Likelihood of Craniofacial Injury and Hospitalization with Alcohol Use While Skateboarding and Scootering

Abstract

Study Design: We designed a cross-sectional epidemiologic study to evaluate the influence of substance use on craniofacial injuries in a population of skateboard and scooter users.

Objective: The primary outcome of our study was craniofacial injury. The secondary outcome was hospitalization.

Methods: We report a cross-sectional study of patients reported to the National Electronic Injury Surveillance System (NEISS) from January 1, 2019, to December 31, 2020, in the United States. Patients were included in our study if they were evaluated in the emergency department (ED) for a skateboard- or scooter-related injury.

Results: There were over 5396 total patients who presented to a NEISS-participating ED after skateboard- or scooter- related trauma during the study period. There were 1136 patients with a craniofacial injury (primary endpoint), and patients under the influence of alcohol or drugs had greater odds of experiencing a craniofacial injury than those not under the influence (odds ratio [OR]: 4.16, 95% confidence interval [CI]: 3.24-5.32, P < .0001). Four hundred-thirty patients were hospitalized (secondary endpoint), and patients under the influence had greater odds of being hospitalized than those not under the influence (OR: 2.83, 95% CI: 2.04-3.91, P < .0001).

Conclusions: Alcohol and drug use while skateboarding or scootering drastically increases the likelihood of craniofacial injury and subsequent hospitalization and should be avoided whenever possible. The importance of wearing a helmet while operating these devices cannot be overstated.

Introduction

Skateboarding and scootering, both manual and electric, are recreational activities that have previously been widely associated with traumatic head and facial injuries.^1,2 This high head and facial injury rate is related to many factors, including low helmet usage^3,4; however, the risks associated with participating in these activities while under the influence of alcohol or drugs are not well specified. The purpose of this study was to determine the relationship between substance use and craniofacial injury in a population of patients experiencing skateboard- and scooter-related trauma. We hypothesized that substance (alcohol or drugs) use increases the likelihood of experiencing a craniofacial injury, and increases the likelihood of subsequent hospitalization in the setting of skateboard- or scooter-related trauma compared to patients without substance use. We aimed to calculate the odds ratio (OR) of craniofacial injuries and hospitalization in a large cohort of skateboard and scooter injury patients who presented to the ED with and without concurrent substance use to guide interventions for reducing the incidence of these injuries.

Materials and Methods

Study Design and Sample

To address the research purpose, the investigators designed and implemented a cross-sectional study of consecutive cases reported to the United States (US) Consumer Product Safety Commissions’ National Electronic Injury Surveillance System (NEISS) database between January 1, 2019, and December 31, 2020. The study population was composed of all patients presenting to a NEISS-participating emergency department (ED) for management of injuries sustained after a skateboard- or scooter-related accident during the 2-year study period. To be included in the study sample, patients had to have (a) been over the age of 16 years and (b) presented to the ED with a skateboard- or scooter-related injury. Patients were excluded as study subjects if they were (a) under 16 years old, (b) did not present to the ED, or (c) if their injury was not related to a skateboard or scooter accident. Our institution did not require Institutional Review Board approval for this population-based, retrospective descriptive study.

Variables

Our study sample is consecutive patients who presented to NEISS-participating EDs after experiencing a skateboard- or scooter-related accident. This included manual and powered skateboards and manual and powered scooters. Due to the method for coding the database, we are unable to accurately stratify our results based on manual vs powered or skateboards vs scooters, so the study population is considered together. Our predictor variable is categorical (yes or no) alcohol or drug use before or at the time of the accident, and the primary outcome is general craniofacial injury, which was further specified by type of injury. The secondary outcome was hospitalization after injury. Demographic information including age and sex were collected for each included patient. Other variables of interest, including ED disposition (left without being seen, treated and released, treated and admitted, treated and transferred, held for observation, and treated and died), type of injury (laceration, contusion, abrasion, fracture, etc), and location of injury (forehead, nose, orbit, mandible, etc) were collected as well.

Data Collection

The NEISS database collects information on the date of treatment, age, sex, diagnosis, involved body part, patient disposition from the ED, consumer products involved, location, and free-text description for each unintentional injury treated in the ED. This information is entered into computers in the EDs and uploaded each night into the Consumer Product Safety Commission computer database. For this study, the authors queried the NEISS database for all entries related to “SKATEBOARDS, SCOOTERS” in patients over the age of 16 years during the study period. Patients had alcohol use recorded if they were found to be intoxicated or admitted to alcohol use at the time of ED evaluation. Patients had drug use recorded if they were found to be under the influence of illicit mood-altering substance or admitted to being under the influence at the time of ED evaluation. Though legal in some states, marijuana was included as a “drug”; cigarettes and nicotine were not considered a “drug.” Further specifics on what type of alcohol or drug was being used were not provided.

Data Analyses

Descriptive statistics were reported as a mean or median and standard deviation for continuous variables or frequency and percentage for categorical variables, respectively. Comparisons of means were performed with a two-tailed t-test. Comparisons of proportions were performed with an “N-1” Chi-squared test. ORs were calculated and evaluated according to Altman ⁵ and Sheskin. ⁶ Before performing any tests, statistical significance was defined with a P-value < .05. All statistical analyses were performed using commercially available software.

Results

Overall Characteristics

5396 patients with skateboard- or scooter-related injury were reported from NEISS-participating EDs during the study period. The mean (± SD) age was 29.7 (± 14.0) years, and 72% of patients were male (n = 3893). Of these total patients, 271 had alcohol or drug use recorded (271/5396; 5.02%). The most common type of overall injury was fracture (1682/5396; 31.2%). The most common ED disposition was treated and released (4730/5396; 87.7%). The most common body part injured was the head/face (1136/5396; 21.1%). These results are summarized in Supplemental Table 1.

Alcohol or Drug Use and Craniofacial Injuries

There were 1136 patients with craniofacial injuries (primary endpoint) after skateboard or scooter trauma. Of these 1136 patients, 136 had alcohol or drug use recorded (136/1136; 12.0%). The average age of craniofacial injury patients under the influence was higher than the average age of craniofacial injury patients not under the influence (36.7 years vs 29.7 years, respectively; P < .0001). The proportion of males was higher in the craniofacial injury patients under the influence than the craniofacial injury patients not under the influence (82.4% vs 68.5%, respectively; P < .0009). There was no difference in incidence of different types of craniofacial injury between the 2 groups. The proportion of patients hospitalized after craniofacial injury was higher in the substance use group compared to the no substance use group (16.2% vs 9.7%, respectively; P < .0203). Full results are in Supplemental Table 2.

Overall, patients under the influence of alcohol or drugs had greater odds of experiencing a craniofacial injury than those in the no alcohol or drugs group (OR: 4.16, 95% confidence interval [CI]: 3.24-5.32, P < .0001). When stratified by sex, male patients under the influence of alcohol or drugs had greater odds of experiencing a craniofacial injury than those not under the influence (OR: 4.52, 95% CI: 3.43-5.97, P < .0001). Female patients under the influence of alcohol or drugs also had greater odds of experiencing a craniofacial injury than those not under the influence (OR: 3.21, 95% CI: 1.83-5.64, P < .0001). These data are summarized in Supplemental Table 3.

Alcohol or Drug Use and Hospitalization

There were 430 patients hospitalized (secondary endpoint) after skateboard- or scooter-related trauma. Patients under the influence of alcohol or drugs had greater odds of being hospitalized than those in the no alcohol or drugs group (OR: 2.83, 95% CI: 2.04-3.91, P < .0001) (Supplemental Table 4).

Discussion

For this study, there were over 5000 total patients who presented to a NEISS-participating ED after skateboard- or scooter-related trauma during the 2-year study period. With this data set, we hypothesized that substance (alcohol or drugs) use increases the likelihood of experiencing a craniofacial injury or hospitalization in the setting of skateboard- or scooter-related trauma compared to patients without substance use. There were 1136 patients with a craniofacial injury (primary endpoint), and patients under the influence of alcohol or drugs had greater odds of experiencing a craniofacial injury than those not under the influence (OR: 4.16, 95% CI: 3.24-5.32, P < .0001). Four hundred thirty patients were hospitalized (secondary endpoint), and patients under the influence had greater odds of being hospitalized than those not under the influence (OR: 2.83, 95% CI: 2.04-3.91, P < .0001).

Other trends observed in our patient cohort are worth discussing. As with most trauma cohorts, our patients were overwhelmingly young (mean age: ∼30 years) and male (proportion male: 72%). The prevalence of alcohol use in the overall cohort was about 5% with most patients using alcohol alone. However, when considering the cohort of patients with craniofacial injuries, the prevalence of alcohol or drug use was almost 12%. Furthermore, there were significant differences in age in patients with craniofacial injuries, comparing those under the influence and those not under the influence. Interestingly, craniofacial injury patients in the alcohol or drug cohort were older than their sober counterparts by 7 years. We suggest that this is perhaps explained by the emboldening effect of inebriation that may encourage older adult participation in an activity that typically attracts younger people. Furthermore, the use of electric scooters (which are included in this patient cohort) are frequently observed as modes of transportation as bar-hoppers move from one destination to another. This crowd is also likely older than the typical skateboard crowd, which may contribute to the increased age of patients with craniofacial injuries under the influence of alcohol or drugs.

Alcohol and drug use while skateboarding or scootering is well reported in descriptive studies to occur concurrently.^7-12 Furthermore, craniofacial injuries are common following skateboard- and scooter-related injury.^1,12-14 Our cross-sectional study is a natural extension of this research as we are the first to report the ORs of sustaining these craniofacial injuries while under the influence of alcohol or drugs. The likelihood of craniofacial injury is drastic; our paper revealing over a 4-fold increase compared to not using alcohol or drugs. Though we are unable to stratify based on manual vs powered status, we would assume that a stratified OR for powered skateboard and scooter use would be similar and would hope that our results could inform public policy or legislative efforts to curtail these injuries. As the use of these powered skateboards and scooters continues to spread, it will be important to have mechanisms in place to curtail the concurrent spread of injury. ¹⁵ One solution could include a legal extension to include electric scooters under the umbrella of motorized vehicle for the purpose of policing driving under influence laws as there are no current legal implications for operating these devices while intoxicated (at least in our state).

Another such effort could be the mandatory use of helmets. Unfortunately, we are unable to comment on helmet use in our study population, but past research has well documented that alcohol and helmet use during recreational activities frequently do not occur together. ¹⁶ Though suggestions to wear a helmet are included in the terms of use for the popular electric scooter companies, there are no obvious warnings or recommendations to wear a helmet while registering to use an electric scooter. As these warnings are easily disregarded by enthusiastic scooter users, further emphasis must be made to inform users of the dangers associated with un-helmeted scooter use, especially under the influence of alcohol or drugs. Efforts to mandate helmet use on powered skateboards or scooters may be the single most useful intervention for preventing these injuries. ¹⁷

Alcohol use and increased injury severity have also been reported in the past,^18-21 though not without controversy. ²² Our study continues to be an extension of prior research and is the first to report ORs of hospitalization following their skateboard or scooter injuries under the influence, which is relevant for the sake of both the physical and financial health of the patient and the prevention of these injuries. Though we are unable to assess injury severity in our population cohort, we have used ED disposition as a proxy for severity, assuming that patients who are subsequently hospitalized have generally greater injury severity than patients who are discharged. Alcohol and drug use while skateboarding or scootering should be avoided as the likelihood of physical injury requiring hospitalization increases by over 2-fold compared to no substance use group; this angle may be enough to encourage only sober participation in these activities. Furthermore, hospitalization is very expensive, and the financial implications of this increased risk of hospitalization may also be a deterrent to some skateboard or scooter users.

Limitations

There are limitations. Though the large numbers present provide strength to this study, there is documented evidence that large nationwide databases can have inaccurate data.^23,24 Furthermore, this database was not specifically designed with medical researchers in mind but is a useful tool for computing population healthcare trends and has been of great importance to many specialties in numerous prior analyses.^25-30 However, only patients who present to the ED for emergency care are recorded, which can introduce biases against minor injuries, uninsured patients, or patients who prefer to use outpatient or urgent care settings. ³¹ Nevertheless, our study reports strong evidence to support the increased likelihood of craniofacial injury and hospitalization while using skateboards and scooters under the influence of alcohol or drugs.

Conclusions

Alcohol and drug use while any skateboarding or scootering drastically increases the likelihood of craniofacial injury and subsequent hospitalization and should be avoided whenever possible. The importance of wearing a helmet while operating these devices cannot be overstated.

ORCID iDs

Thomas J. Sorenson https://orcid.org/0000-0001-6658-254X

Rachael Gotlieb https://orcid.org/0000-0002-5932-7054