published,9,15 the proportion of skiers aged 30 and below is 51.5% in China and 46.3% in Japan, while skiers aged 50 or over account for 3.0% in China and 7.0% in Japan. In our study, skiers aged 50 or above account for 7.1% of injuries in Chongli resorts and 17.3% in Japanese resorts. In a study of Patrick et al.,16 injuries were more likely among skiers and snowboarders aged between 46 and 55 years, who had never received professional training or used rental gear. Girardi et al.17 indicated that skiers aged 60 years and older have a higher injury severity score (ISS). Another study observed a difference of age between snowboarders and skiers with severe injury (defined as an ISS >15), the mean age of who were 38 and 20 years, respectively.18 In conclusion, young people, who account for a large proportion of skiing injuries, may be more likely to attempt high-risk and high-tech activities like snowboarding.
The studies noted that the knee joint is one of the most common sites of skiing injuries, which is consistent with current results that knee injuries accounted for 24.9% and 28.4% of skiing injuries in Chinese and Japanese ski resorts, respectively.16,19 In a study of Sakamoto et al.,13 calf fractures comprised 39.6% of the fractures sustained in skiing accidents. In comparison with snowboarders, skiers had a higher rate of knee joint injury, femoral fractures, and calf fractures with a higher ISS (ISS >9).20 In short, skiers were more likely to sustain lower limb injuries.
In a case-control study, the injury rate of snowboarders fluctuated over time but remained higher than that of skiers.21 Wrist, shoulder joint and ankle injuries were more common among snowboarders, whereas knee joint and ligament injuries were more prevalent among skiers.21,22 In this study, shoulder joint injuries were common (17.7%) among snowboarders at Japanese ski resorts. In contrast, injuries to the hands and fingers (16.7%) were more common at Wanlong ski resort, consistent with the literature. Maat et al.20 observed that concussions and lower limb fractures were more common among snowboarders than skiers. In addition, the direction of falls can be used to determine which parts of the body may be injured. In a descriptive epidemiological study of 1918 skiers, upper extremity injuries from snowboarding falls, wrist fractures and elbow dislocations (68.1% and 63.5%, respectively) were more likely to occur in backward falls. If falling anteriorly, shoulder joint dislocations (68.9%) and upper arm fractures (60.7%) were the most common injuries.23
Since serious injuries are common in skiing and snowboarding, precautions must be taken (e.g., wearing helmets and informed of notice on injury prevention).24 Kuzuhara et al.25 analyzed ski- and snowboard-related injury rates in Japan from 2012 to 2018, and found that snowboarding has a higher incidence than skiing. Sprains are the most common injury in skiing, while fractures and contusions are the most common in snowboarding. Helmet use rate among skiers is increasing year by year and has approached 50% in Japanese ski resorts, however, it is not comparable to that of the American and European skiers (approximately 80%). Skiers in Japanese resorts use helmets about twice as often as snowboarders. Follow-up studies involving the collection of statistics on the observed increase in both ski- and snowboard-related injuries are necessary.
The skiing skills of leisure skiers should be standardized, skiers should be qualified for high-risk skiing, and resorts with high-risk skiing should be equipped with experienced and professionally trained first aiders and surgeons. The site condition should also be considered. In the ski resort, "dry snow" should be used for the ski activity, i.e. it should have very little moisture content. Due to weather and maintenance, the snow in a ski area can turn into "wet snow" with more water content, and skiing in wet snow becomes more complex, and the injury rate increases.26 In Japanese ski resorts, 35.1% of injuries occur when the snow is wet. The management of the ski resort shall ensure the regular operation of bombardiers and snowmakers, and keep timely maintenance of equipment.
Overall, the injury rate was slightly higher at the ski resorts in Chongli than that in Japan. The knowledge and experience of the Japanese ski resorts should be used to manage the high influx of skiers to Chongli ski resorts and reduce the rate and severity of injury. Our study provides suggestions on the number of skiers, age, and injury prevention by comparing skiing injuries in China and Japan. First, the number of skiers should be maintained at a reasonable level. At Wanlong ski resort, 31.3% of the visitors were injured in collisions with others. Second, the majority of skiing injuries are young people in both China and Japan. Young skiers make a false assessment of their skills because of media hype. Thus, the professional coach should inform skiers the risks of these unsafe behaviors. Third, old individuals constituted a more significant proportion of injury at the Japanese resorts. Given that skiers aged 60 years and above are more prone to severe injury, staff members of medical stations at ski resort are advised to observe the injured skiers of this age group for a longer time, and transfer them to a higher-level hospital timely if necessary. Fourth, a health weight, long-term exercises of quadriceps and hamstring, and a knee brace can all be effective in preventing knee injuries. Patients with soft tissue lesions such as anterior cruciate ligament should pay attention to knee protection during skiing. In the event of a fall, the bracer can protect the wrist, and loosening the ski poles can reduce injuries of hand and wrist. And the use of helmets should be encouraged to prevent severe injury. Last, skier skill rating and ski resort management should be further promoted.
Our study still have some limitations. First, the analysis is not based on the synchronous data, given that the data of Japanese ski resorts merely covers February 2020. Second, compared with the 47 ski resorts in Japan, this study only focused on injuries from the two ski resorts in Chongli, without providing data for all ski resorts across China, which might have negatively affected the results. Despite of lacking data, the necessity of our analysis is that these two ski resorts need evidence to guide them in order to be fully eligible to receive the increase in visitors after the 2022 Winter Olympics.
Funding
This study was supported by 2019 Nation Key Research and Development Program for “Science and Technology Winter Olympics” of China[grant numbers 2019YFF0302305]; Integrated application of technology and comprehensive demonstration Project of Scientific and Technological Winter Olympics of Zhangjiakou in 2020[grant numbers 20110004D]; Integrated application of technology and comprehensive demonstration Project of Scientific and Technological Winter Olympics of Zhangjiakou in 2021[grant numbers 21110006D].
Ethical statement
The study was approved by the Peking University Third Hospital Medical Science Research Ethics Committee.
Declaration of competing interest
The study protocol was established, according to the ethical guidelines of the Helsinki Declaration and was approved by Peking University Third Hospital Medical Science Research Ethics Committee. Project Number: M2019456.
The authors certify that there is no competing interest with any financial organization regarding the material discussed in the manuscript.
Author contributions
Xiao Ma carried out the data analysis, collected the data and drafted the manuscript. Jiong-Yuan Li carried out the data analysis and edited the manuscript. Yu-Ping Yang carried out the design of study, collected the data and helped to draft the manuscript. SHI GERU ANDD collected the data. Ying-Fang Ao conceived of the study, and participated in its design. All authors have read and approved the content of the manuscript.
Footnotes
Peer review under responsibility of Chinese Medical Association.
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