Brain Injury
ISSN: 0269-9052 (Print) 1362-301X (Online) Journal homepage: http://www.tandfonline.com/loi/ibij20
Head injuries in hospital-admitted adolescents and adults with skateboard-related trauma Gail T. Tominaga, Kathryn B. Schaffer, Imad S. Dandan, Frank J. Coufal & Jess F. Kraus To cite this article: Gail T. Tominaga, Kathryn B. Schaffer, Imad S. Dandan, Frank J. Coufal & Jess F. Kraus (2015) Head injuries in hospital-admitted adolescents and adults with skateboardrelated trauma, Brain Injury, 29:9, 1044-1050, DOI: 10.3109/02699052.2014.989404 To link to this article: http://dx.doi.org/10.3109/02699052.2014.989404
Published online: 16 Jul 2015.
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Date: 18 February 2016, At: 08:06
http://tandfonline.com/ibij ISSN: 0269-9052 (print), 1362-301X (electronic) Brain Inj, 2015; 29(9): 1044–1050 ! 2015 Taylor & Francis Group, LLC. DOI: 10.3109/02699052.2014.989404
Head injuries in hospital-admitted adolescents and adults with skateboard-related trauma Gail T. Tominaga1, Kathryn B. Schaffer1, Imad S. Dandan1, Frank J. Coufal1, & Jess F. Kraus2 Scripps Memorial Hospital La Jolla Trauma Service, La Jolla, CA, USA and 2UCLA Department of Epidemiology, UCLA, Los Angeles, CA, USA
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1
Abstract
Keywords
Objective: To provide new information on properties of skateboarders who were hospital admitted with head injuries with details of the injuries including region of head impact. Methods: Hospital records of patients aged 15 and older with a skateboard injury admitted to one Level II Trauma Centre during a 10-year period were reviewed. Data on demographic, exposure, severity, diagnostic and clinical factors for patients with head injury (HI) and without HI (N-HI) were compared analytically. Results: While there were no differences for patients with HI and N-HI by age, gender, mechanism of injury or alcohol use, patients with HI were more severely injured. Although significantly more head impacts occurred to the occipital region of the head, haematomas and/ or contusions were much more likely to occur in the frontal region of the brain. Acute neurosurgical intervention was needed in 14% of HI skateboarders. Conclusion: Skateboarding is not an innocuous recreational activity, with head injury present in 75% of patients who were hospital-admitted. Pre-hospital treatment protocols should be aware of this growing injured population. Falls while on a skateboard lead to impacts to the back of head with a contra-coup brain injury resulting in severe and sometimes fatal outcomes. The very low prevalence of helmet use among skateboarders with head injuries indicates that greater efforts should be directed toward incentives for their use.
Contra-coup injury, epidemiology, skateboard-related injury, skull impact
Introduction From the initial 1965 article [1] on the hazards associated with skateboarding, some 60 reports have appeared in the literature and are represented by an eclectic mixture of editorials, commentaries, reviews, secondary and empirical data analyses in a variety of different journals. Twenty-five articles that mention head injuries from skateboarding based on peer-reviewed empirical studies or existing databases have been published since 1977 [2–26]. In almost all of these reports, information on head trauma was anecdotal and clinical details were missing. The range of head injuries in these 25 reports was from 3–67%, with many reporting from 3–10% [2, 4, 5, 14, 15]. The head injuries identified in these earlier reports were most often of the soft tissue variety. Four accounts reported head injuries of 25–67% [9, 11, 16, 17] but findings on the nature, extent and outcomes from these injuries are generally incomplete. This study was undertaken given the popularity of skateboarding and the limited, albeit confusing information, on head injuries including the potential for severe if not fatal outcomes from related falls. The objectives of this study were
Correspondence: Gail T. Tominaga, MD, Scripps Memorial Hospital La Jolla, 9888 Genesee Ave. LJ 601, La Jolla, CA 92037, USA. E-mail: [email protected]
History Received 29 April 2014 Revised 24 September 2014 Accepted 15 November 2014 Published online 16 July 2015
to: provide new information on the epidemiological and clinical properties of skateboarders who were hospital admitted with a head injury (HI); describe how these factors relate to older age, mechanism of injury (MOI), alcohol use and severity of injury; and delineate details of the head injuries sustained including the impact region of the head. Skateboarders who were hospital admitted without a head injury (N-HI) are compared to skateboarders with a head injury (HI) to illustrate the unique features and in-hospital outcomes from this cohort of patients.
Methods Patients aged 15 years and older admitted to one Level II Trauma Centre from January 2000–December 2009, who suffered an injury while skateboarding, were included in the study population. Only patients aged 15 and older are admitted to the Level II Trauma Centre; younger patients are referred to their regional Paediatric Trauma Centre. Patients were identified from the institution’s Trauma Registry and by International Classification of Disease (ICD), 9th edition code for falls. Because of the potential for code misclassification of falls from skateboards a search of all external cause of injury (E) codes 880–888 (a fall of any type) and E 814 (pedestrian–motor vehicle mishaps) also was employed.
Head injuries while skateboarding
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DOI: 10.3109/02699052.2014.989404
Data on the following factors were extracted from medical chart review: demographics, mechanism of injury (MOI), helmet use, pre-hospital care with mode of transportation, location of skull impact, Glasgow Coma Score (GCS), Abbreviated Injury Score (AIS) for each body region, Injury Severity Score (ISS), length of hospital stay (LOS), Intensive Care Unit (ICU) days and discharge disposition. Head injury was defined as impact to the head from any source while skateboarding, with a head-AIS of 1–5 and included concussions, contusions, intracranial haemorrhages and fractures. Skull impact location and skull fractures were identified. Depressed fractures were given preference in coding over other concurrent skull fractures in the same patient. All computerized tomography (CT) imaging of the head was reviewed and positive findings were collected. Brain contusions, intracranial haematomas and intracranial haemorrhages were classified as Intracranial Haemorrhage (ICH) for purposes of the analyses. The approximate surface area of bones of the skull was estimated by visual measurement of each bone, repeated 10-times for each of five published pictorials of the skull [27]. MOI was categorized into three groups: (1) Loss of control, riding down a hill or street at high speed; (2) Pulled by a vehicle or performing tricks (categorized as ‘manoeuvres’); (3) struck by a motor vehicle. Evidence of alcohol use was recorded as positive if noted by the physician in the medical record and/or by positive serum blood alcohol level. Otherwise, it was considered negative. The authors searched for evidence of head protection while skateboarding in each of the pre-hospital records and hospital medical records The severity of each injury was measured by AIS for each body region [28]. Maximum AIS (MAIS) refers to the most severe injury of a specific body region and was calculated with ISS for all patients [29]. Admission GCS [30] was recorded. Protocols for this research were approved by the hospital’s Institutional Review Committee.
Analyses Patients with HI and N-HI were compared on age, gender, MOI, alcohol use and means of transport. Older age was defined as 30 years of age and older. Head injuries were characterized by AIS, ISS, GCS, skull impact point, presence of skull fractures or ICH and need for neurosurgical operation. Student’s t-test, Odds Ratios and 95% Confidence Intervals (CI) were derived where relevant. Chi-square ( 2) tests for linear trend, Pearson’s goodness of fit, contingency, independence, Mantel-Haenszel and Fisher’s exact probability tests (for very small numbers) [31] were used to identify differences in the distributions of relevant variables. Unless otherwise noted, 2-tail results are reported. Yates correction for small sample sizes was used when one or more cells had an observed number less than six. Chi-squares were selected with unequal variance if indicated. Level of significance was set at 5% a priori.
Results Skateboarders with HI vs. N-HI Age and gender The age range of injured skateboarders was 15–61 years. The age distributions of skateboarders with a HI compared with N-HI were not significantly different ( 2 ¼ 1.49, p ¼ 0.684) (Table I). There was no stepwise increase in odds of HI vs. N-HI with increasing age when compared with the reference age of 15–19 years (Table I). Males comprised 92% of patients who were hospital admitted following a skateboard-related injury and, while they were somewhat more likely to have had a HI compared with females, the difference in occurrences was not significant (OR ¼ 2.91, 95% CI ¼ 0.99–8.52, p corrected ¼ 0.087). Males who sustained a skateboard-related injury were no more likely to be age 30 or older than females (OR ¼ 0.55, 95% CI ¼ 0.14–2.12, p corrected ¼ 0.637).
Table I. Demographics and study patient characteristics of HI and N-HI skateboarders. HI (n ¼ 141)
Age group (in years) 15–19 20–24 25–29 30+ Gender Male Female Mechanism of injury Lost control or on streetc Manoeuvresd Struck by car Alcohol use No Yes a
N-HI (n ¼ 47)
n
%
n
%
OR (95% CI)
p Value
83 28 13 17
58.9 19.9 9.2 12.1
23 11 6 7
48.9 23.4 12.8 14.9
1.0 Reference 0.71 (0.30–1.63) 0.60 (0.20–1.75) 0.66 (0.25–1.94)
0.411 0.347a 0.433a
133 8
94.3 5.7
40 7
85.1 14.9
1.0 Reference 0.35 (0.10–1.12)
0.098b
102 32 7
72.3 22.7 5.0
27 14 6
57.4 29.8 12.8
1.0 Reference 0.61 (0.28–1.29) 0.31 (0.08–1.22)
0.192a 0.100b
114 27
80.9 19.1
40 7
85.1 14.9
1.0 Reference 1.35 (0.56–3.58)
0.662a
Yates corrected 2. Fisher two-tail exact probability. c Includes loss of control, riding downhill or street at high speed. d Includes pulled by vehicle, jumps/tricks, in skateboard park, in swimming pool and striking object not on street. b
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Skateboarders with HI were no more likely to be aged 30 or older than N-HI (OR ¼ 9.57, 95% CI ¼ 0.11–8.30, p corrected ¼ 0.604). Mechanism of injury Almost 73% of skateboarders with HI had lost control of a skateboard, with only 5% struck by a motor vehicle (MV), while 57.4% of skateboarders without HI lost control, with 12.8% struck by a MV. There was no significant difference in the distributions of mechanism of injury for skateboarders with and without a head injury ( 2 ¼ 4.97, p ¼ 0.083) (Table I).
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Alcohol use Although alcohol use was recorded for 19.1% of patients with HI compared with 14.9% in patients without a head injury, the difference in proportions was not statistically significant (Table I). Patients 30 years of age and older were no more likely to have used alcohol than patients without a HI in the same age group (OR ¼ 2.53, 95% CI ¼ 0.26–24.5, Fishers exact p ¼ 0.297). Helmet use Less than 5% (n ¼ 7) of skateboarders with head injuries were noted to have been wearing helmets and three of these were active in skateboarding parks where helmet use is required. There were too few numbers for additional analysis.
HI were almost 12-times more likely than patients without HI to have ground or air ambulance transport to the ED (Table II). Whereas 22.7% of patients with HI were transported by air, only 4.3% of patients without HI were transported by air. While 65.2% of patients with HI came to the hospital by ground ambulance, 61.7% of patients without HI arrived by private vehicle. Severity Skateboarders with HI were 29-times more likely to have an MAIS of 4–5 compared with skateboarders without HI (Table II). The body region with the most severe injury was the head for MAIS 4–5 patients. Those with a HI were over 35-times more likely to have an ISS of 16 or greater compared with skateboarders without HI (Table II). LOS/ICU days The distributions of LOS for skateboarders with or without HI were not significantly different from one another ( 2 ¼ 1.46, p ¼ 0.693) (Table II) and patients with HI admitted for 7 days or longer were no more likely to be aged 30 or older than patients without HI (OR ¼ 1.85, 95% CI ¼ 0.17–21.26, p corrected ¼ 0.963). However, the distributions of ICU days for skateboarders with or without HI were significantly different (Yates corrected 2 ¼ 32.85, p50.0001). Disposition
Transport Mode of transport to the hospital for patients with and without HI was significantly different (Table II). Skateboarders with
Eighty-eight per cent of skateboarders with HI were discharged home, while 3.5% were transferred to another acute care hospital, 6.3% were transferred to a rehabilitation
Table II. Mode of transportation, injury severity and hospital stay data. HI (n ¼ 141)
Mode of transportation Private vehicle Air/ground AIS 1–3 4–5 ISS 1–3 4–8 9–15 16+ LOS 1 2–3 4–6 7+ ICU** 1–2 3–6 7+
N-HI* (n ¼ 47)
n
%
n
%
OR (95%CI)
p Value
17 124
12.1 87.9
29 18
61.7 38.3
1.0 reference 11.75 (5.41–25.54)
50.000 0001
86 55
61.0 39.0
46 1
97.9 2.1
1.0 reference 29.11 (5.39–610.4)
50.000 001a
0 43 39 59
0.0 30.5 27.7 41.8
6 26 14 1
12.8 55.3 29.8 2.1
not tested 1.0 reference 1.68 (0.77–3.68) 35.67 (4.83–733.28)
0.189 50.000 001a
28 61 27 25
19.9 43.3 19.1 17.7
9 23 10 5
19.1 48.9 21.3 10.6
1.0 reference 0.85 (0.35–2.08) 0.79 (0.35–2.08) 1.61 (0.47–5.44)
0.725 0.790 0.642b
58 15 12
68.2 17.6 14.1
2 1 2
40.0 20.0 40.0
1.00 reference 0.52 (0.03–32.53) 0.21 (0.02–1.62)
0.513b 0.320b
*Non-head injured are MAIS. **For only those with at least 1 ICU day. a Fisher exact 2-tail probability test. b Yates corrected 2. OR, odds ratio.
Head injuries while skateboarding
DOI: 10.3109/02699052.2014.989404
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Table III. Skull impact location and injury factors of HI skateboarders. Skull impact location Occipital
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n Factor Obs 84 Exp 9.9 Age 15–19 49 20–29 27 30+ 8 Gender Male 79 Female 5 Mechanism of injury Controld 67 Manoeuvres 17 Alcohol use No 66 Yes 18
Temporal
Frontal
Parietal ORa (95% CI)
p Value
%
n
%
n
%
n
%
59.6 7.0
25 32.4
17.7 23.0
21 25.4
14.9 18.0
11 73.3
7.8 52.0
b
58.3 32.1 9.5
14 7 4
56.0 28.0 16.0
13 5 3
61.9 23.8 14.4
7 2 2
63.6 18.2 18.2
1.00 Reference 1.34 (0.61–2.92) 0.62 (0.21–1.76)
0.591 0.522
94.0 6.0
24 1
96.0 4.0
19 2
90.5 9.5
11 0
100.0 0.0
1.00 Reference 0.88 (0.16–4.46)
0.844c
9.8 20.2
21 4
84.0 16.0
13 8
61.9 38.1
8 3
72.7 27.3
1.00 Reference 0.71 (0.32–1.57)
0.521
57.9 66.7
21 4
18.4 14.8
19 2
16.7 7.4
8 3
7.0 11.1
1.00 Reference 1.45 (0.60–3.66)
0.404
a
Odds ratios compare occipital with the sum of all other impact locations. goodness of fit ¼ 88.91, p50.000 001. Yates corrected 2. d Loss of control of skateboard. Obs, Observed number for each anatomic head region; Exp, Expected number for each anatomic head region based on estimated percentage surface area of each bone measured in the standard adult skull. b2 c
facility and 2.1% died (all HI). All skateboarders without HI survived and were discharged home. Head injuries Head injuries were diagnosed in 141 (75%) of all skateboarders admitted to the hospital (Table I) and the head had the highest MAIS in 134 of the group with HI, while the remaining patients with HI had their MAIS in other body areas they were still included in the HI group. Among the 141 patients with HI there were 343 head injury diagnoses (an average of 2.4 per patient) including skull fractures (n ¼ 51), ICH (n ¼ 182) and concussion (n ¼ 110). The odds of an AIS level 4–5 vs. AIS level 2–3 head injury was no greater for those aged 30 or older compared with those aged 15–19 years (OR ¼ 1.81, 95% CI ¼ 0.63–5.22, p ¼ 0.267). A similar non-significant finding was seen for skateboarders with HI aged 30 and older compared with those aged 20–29 (OR ¼ 1.03, 95% CI ¼ 0.33–3.20, p ¼ 0.960). Skateboarders with a head AIS of 4–5 were more likely to have been injured in loss of control–street impacts than those with an AIS of 2–3 (OR ¼ 5.60, 95% CI ¼ 1.58–19.81, p corrected ¼ 0.007). Among skateboarders with HI, those aged 30 and older were no more likely to have an ISS of 16 or greater than younger skateboarders with HI (OR ¼ 2.52, 95% CI ¼ 0.87–7.32, p corrected ¼ 0.142). Skateboarders with HI and an ISS of 16 or more were more likely to have been injured in loss of control–street collisions than those with an ISS of less than 16 (OR ¼ 4.19, 95% CI ¼ 1.34–13.05, p ¼ 0.009). Skateboarders with HI and a GCS of 8 or less were much more likely to have a LOS of 7 days or longer compared with those with a GCS of 9–15 (OR ¼ 7.00, 95% CI ¼ 1.73–28.34, p corrected ¼ 0.009). Similarly, skateboarders with a head
AIS of 4–5 were much more likely to have a LOS of 7 days or longer compared with those with an AIS of 2–3 (OR ¼ 9.26, 95% CI ¼ 3.22–26.64, p50.0001). Skateboarders with HI who used alcohol were no more likely to have a LOS of 7 days or longer than those not using alcohol (OR ¼ 1.07, 95% CI ¼ 0.36–3.16, p40.999). Head impact point It was determined that the surface area of the skull for an average adult is composed of 7% occipital bone, 23% temporal bone (includes sphenoid), 18% frontal bone and 52% parietal bone. The probability of a distribution of skull impact points from skateboarding as recorded in Table III is less than 0.000 001. Skateboarders with HI are significantly more likely to have an AIS of 4–5 because of impact to the occipital region than any other skull region (OR ¼ 2.22, 95% CI ¼ 1.08–4.56, p ¼ 0.028); this finding was similar for all age groups and both genders. Skateboarders with an impact to the occipital skull were no more likely to have lost control (OR ¼ 1.31, 95% CI ¼ 0.54–3.16, p ¼ 0.521) or have used alcohol than riders with impacts to other parts of the skull (OR ¼ 1.45, 95% CI ¼ 0.60–3.52, p ¼ 0.404). Skull fractures Fifty-one (36.4%) of the 140 skateboarders with HI and a completed head CT scan had a skull fracture and 72.5% of these were located in the occipital region of the skull. Also, those with a skull fracture were over 19-times more likely also to have an ICH compared with those with no skull fracture (Table IV). There was no difference in gender (OR ¼ 1.69, 95% CI ¼ 0.33–8.73, p ¼ 0.798) or age (OR ¼ 1.74, 95% CI ¼ 0.62–4.82, p ¼ 0.286) in those sustaining skull fractures.
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Table IV. Factors related to skull impact locationa for patients with HI. Skull impact location Occipital Factor
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GCS 14–15 9–13 3–8 AIS 2–3 4–5 Skull fx ICHc No ICHd No skull fx ICHc No ICHd
Temporal
Frontal
Parietal ORb (95% CI)
p Value
100.0 0.0 0.0
1.00 Reference 0.91 (0.32–2.61) 2.46 (0.44–25.22)
0.928e 0.314f
72.7 27.3 5.9 6.5
1.00 Reference 2.22 (1.08–4.56) n ¼ 51 n ¼ 46 n¼5 n ¼ 89 n ¼ 29 n ¼ 60
n
%
n
%
n
%
n
%
68 9 7
81.0 10.7 8.3
17 7 1
68.0 28.0 4.0
20 0 1
95.2 100.0 4.8
11 0 0
45 39 37 32 5 46 18 28
53.6 46.4 72.5 69.6 100.0 51.7 62.1 46.7
15 10 10 10 0 15 3 12
60.0 40.0 19.6 21.7
18 3 1 1 0 20 4 16
85.7 14.3 2.0 2.2
8 3 3 3 0 8 4 4
16.9 10.3 20.0
22.5 13.8 26.7
9.0 3.8 6.7
0.029
Odds ratio comparing ICH with/without skull fracture ¼ 19.03, 95% CI ¼ 6.838–52.99, p50.000 001 Neurosurgical operation No Yes
71 13
84.5 15.5
20 5
80.0 20.0
20 1
95.2 4.8
10 1
90.9 9.1
1.00 Reference 1.31 (0.49–3.51)
0.774e
a
One patient did not have a CT scan. All odds ratios compare occipital impact location with the sum of all other head impact locations. c ICH includes haemorrhages and/or contusions. d Includes concussions. e Yates corrected 2. f Fisher exact 2-tail probability test. b
GCS/head AIS Slightly more than 82% of skateboarders with HI had a GCS of 14–15, 11.3% had a GCS of 9–13 and 6.4% had a GCS of 3–8. Patients with a GCS of 3–8 were no more likely to have a HI impact in the occipital region than those with an impact to other parts of the head (Table IV). Those with a GCS of 8 or less were no more likely to have used alcohol than those with a higher GCS (OR ¼ 0.51, 95% CI ¼ 0.51–4.26, Fishers exact p ¼ 1.000). Those with a head-AIS of 4 or 5 were more than twice as likely to have an occipital skull impact as any other impact point (Table IV). Intracranial haematomas/haemorrhage and contusions (ICH) ICH were diagnosed in 53.6% of skateboarders with HI and three-quarters of these had an AIS of 4–5. Patients with an ICH were almost 15-times more likely than expected to have it located in the frontal region of the brain compared with any other region of the brain (OR ¼ 14.60, 95% CI ¼ 6.56–32.50, p50.000 000 1). Two-thirds of ICHs in the frontal region resulted from an impact to the occipital region of the skull. ICH was more often related to a loss of control MOI (OR ¼ 7.61, 95% CI ¼ 2.44–27.00, p ¼ 0.0002) when compared with any other type of mechanism of injury. Surgery Acute neurosurgical intervention was required in 14% of skateboarders with HI. The neurosurgery rate for the occipital and temporal skull impact regions was 18.3% and 20%, respectively. Surgery rates for the frontal and parietal skull impact regions could not be tested because of very small numbers. However, the odds of surgical vs. non-surgical
intervention for the occipital region vs. all other regions was not significantly dissimilar (p ¼ 0.774) (Table IV). Patients requiring neurosurgical intervention were almost 23-times more likely to have a LOS of 7 or more days (OR ¼ 23.55, 95% CI ¼ 7.53–73.58, p50.000 01) than those not requiring neurosurgical intervention. Those requiring neurosurgical intervention were no more likely to have been involved in loss of control of the skateboard than those not requiring surgery (OR ¼ 4.46, 95% CI ¼ 0.57–35.04, Fisher exact p ¼ 0.197).
Discussion This report is one of the first reports in the Western medical literature illustrating head trauma among older recreational skateboarders. Although there are reports that list head trauma among the injuries sustained by skateboarders, some of these reports utilized the National Electronic Injury Surveillance System (NEISS) for case-finding and, hence, their data were limited to only general descriptions as found in the emergency department record [2, 7, 13, 15]. Many reports limited their study groups to patients aged 20 or less [4–6, 9–12, 19, 21–23] and some reports combined data from a variety of exposures beside skateboarding, such as bicycling and in-line skating [7–11, 14, 19, 23, 24], which made it difficult to isolate findings specific for skateboarders. Finally, only one published report [16] provided information on head injury for older adolescents and/or adults, but the age categories in that report included mostly children and early adolescents and the oldest age category included those over age 16 years without additional age group detail. Thus, the comparison of these findings with those in that report is not recommended.
Head injuries while skateboarding
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DOI: 10.3109/02699052.2014.989404
This study found three-quarters of all skateboarders admitted to the hospital had a head injury, significantly higher than that reported in the earlier published literature and twice the proportion reported by the only published report with somewhat similar case-identification methods [16] as this current report. The variations in hospital admission policies, E-code misclassification of skateboarding and/or the variation of skateboarding head-injury prevalence across the US within the patients included in the aggregate National Trauma Database (NTDB) [16] might explain the differences in head injury occurrence as found in the data. Although the types of head injuries are listed in the NTDB report [16], their respective severities, multiplicity, relationship to head impact points and connection with alcohol use and mechanism of injury are not fully described. The occurrence of skull fracture in this series of patients was more than double that reported by Lustenberger et al. [16]. In addition, 90% of these patients were diagnosed with one or more ICHs. Also, intracranial haemorrhages and contusions were diagnosed in about one-third of patients without skull fractures, suggesting further that ED physicians should be alerted to the intracranial injury profile of skateboarders observed in this study. Despite the decades since its introduction, skateboarding still appears to be a male dominated activity, at least as represented by the injuries this activity produces. Without information on the total population of active skateboarders during the study period, one cannot conclude that males are at higher risk of hospital admitted injury than females. Skate parks are not immune from injuries including head injuries [8, 19], even with mandated helmet use. One of the limitations of this current study was the inability to accurately portray the exact MOI in the study population. For example, while the medical record may document ‘being struck by a vehicle’, full details of the skateboarding exposure were often not recorded. Also, this study was not able, with the information available, to determine the type of skateboard used by the injured patient. Future studies should incorporate methods to document and describe fully the activities, environments and types of equipment used when the injuries occur and record the helmet status of the injured skateboarder. We recommend adding skateboarding to the list of alcoholinvolved recreational activities that result in head injuries. It is noteworthy that 24% of those with evidence of alcohol use while skateboarding were under the age of 20 in a state (CA) where there is zero alcohol tolerance for this age group. While there is no reason to believe alcohol use was misreported among those skateboarders with HI compared with N-HI, it is acknowledged that blood alcohol concentrations were not performed on all patients; hence, the true prevalence of alcohol use may have been underestimated. Unlike the report using data from the NTDB [16], no increase was found in frequency of AIS 4–5 head injuries in the three age groups (15–19, 20–29 and 30+) but the age categories were different from that of the NTDB data. Nevertheless, these injuries are life threatening and require a much different emergency room culture to anticipate profiles
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of the injured and the treatments needed including neurosurgical intervention. Despite a California state law requiring mandatory helmet use among skateboarders less than 18 years of age, the absence of helmet use in all age groups is commonly observed. There is at present no effective enforcement of helmet use, even in skate parks where state law can be more easily monitored [32]. Use of helmets by older skateboarders is, at this time, voluntary and they were worn by less than 5% of the injured skateboarders in this study. This preventive measure when employed is effective, but incentives for helmet compliance for skateboarders of all ages are illusive [32]. The significantly higher than expected frequency of falls from skateboards resulting in impacts to the occipital region of the skull, not related to age, gender or mechanism of injury, suggests that skateboarders fall backward following loss of control. This finding contradicts those from other forms of recreational activity such as bicycling which show that, with loss of control, there is forward momentum generally resulting in an impact to the front of the head and face. The implications for design of head protection to ameliorate this impact region are clear but, again, skateboarders must first recognize the need for and then act on the use of head protection. More study is needed on this question. The data describe the well-known contra-coup type of intracranial injury; that is, traumatic brain lesions are often located at a distance (generally opposite) from the impact site [33]. The findings of an occipital skull impact with potential frontal lobe damage associated with symptoms such as confusion and behavioural problems should alert pre-hospital and Emergency Department personnel of the need for urgent neurosurgical consultation in patients with such presentations. Skateboarding can no longer be considered an innocuous recreational activity, with 75% of skateboarders requiring hospital admission having a head injury in this study group. Pre-hospital triage protocols may need to be adjusted to ensure patient evaluation at an Emergency Department with neurosurgical coverage. The nature of skateboarding and the resulting anatomic location of the impact to the head of these patients suggest that much more must be done to prevent these injuries. Other limitations This study population may not be representative of wider geographic regions. The service area of the Trauma Centre is in a very temperate climate, with many people engaged in outdoor activities year round. Skateboarding is commonly observed on private property as well as public areas and roadways year-round, by all ages and genders and often used as a mode of commuting to work or school as well as for recreational purposes. There is no reason to doubt that these findings do not mirror the changing trends in use of and injury from skateboards, especially older riders. Extra precautions were taken in case finding to ensure that all patients with skateboard-related injury were identified and included in the database. However, the authors were not able to verify in the medical record some factors such as exact MOI, alcohol and helmet use for all patients; hence, the findings may be incomplete. Further exploration of these factors appears
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warranted. However, a Trauma Centre can perform a much needed service in attempting to obtain this type of information for future studies. The authors could not locate in the published literature precise measurements of the surface area of the major bones of the adult skull, hence an approximation was undertaken by visual assessments with repetitions. Despite the possibility of somewhat less than accurate skull bone sizes used in the analyses, it is believed the approximations represent a reasonable average value and the statistical finding was so huge that no change in conclusion would be warranted. Certain analyses such as multivariate testing could not be undertaken in this evaluation because of very small numbers in many cells (e.g. sub-samples of those having surgical interventions). Collaboration with other institutions to expand the database on the clinical/exposure/outcome factors might better address this shortcoming.
Conclusions In this study an overwhelming proportion of patients with skateboard-related injury had trauma to the head. This fact alone should prompt changes in pre-hospital treatment protocols. It appears that skateboarders who fall backwards after a collision of any kind very frequently sustain an impact in the occipital region of the skull. This in turn results in the common contra-coup type of brain injury. Such injuries often are severe and have fatal outcomes. While helmets have been shown to ameliorate head trauma from skateboarding mishaps their use is woefully deficient and this fact should prompt better ways to influence their greater use among skateboarders.
Acknowledgements We thank our Trauma Nurse Director, Cheryl Wooten, RN, MSN, for facilitating access to trauma registry data and support for this project and consultation/manuscript review of data by Kevin Yoo, MD (Neurosurgeon).
Declaration of interest The authors report no conflicts of interest. This study was sponsored in part by the N. Paul Whittier Trauma Foundation and a Research Grant from the Santiago and Cecilia Aguerre Family.
References 1. Kincaid CK. The high price of skateboarding. Quarterly Bulletin Wisconsin State Board of Health 1965;17:9. 2. Jacobs R, Keller E. Skateboard accidents. Pediatrics 1977;59: 939–942. 3. Maitra A. Skateboard injuries. British Journal of Clinical Practice 1979;33:281–282. 4. Allum RL. Skateboard injuries: A new epidemic. Injury 1977;10: 152–153. 5. Fyfe I, Guion A. Skateboard injuries. Injury 1978;10:149–151. 6. Cass D, Ross F. Skateboard injuries. Medical Journal of Australia 1990;153:140–144. 7. Scheiber R, Branche-Dorsey C, Ryan G. Comparison of in-line skating injuries with roller skating and skateboarding injuries. Journal of the American Medical Association 1994;271: 1856–1858.
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8. Vaca F, Fox JC, Mai D, Anderson CL, Kwon KT. Skatepark-related injuries in a Southern California skatepark and their associated short-term disability and health care utilization. Clinical Journal of Sport Medicine 2005;15:142–147. 9. Osberg J, Schneps S, DiScala C, Li G. Skateboarding: More dangerous than roller-skating or in-line skating. Archives of Pediatrics & Adolescent Medicine 1998;152:985–991. 10. Schalamon J, Sarkola T, Nietosvaara Y. Injuries in children associated with the use of non-motorized scooters. Journal of Pediatric Surgery 2003;38:1612–1615. 11. Chapman S, Webber C, O’Meara M. Scooter injuries in children. Journal of Pediatrics & Child Health 2001;37:567–570. 12. McGeehan J, Shields BJ, Smith GA. Children should wear helmets while ice-skating: A comparison of skating-related injuries. Pediatrics 2004;114:124–128. 13. Retsky J, Jaffe D, Christoffel K. Skateboarding injuries in children. American Journal of Diseases of Children 1991;145:188–193. 14. Orenstein JB. Injuries and small-wheel skates. Annals of Emergency Medicine 1996;27:204–209. 15. Kyle S, Nance M, Rutherford G, Winston F. Skateboard-associated injuries: Participation-based estimates and injury characteristics. Journal of Trauma 2002;53:686–690. 16. Lustenberger T, Talving P, Barmparas G, Schnuriger B, Lam L, Inaba K, Demetriades D. Skateboard-related injuries: Not to be taken lightly. A National Trauma Databank analysis. Journal of Trauma 2010;69:924–927. 17. Tominaga GT, Schaffer KB, Dandan IS, Kraus J. Epidemiological and clinical features of an older high-risk population of skateboarders. Injury 2013;44:645–649. 18. Baker SP, Fowler C, Li G, Warner M, Dannenberg. Head injuries incurred by children and young adults during informal recreation. American Journal Public Health 1994;84:649–652. 19. Everett WW. Skatepark injuries and the influence of skatepark design: A one year consecutive case series. Journal of Emergency Medicine 2002;23:269–274. 20. Forsman L, Eriksson A. Skateboard injuries today. British Journal of Sports Medicine 2001;35:325–328. 21. Illingworth CM, Jay A, Noble D, Collick M. 225 Skateboard injuries in children. Clinical Pediatrics 1978;17:781–789. 22. Pendergrast RA. Skateboard injuries in children and adolescents. Journal of Adolescent Health Care 1990;11:408–412. 23. Sorensen L, Larsen SE, Rock ND. The epidemiology of sports injuries in school-aged children. Scandinavian Journal of Medicne & Science in Sports 1996;6:281–286. 24. Konkin D, Garraway N, Hameed M, Brown DR, Granger R, Wheeler S, Simons RK. Population-based analysis of severe injuries from non-motorized wheeled vehicles. American Journal of Surgery 2006;191:615–618. 25. Macdonald DJM, McGlone S, Exton A, Perry S. A new skatepark: The impact on the local hospital. Injury 2006;37:238–242. 26. Christian MS, Khan O. Skateboard injuries: A current appraisal. British Journa of Sports Medcine 1980;14:102–104. 27. Human Skull. Wikipedia. Available from: http://en.wikipedia. org/wiki/Human_skull#site_note-Rushton1-6. Accessed 30 August 2013. 28. Association for the Advancement of Automotive Medicine. The Abbreviated Injury Scale; 1990 revision. Des Plaines, IL: Association of the Advancement of Automotive Medicine; 1990. 29. Baker S, O’Neill B, Haddon W, Long W. The Injury Severity Score: A method for describing multiple injuries and evaluating emergency care. Journal of Trauma 1974;14:187–196. 30. Teasdale G, Jennett B. Assessment of coma and impaired consciousness: A practical scale. Lancet 1974;2:81–83. 31. Jekel JF, Elmore JG, Katz DL. Epidemiology, biostatistics and preventive medicine. Philadelphia, PA: W.B. Saunders Company; 1996. 32. Gupta R. Trading skate park supervisors for helmetless kids and vandalism. March 30, 2009. San Diego, CA: Voice of San Diego. Available from: http://www.voiceofsandiego.org/topics/government/trading-skate-park-supervisors-for-helmetless-kids-and-vandalism/. Accessed 17 August 2011. 33. Cooper PR. Post-traumatic intracranial mass lesions. In: Cooper PR, editor. Head injury. 4th ed. New York: McGraw-Hill; 2000. pp 293–348.
ISSN: 0269-9052 (Print) 1362-301X (Online) Journal homepage: http://www.tandfonline.com/loi/ibij20
Head injuries in hospital-admitted adolescents and adults with skateboard-related trauma Gail T. Tominaga, Kathryn B. Schaffer, Imad S. Dandan, Frank J. Coufal & Jess F. Kraus To cite this article: Gail T. Tominaga, Kathryn B. Schaffer, Imad S. Dandan, Frank J. Coufal & Jess F. Kraus (2015) Head injuries in hospital-admitted adolescents and adults with skateboardrelated trauma, Brain Injury, 29:9, 1044-1050, DOI: 10.3109/02699052.2014.989404 To link to this article: http://dx.doi.org/10.3109/02699052.2014.989404
Published online: 16 Jul 2015.
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Date: 18 February 2016, At: 08:06
http://tandfonline.com/ibij ISSN: 0269-9052 (print), 1362-301X (electronic) Brain Inj, 2015; 29(9): 1044–1050 ! 2015 Taylor & Francis Group, LLC. DOI: 10.3109/02699052.2014.989404
Head injuries in hospital-admitted adolescents and adults with skateboard-related trauma Gail T. Tominaga1, Kathryn B. Schaffer1, Imad S. Dandan1, Frank J. Coufal1, & Jess F. Kraus2 Scripps Memorial Hospital La Jolla Trauma Service, La Jolla, CA, USA and 2UCLA Department of Epidemiology, UCLA, Los Angeles, CA, USA
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1
Abstract
Keywords
Objective: To provide new information on properties of skateboarders who were hospital admitted with head injuries with details of the injuries including region of head impact. Methods: Hospital records of patients aged 15 and older with a skateboard injury admitted to one Level II Trauma Centre during a 10-year period were reviewed. Data on demographic, exposure, severity, diagnostic and clinical factors for patients with head injury (HI) and without HI (N-HI) were compared analytically. Results: While there were no differences for patients with HI and N-HI by age, gender, mechanism of injury or alcohol use, patients with HI were more severely injured. Although significantly more head impacts occurred to the occipital region of the head, haematomas and/ or contusions were much more likely to occur in the frontal region of the brain. Acute neurosurgical intervention was needed in 14% of HI skateboarders. Conclusion: Skateboarding is not an innocuous recreational activity, with head injury present in 75% of patients who were hospital-admitted. Pre-hospital treatment protocols should be aware of this growing injured population. Falls while on a skateboard lead to impacts to the back of head with a contra-coup brain injury resulting in severe and sometimes fatal outcomes. The very low prevalence of helmet use among skateboarders with head injuries indicates that greater efforts should be directed toward incentives for their use.
Contra-coup injury, epidemiology, skateboard-related injury, skull impact
Introduction From the initial 1965 article [1] on the hazards associated with skateboarding, some 60 reports have appeared in the literature and are represented by an eclectic mixture of editorials, commentaries, reviews, secondary and empirical data analyses in a variety of different journals. Twenty-five articles that mention head injuries from skateboarding based on peer-reviewed empirical studies or existing databases have been published since 1977 [2–26]. In almost all of these reports, information on head trauma was anecdotal and clinical details were missing. The range of head injuries in these 25 reports was from 3–67%, with many reporting from 3–10% [2, 4, 5, 14, 15]. The head injuries identified in these earlier reports were most often of the soft tissue variety. Four accounts reported head injuries of 25–67% [9, 11, 16, 17] but findings on the nature, extent and outcomes from these injuries are generally incomplete. This study was undertaken given the popularity of skateboarding and the limited, albeit confusing information, on head injuries including the potential for severe if not fatal outcomes from related falls. The objectives of this study were
Correspondence: Gail T. Tominaga, MD, Scripps Memorial Hospital La Jolla, 9888 Genesee Ave. LJ 601, La Jolla, CA 92037, USA. E-mail: [email protected]
History Received 29 April 2014 Revised 24 September 2014 Accepted 15 November 2014 Published online 16 July 2015
to: provide new information on the epidemiological and clinical properties of skateboarders who were hospital admitted with a head injury (HI); describe how these factors relate to older age, mechanism of injury (MOI), alcohol use and severity of injury; and delineate details of the head injuries sustained including the impact region of the head. Skateboarders who were hospital admitted without a head injury (N-HI) are compared to skateboarders with a head injury (HI) to illustrate the unique features and in-hospital outcomes from this cohort of patients.
Methods Patients aged 15 years and older admitted to one Level II Trauma Centre from January 2000–December 2009, who suffered an injury while skateboarding, were included in the study population. Only patients aged 15 and older are admitted to the Level II Trauma Centre; younger patients are referred to their regional Paediatric Trauma Centre. Patients were identified from the institution’s Trauma Registry and by International Classification of Disease (ICD), 9th edition code for falls. Because of the potential for code misclassification of falls from skateboards a search of all external cause of injury (E) codes 880–888 (a fall of any type) and E 814 (pedestrian–motor vehicle mishaps) also was employed.
Head injuries while skateboarding
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DOI: 10.3109/02699052.2014.989404
Data on the following factors were extracted from medical chart review: demographics, mechanism of injury (MOI), helmet use, pre-hospital care with mode of transportation, location of skull impact, Glasgow Coma Score (GCS), Abbreviated Injury Score (AIS) for each body region, Injury Severity Score (ISS), length of hospital stay (LOS), Intensive Care Unit (ICU) days and discharge disposition. Head injury was defined as impact to the head from any source while skateboarding, with a head-AIS of 1–5 and included concussions, contusions, intracranial haemorrhages and fractures. Skull impact location and skull fractures were identified. Depressed fractures were given preference in coding over other concurrent skull fractures in the same patient. All computerized tomography (CT) imaging of the head was reviewed and positive findings were collected. Brain contusions, intracranial haematomas and intracranial haemorrhages were classified as Intracranial Haemorrhage (ICH) for purposes of the analyses. The approximate surface area of bones of the skull was estimated by visual measurement of each bone, repeated 10-times for each of five published pictorials of the skull [27]. MOI was categorized into three groups: (1) Loss of control, riding down a hill or street at high speed; (2) Pulled by a vehicle or performing tricks (categorized as ‘manoeuvres’); (3) struck by a motor vehicle. Evidence of alcohol use was recorded as positive if noted by the physician in the medical record and/or by positive serum blood alcohol level. Otherwise, it was considered negative. The authors searched for evidence of head protection while skateboarding in each of the pre-hospital records and hospital medical records The severity of each injury was measured by AIS for each body region [28]. Maximum AIS (MAIS) refers to the most severe injury of a specific body region and was calculated with ISS for all patients [29]. Admission GCS [30] was recorded. Protocols for this research were approved by the hospital’s Institutional Review Committee.
Analyses Patients with HI and N-HI were compared on age, gender, MOI, alcohol use and means of transport. Older age was defined as 30 years of age and older. Head injuries were characterized by AIS, ISS, GCS, skull impact point, presence of skull fractures or ICH and need for neurosurgical operation. Student’s t-test, Odds Ratios and 95% Confidence Intervals (CI) were derived where relevant. Chi-square ( 2) tests for linear trend, Pearson’s goodness of fit, contingency, independence, Mantel-Haenszel and Fisher’s exact probability tests (for very small numbers) [31] were used to identify differences in the distributions of relevant variables. Unless otherwise noted, 2-tail results are reported. Yates correction for small sample sizes was used when one or more cells had an observed number less than six. Chi-squares were selected with unequal variance if indicated. Level of significance was set at 5% a priori.
Results Skateboarders with HI vs. N-HI Age and gender The age range of injured skateboarders was 15–61 years. The age distributions of skateboarders with a HI compared with N-HI were not significantly different ( 2 ¼ 1.49, p ¼ 0.684) (Table I). There was no stepwise increase in odds of HI vs. N-HI with increasing age when compared with the reference age of 15–19 years (Table I). Males comprised 92% of patients who were hospital admitted following a skateboard-related injury and, while they were somewhat more likely to have had a HI compared with females, the difference in occurrences was not significant (OR ¼ 2.91, 95% CI ¼ 0.99–8.52, p corrected ¼ 0.087). Males who sustained a skateboard-related injury were no more likely to be age 30 or older than females (OR ¼ 0.55, 95% CI ¼ 0.14–2.12, p corrected ¼ 0.637).
Table I. Demographics and study patient characteristics of HI and N-HI skateboarders. HI (n ¼ 141)
Age group (in years) 15–19 20–24 25–29 30+ Gender Male Female Mechanism of injury Lost control or on streetc Manoeuvresd Struck by car Alcohol use No Yes a
N-HI (n ¼ 47)
n
%
n
%
OR (95% CI)
p Value
83 28 13 17
58.9 19.9 9.2 12.1
23 11 6 7
48.9 23.4 12.8 14.9
1.0 Reference 0.71 (0.30–1.63) 0.60 (0.20–1.75) 0.66 (0.25–1.94)
0.411 0.347a 0.433a
133 8
94.3 5.7
40 7
85.1 14.9
1.0 Reference 0.35 (0.10–1.12)
0.098b
102 32 7
72.3 22.7 5.0
27 14 6
57.4 29.8 12.8
1.0 Reference 0.61 (0.28–1.29) 0.31 (0.08–1.22)
0.192a 0.100b
114 27
80.9 19.1
40 7
85.1 14.9
1.0 Reference 1.35 (0.56–3.58)
0.662a
Yates corrected 2. Fisher two-tail exact probability. c Includes loss of control, riding downhill or street at high speed. d Includes pulled by vehicle, jumps/tricks, in skateboard park, in swimming pool and striking object not on street. b
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Brain Inj, 2015; 29(9): 1044–1050
Skateboarders with HI were no more likely to be aged 30 or older than N-HI (OR ¼ 9.57, 95% CI ¼ 0.11–8.30, p corrected ¼ 0.604). Mechanism of injury Almost 73% of skateboarders with HI had lost control of a skateboard, with only 5% struck by a motor vehicle (MV), while 57.4% of skateboarders without HI lost control, with 12.8% struck by a MV. There was no significant difference in the distributions of mechanism of injury for skateboarders with and without a head injury ( 2 ¼ 4.97, p ¼ 0.083) (Table I).
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Alcohol use Although alcohol use was recorded for 19.1% of patients with HI compared with 14.9% in patients without a head injury, the difference in proportions was not statistically significant (Table I). Patients 30 years of age and older were no more likely to have used alcohol than patients without a HI in the same age group (OR ¼ 2.53, 95% CI ¼ 0.26–24.5, Fishers exact p ¼ 0.297). Helmet use Less than 5% (n ¼ 7) of skateboarders with head injuries were noted to have been wearing helmets and three of these were active in skateboarding parks where helmet use is required. There were too few numbers for additional analysis.
HI were almost 12-times more likely than patients without HI to have ground or air ambulance transport to the ED (Table II). Whereas 22.7% of patients with HI were transported by air, only 4.3% of patients without HI were transported by air. While 65.2% of patients with HI came to the hospital by ground ambulance, 61.7% of patients without HI arrived by private vehicle. Severity Skateboarders with HI were 29-times more likely to have an MAIS of 4–5 compared with skateboarders without HI (Table II). The body region with the most severe injury was the head for MAIS 4–5 patients. Those with a HI were over 35-times more likely to have an ISS of 16 or greater compared with skateboarders without HI (Table II). LOS/ICU days The distributions of LOS for skateboarders with or without HI were not significantly different from one another ( 2 ¼ 1.46, p ¼ 0.693) (Table II) and patients with HI admitted for 7 days or longer were no more likely to be aged 30 or older than patients without HI (OR ¼ 1.85, 95% CI ¼ 0.17–21.26, p corrected ¼ 0.963). However, the distributions of ICU days for skateboarders with or without HI were significantly different (Yates corrected 2 ¼ 32.85, p50.0001). Disposition
Transport Mode of transport to the hospital for patients with and without HI was significantly different (Table II). Skateboarders with
Eighty-eight per cent of skateboarders with HI were discharged home, while 3.5% were transferred to another acute care hospital, 6.3% were transferred to a rehabilitation
Table II. Mode of transportation, injury severity and hospital stay data. HI (n ¼ 141)
Mode of transportation Private vehicle Air/ground AIS 1–3 4–5 ISS 1–3 4–8 9–15 16+ LOS 1 2–3 4–6 7+ ICU** 1–2 3–6 7+
N-HI* (n ¼ 47)
n
%
n
%
OR (95%CI)
p Value
17 124
12.1 87.9
29 18
61.7 38.3
1.0 reference 11.75 (5.41–25.54)
50.000 0001
86 55
61.0 39.0
46 1
97.9 2.1
1.0 reference 29.11 (5.39–610.4)
50.000 001a
0 43 39 59
0.0 30.5 27.7 41.8
6 26 14 1
12.8 55.3 29.8 2.1
not tested 1.0 reference 1.68 (0.77–3.68) 35.67 (4.83–733.28)
0.189 50.000 001a
28 61 27 25
19.9 43.3 19.1 17.7
9 23 10 5
19.1 48.9 21.3 10.6
1.0 reference 0.85 (0.35–2.08) 0.79 (0.35–2.08) 1.61 (0.47–5.44)
0.725 0.790 0.642b
58 15 12
68.2 17.6 14.1
2 1 2
40.0 20.0 40.0
1.00 reference 0.52 (0.03–32.53) 0.21 (0.02–1.62)
0.513b 0.320b
*Non-head injured are MAIS. **For only those with at least 1 ICU day. a Fisher exact 2-tail probability test. b Yates corrected 2. OR, odds ratio.
Head injuries while skateboarding
DOI: 10.3109/02699052.2014.989404
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Table III. Skull impact location and injury factors of HI skateboarders. Skull impact location Occipital
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n Factor Obs 84 Exp 9.9 Age 15–19 49 20–29 27 30+ 8 Gender Male 79 Female 5 Mechanism of injury Controld 67 Manoeuvres 17 Alcohol use No 66 Yes 18
Temporal
Frontal
Parietal ORa (95% CI)
p Value
%
n
%
n
%
n
%
59.6 7.0
25 32.4
17.7 23.0
21 25.4
14.9 18.0
11 73.3
7.8 52.0
b
58.3 32.1 9.5
14 7 4
56.0 28.0 16.0
13 5 3
61.9 23.8 14.4
7 2 2
63.6 18.2 18.2
1.00 Reference 1.34 (0.61–2.92) 0.62 (0.21–1.76)
0.591 0.522
94.0 6.0
24 1
96.0 4.0
19 2
90.5 9.5
11 0
100.0 0.0
1.00 Reference 0.88 (0.16–4.46)
0.844c
9.8 20.2
21 4
84.0 16.0
13 8
61.9 38.1
8 3
72.7 27.3
1.00 Reference 0.71 (0.32–1.57)
0.521
57.9 66.7
21 4
18.4 14.8
19 2
16.7 7.4
8 3
7.0 11.1
1.00 Reference 1.45 (0.60–3.66)
0.404
a
Odds ratios compare occipital with the sum of all other impact locations. goodness of fit ¼ 88.91, p50.000 001. Yates corrected 2. d Loss of control of skateboard. Obs, Observed number for each anatomic head region; Exp, Expected number for each anatomic head region based on estimated percentage surface area of each bone measured in the standard adult skull. b2 c
facility and 2.1% died (all HI). All skateboarders without HI survived and were discharged home. Head injuries Head injuries were diagnosed in 141 (75%) of all skateboarders admitted to the hospital (Table I) and the head had the highest MAIS in 134 of the group with HI, while the remaining patients with HI had their MAIS in other body areas they were still included in the HI group. Among the 141 patients with HI there were 343 head injury diagnoses (an average of 2.4 per patient) including skull fractures (n ¼ 51), ICH (n ¼ 182) and concussion (n ¼ 110). The odds of an AIS level 4–5 vs. AIS level 2–3 head injury was no greater for those aged 30 or older compared with those aged 15–19 years (OR ¼ 1.81, 95% CI ¼ 0.63–5.22, p ¼ 0.267). A similar non-significant finding was seen for skateboarders with HI aged 30 and older compared with those aged 20–29 (OR ¼ 1.03, 95% CI ¼ 0.33–3.20, p ¼ 0.960). Skateboarders with a head AIS of 4–5 were more likely to have been injured in loss of control–street impacts than those with an AIS of 2–3 (OR ¼ 5.60, 95% CI ¼ 1.58–19.81, p corrected ¼ 0.007). Among skateboarders with HI, those aged 30 and older were no more likely to have an ISS of 16 or greater than younger skateboarders with HI (OR ¼ 2.52, 95% CI ¼ 0.87–7.32, p corrected ¼ 0.142). Skateboarders with HI and an ISS of 16 or more were more likely to have been injured in loss of control–street collisions than those with an ISS of less than 16 (OR ¼ 4.19, 95% CI ¼ 1.34–13.05, p ¼ 0.009). Skateboarders with HI and a GCS of 8 or less were much more likely to have a LOS of 7 days or longer compared with those with a GCS of 9–15 (OR ¼ 7.00, 95% CI ¼ 1.73–28.34, p corrected ¼ 0.009). Similarly, skateboarders with a head
AIS of 4–5 were much more likely to have a LOS of 7 days or longer compared with those with an AIS of 2–3 (OR ¼ 9.26, 95% CI ¼ 3.22–26.64, p50.0001). Skateboarders with HI who used alcohol were no more likely to have a LOS of 7 days or longer than those not using alcohol (OR ¼ 1.07, 95% CI ¼ 0.36–3.16, p40.999). Head impact point It was determined that the surface area of the skull for an average adult is composed of 7% occipital bone, 23% temporal bone (includes sphenoid), 18% frontal bone and 52% parietal bone. The probability of a distribution of skull impact points from skateboarding as recorded in Table III is less than 0.000 001. Skateboarders with HI are significantly more likely to have an AIS of 4–5 because of impact to the occipital region than any other skull region (OR ¼ 2.22, 95% CI ¼ 1.08–4.56, p ¼ 0.028); this finding was similar for all age groups and both genders. Skateboarders with an impact to the occipital skull were no more likely to have lost control (OR ¼ 1.31, 95% CI ¼ 0.54–3.16, p ¼ 0.521) or have used alcohol than riders with impacts to other parts of the skull (OR ¼ 1.45, 95% CI ¼ 0.60–3.52, p ¼ 0.404). Skull fractures Fifty-one (36.4%) of the 140 skateboarders with HI and a completed head CT scan had a skull fracture and 72.5% of these were located in the occipital region of the skull. Also, those with a skull fracture were over 19-times more likely also to have an ICH compared with those with no skull fracture (Table IV). There was no difference in gender (OR ¼ 1.69, 95% CI ¼ 0.33–8.73, p ¼ 0.798) or age (OR ¼ 1.74, 95% CI ¼ 0.62–4.82, p ¼ 0.286) in those sustaining skull fractures.
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Table IV. Factors related to skull impact locationa for patients with HI. Skull impact location Occipital Factor
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GCS 14–15 9–13 3–8 AIS 2–3 4–5 Skull fx ICHc No ICHd No skull fx ICHc No ICHd
Temporal
Frontal
Parietal ORb (95% CI)
p Value
100.0 0.0 0.0
1.00 Reference 0.91 (0.32–2.61) 2.46 (0.44–25.22)
0.928e 0.314f
72.7 27.3 5.9 6.5
1.00 Reference 2.22 (1.08–4.56) n ¼ 51 n ¼ 46 n¼5 n ¼ 89 n ¼ 29 n ¼ 60
n
%
n
%
n
%
n
%
68 9 7
81.0 10.7 8.3
17 7 1
68.0 28.0 4.0
20 0 1
95.2 100.0 4.8
11 0 0
45 39 37 32 5 46 18 28
53.6 46.4 72.5 69.6 100.0 51.7 62.1 46.7
15 10 10 10 0 15 3 12
60.0 40.0 19.6 21.7
18 3 1 1 0 20 4 16
85.7 14.3 2.0 2.2
8 3 3 3 0 8 4 4
16.9 10.3 20.0
22.5 13.8 26.7
9.0 3.8 6.7
0.029
Odds ratio comparing ICH with/without skull fracture ¼ 19.03, 95% CI ¼ 6.838–52.99, p50.000 001 Neurosurgical operation No Yes
71 13
84.5 15.5
20 5
80.0 20.0
20 1
95.2 4.8
10 1
90.9 9.1
1.00 Reference 1.31 (0.49–3.51)
0.774e
a
One patient did not have a CT scan. All odds ratios compare occipital impact location with the sum of all other head impact locations. c ICH includes haemorrhages and/or contusions. d Includes concussions. e Yates corrected 2. f Fisher exact 2-tail probability test. b
GCS/head AIS Slightly more than 82% of skateboarders with HI had a GCS of 14–15, 11.3% had a GCS of 9–13 and 6.4% had a GCS of 3–8. Patients with a GCS of 3–8 were no more likely to have a HI impact in the occipital region than those with an impact to other parts of the head (Table IV). Those with a GCS of 8 or less were no more likely to have used alcohol than those with a higher GCS (OR ¼ 0.51, 95% CI ¼ 0.51–4.26, Fishers exact p ¼ 1.000). Those with a head-AIS of 4 or 5 were more than twice as likely to have an occipital skull impact as any other impact point (Table IV). Intracranial haematomas/haemorrhage and contusions (ICH) ICH were diagnosed in 53.6% of skateboarders with HI and three-quarters of these had an AIS of 4–5. Patients with an ICH were almost 15-times more likely than expected to have it located in the frontal region of the brain compared with any other region of the brain (OR ¼ 14.60, 95% CI ¼ 6.56–32.50, p50.000 000 1). Two-thirds of ICHs in the frontal region resulted from an impact to the occipital region of the skull. ICH was more often related to a loss of control MOI (OR ¼ 7.61, 95% CI ¼ 2.44–27.00, p ¼ 0.0002) when compared with any other type of mechanism of injury. Surgery Acute neurosurgical intervention was required in 14% of skateboarders with HI. The neurosurgery rate for the occipital and temporal skull impact regions was 18.3% and 20%, respectively. Surgery rates for the frontal and parietal skull impact regions could not be tested because of very small numbers. However, the odds of surgical vs. non-surgical
intervention for the occipital region vs. all other regions was not significantly dissimilar (p ¼ 0.774) (Table IV). Patients requiring neurosurgical intervention were almost 23-times more likely to have a LOS of 7 or more days (OR ¼ 23.55, 95% CI ¼ 7.53–73.58, p50.000 01) than those not requiring neurosurgical intervention. Those requiring neurosurgical intervention were no more likely to have been involved in loss of control of the skateboard than those not requiring surgery (OR ¼ 4.46, 95% CI ¼ 0.57–35.04, Fisher exact p ¼ 0.197).
Discussion This report is one of the first reports in the Western medical literature illustrating head trauma among older recreational skateboarders. Although there are reports that list head trauma among the injuries sustained by skateboarders, some of these reports utilized the National Electronic Injury Surveillance System (NEISS) for case-finding and, hence, their data were limited to only general descriptions as found in the emergency department record [2, 7, 13, 15]. Many reports limited their study groups to patients aged 20 or less [4–6, 9–12, 19, 21–23] and some reports combined data from a variety of exposures beside skateboarding, such as bicycling and in-line skating [7–11, 14, 19, 23, 24], which made it difficult to isolate findings specific for skateboarders. Finally, only one published report [16] provided information on head injury for older adolescents and/or adults, but the age categories in that report included mostly children and early adolescents and the oldest age category included those over age 16 years without additional age group detail. Thus, the comparison of these findings with those in that report is not recommended.
Head injuries while skateboarding
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DOI: 10.3109/02699052.2014.989404
This study found three-quarters of all skateboarders admitted to the hospital had a head injury, significantly higher than that reported in the earlier published literature and twice the proportion reported by the only published report with somewhat similar case-identification methods [16] as this current report. The variations in hospital admission policies, E-code misclassification of skateboarding and/or the variation of skateboarding head-injury prevalence across the US within the patients included in the aggregate National Trauma Database (NTDB) [16] might explain the differences in head injury occurrence as found in the data. Although the types of head injuries are listed in the NTDB report [16], their respective severities, multiplicity, relationship to head impact points and connection with alcohol use and mechanism of injury are not fully described. The occurrence of skull fracture in this series of patients was more than double that reported by Lustenberger et al. [16]. In addition, 90% of these patients were diagnosed with one or more ICHs. Also, intracranial haemorrhages and contusions were diagnosed in about one-third of patients without skull fractures, suggesting further that ED physicians should be alerted to the intracranial injury profile of skateboarders observed in this study. Despite the decades since its introduction, skateboarding still appears to be a male dominated activity, at least as represented by the injuries this activity produces. Without information on the total population of active skateboarders during the study period, one cannot conclude that males are at higher risk of hospital admitted injury than females. Skate parks are not immune from injuries including head injuries [8, 19], even with mandated helmet use. One of the limitations of this current study was the inability to accurately portray the exact MOI in the study population. For example, while the medical record may document ‘being struck by a vehicle’, full details of the skateboarding exposure were often not recorded. Also, this study was not able, with the information available, to determine the type of skateboard used by the injured patient. Future studies should incorporate methods to document and describe fully the activities, environments and types of equipment used when the injuries occur and record the helmet status of the injured skateboarder. We recommend adding skateboarding to the list of alcoholinvolved recreational activities that result in head injuries. It is noteworthy that 24% of those with evidence of alcohol use while skateboarding were under the age of 20 in a state (CA) where there is zero alcohol tolerance for this age group. While there is no reason to believe alcohol use was misreported among those skateboarders with HI compared with N-HI, it is acknowledged that blood alcohol concentrations were not performed on all patients; hence, the true prevalence of alcohol use may have been underestimated. Unlike the report using data from the NTDB [16], no increase was found in frequency of AIS 4–5 head injuries in the three age groups (15–19, 20–29 and 30+) but the age categories were different from that of the NTDB data. Nevertheless, these injuries are life threatening and require a much different emergency room culture to anticipate profiles
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of the injured and the treatments needed including neurosurgical intervention. Despite a California state law requiring mandatory helmet use among skateboarders less than 18 years of age, the absence of helmet use in all age groups is commonly observed. There is at present no effective enforcement of helmet use, even in skate parks where state law can be more easily monitored [32]. Use of helmets by older skateboarders is, at this time, voluntary and they were worn by less than 5% of the injured skateboarders in this study. This preventive measure when employed is effective, but incentives for helmet compliance for skateboarders of all ages are illusive [32]. The significantly higher than expected frequency of falls from skateboards resulting in impacts to the occipital region of the skull, not related to age, gender or mechanism of injury, suggests that skateboarders fall backward following loss of control. This finding contradicts those from other forms of recreational activity such as bicycling which show that, with loss of control, there is forward momentum generally resulting in an impact to the front of the head and face. The implications for design of head protection to ameliorate this impact region are clear but, again, skateboarders must first recognize the need for and then act on the use of head protection. More study is needed on this question. The data describe the well-known contra-coup type of intracranial injury; that is, traumatic brain lesions are often located at a distance (generally opposite) from the impact site [33]. The findings of an occipital skull impact with potential frontal lobe damage associated with symptoms such as confusion and behavioural problems should alert pre-hospital and Emergency Department personnel of the need for urgent neurosurgical consultation in patients with such presentations. Skateboarding can no longer be considered an innocuous recreational activity, with 75% of skateboarders requiring hospital admission having a head injury in this study group. Pre-hospital triage protocols may need to be adjusted to ensure patient evaluation at an Emergency Department with neurosurgical coverage. The nature of skateboarding and the resulting anatomic location of the impact to the head of these patients suggest that much more must be done to prevent these injuries. Other limitations This study population may not be representative of wider geographic regions. The service area of the Trauma Centre is in a very temperate climate, with many people engaged in outdoor activities year round. Skateboarding is commonly observed on private property as well as public areas and roadways year-round, by all ages and genders and often used as a mode of commuting to work or school as well as for recreational purposes. There is no reason to doubt that these findings do not mirror the changing trends in use of and injury from skateboards, especially older riders. Extra precautions were taken in case finding to ensure that all patients with skateboard-related injury were identified and included in the database. However, the authors were not able to verify in the medical record some factors such as exact MOI, alcohol and helmet use for all patients; hence, the findings may be incomplete. Further exploration of these factors appears
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warranted. However, a Trauma Centre can perform a much needed service in attempting to obtain this type of information for future studies. The authors could not locate in the published literature precise measurements of the surface area of the major bones of the adult skull, hence an approximation was undertaken by visual assessments with repetitions. Despite the possibility of somewhat less than accurate skull bone sizes used in the analyses, it is believed the approximations represent a reasonable average value and the statistical finding was so huge that no change in conclusion would be warranted. Certain analyses such as multivariate testing could not be undertaken in this evaluation because of very small numbers in many cells (e.g. sub-samples of those having surgical interventions). Collaboration with other institutions to expand the database on the clinical/exposure/outcome factors might better address this shortcoming.
Conclusions In this study an overwhelming proportion of patients with skateboard-related injury had trauma to the head. This fact alone should prompt changes in pre-hospital treatment protocols. It appears that skateboarders who fall backwards after a collision of any kind very frequently sustain an impact in the occipital region of the skull. This in turn results in the common contra-coup type of brain injury. Such injuries often are severe and have fatal outcomes. While helmets have been shown to ameliorate head trauma from skateboarding mishaps their use is woefully deficient and this fact should prompt better ways to influence their greater use among skateboarders.
Acknowledgements We thank our Trauma Nurse Director, Cheryl Wooten, RN, MSN, for facilitating access to trauma registry data and support for this project and consultation/manuscript review of data by Kevin Yoo, MD (Neurosurgeon).
Declaration of interest The authors report no conflicts of interest. This study was sponsored in part by the N. Paul Whittier Trauma Foundation and a Research Grant from the Santiago and Cecilia Aguerre Family.
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