1. Risk Factors in Snowboarders’ Wrist Fractures Tracey J. Dickson, PhD

2. Background Wrist injuries are the most common snowboard injury (Bladin et al, 2004) Wrist injuries are the most common snowboard injury (Bladin et al, 2004) Wrist guards may assist in reducing wrist injuries (Russell et al, 2007) Wrist guards may assist in reducing wrist injuries (Russell et al, 2007) There is debate about whether wrist guards contribute to upper arm injuries (Hagel et al, 2005) There is debate about whether wrist guards contribute to upper arm injuries (Hagel et al, 2005) There is some evidence that wrist guard design is a contributing factor (Binet, ISSS, 2007) There is some evidence that wrist guard design is a contributing factor (Binet, ISSS, 2007)

3. Risk factors in skiing and snowboarding from previous research (Hagel, 2005) Intrinsic risk factors Intrinsic risk factors Ability (lower) and experience Ability (lower) and experience Age (younger) Age (younger) Previous instruction: unclear what the impact is Previous instruction: unclear what the impact is Past injury (increased risk of future injury) Past injury (increased risk of future injury) Female sex (could be due to a higher level of reporting rather than higher level of injury) Female sex (could be due to a higher level of reporting rather than higher level of injury) Extrinsic risk factors Extrinsic risk factors Activity (snowboarding vs skiing) Activity (snowboarding vs skiing) Snowboarding aerials Snowboarding aerials This may change with twin tip skis This may change with twin tip skis Improper binding adjustment Improper binding adjustment Equipment ownership (rental vs own) Equipment ownership (rental vs own) No helmet No helmet Slope characteristics exceeding ability Slope characteristics exceeding ability No wrist guards No wrist guards

4. Research Design Prospective case-control study using a non-probability sample Prospective case-control study using a non-probability sample Patients: Snowboarders presenting with a snowboard injury to 1 of 10 medical centres and physiotherapy clinics in mainland Australian resorts and gateway communities across the 2007 season Patients: Snowboarders presenting with a snowboard injury to 1 of 10 medical centres and physiotherapy clinics in mainland Australian resorts and gateway communities across the 2007 season

5. Data Collected Using a self-completion, anonymous single page questionnaire Demographics Demographics Snowboarding experience Snowboarding experience Levels of instruction Levels of instruction Protective equipment usage Protective equipment usage Wrist guard design Wrist guard design Mechanism of injury Mechanism of injury Type of injury Type of injury Resort location of injury Resort location of injury Case: those presenting with a wrist fracture Case: those presenting with a wrist fracture Controls: all other snowboarding injuries Controls: all other snowboarding injuries Injury rates are not able to be calculated due to study design and also as skier day figures are not available from the resorts or snowsport industry Injury rates are not able to be calculated due to study design and also as skier day figures are not available from the resorts or snowsport industry

6. Results (1) 611 snowboarders 611 snowboarders Reported 802 injuries (1.3 injuries per person): Reported 802 injuries (1.3 injuries per person): Bruising (82.1%) Bruising (82.1%) Fractures (38.2%) Fractures (38.2%) Wrist, n=108 (17.7%) Wrist, n=108 (17.7%) Dislocations (7.2%) Dislocations (7.2%) Concussions (1.8%) Concussions (1.8%) Age range: 8-57 (mean =22.1 yrs) Age range: 8-57 (mean =22.1 yrs) Significant difference between cases (younger) and controls (p<.000) Significant difference between cases (younger) and controls (p<.000) Gender Gender Females (38.7%) Females (38.7%) Males (61.3%) Males (61.3%)

7. Results (2) Experience Experience Less than 7 days (39.5%) Less than 7 days (39.5%) First day ever snowboarding (11.1%) First day ever snowboarding (11.1%) Significant difference between cases (less experienced) and controls (p<.014) Significant difference between cases (less experienced) and controls (p<.014) Protective Equipment Protective Equipment No protective equipment worn (49.6%) No protective equipment worn (49.6%) Helmets (36.5%) Helmets (36.5%) Wrist guards (22.6%) Wrist guards (22.6%) Previous snowboard injury (46.5%) Previous snowboard injury (46.5%) Mean = 2.1 injuries Mean = 2.1 injuries Mode = 0 Mode = 0

8. Reasons for not wearing wrist guards (n=473) (multiple responses possible) List of reasons provided I don’t see the need for wrist guards Of these 12.9% experienced a wrist fracture 38.7% They are uncomfortable to wear27.7% I can’t get hold of them16.5% I think they will contribute to injuries14.2% I don’t believe they will protect against injury Of these 7.9% experienced a wrist fracture 9.5% They are too expensive7.5%

9. Resort location at time of injury Location On-piste (groomed) areas67.3% Terrain park, slope-style and half pipes Terrain park Slope-style course Half-pipe 23.1% 18.4% 3.3% 1.4% During snowboarding lesson11.5%

10. Risk factors for wrist fractures All (n=611) % Cases: wrist fracture (n=108) % Controls (n=503) % Odds ratio (95% confidence interval) Gender: Male Female 61.3 38.7 57.0 43.0 62.2 37.8.81 (.53 to 1.23) Age: < 16 years 16 years+ 22.2 77.8 45.8 54.2 17.1 82.9 4.10 (2.62 to 6.42) Experience: 1 st day > 1 day 11.1 88.9 17.8 82.2 9.7 90.3 2.02 (1.13 to 3.59) Experience: < 7 days 7 days or more 39.5 60.5 49.5 505. 37.5 62.5 1.64 (1.07 to 2.49) Wrist guard usage: No Yes 77.4 22.6 90.7 9.3 86.9 13.1 1.48 (0.74 to 2.98) Reason for being in area: holidays Live for season or permanent 88.9 11.1 74.0 26.0 2.80 (1.49 to 5.28)

11. A risk ‘profile’ for wrist fractures Risk profile Cases: wrist fracture (n=108) % Controls (n=503) % Odds ratio (95% confidence interval) < 16 years of age; on holidays; 1 st day of snowboarding ever All others 9.3 90.7 1.2 98.8 8.45 (3.00 to 23.80) i.e. a young kid who is on holidays visiting the snow, who is participating in their first day snowboarding ever, were 8 times more likely to experience a wrist fracture than all others (though wide CI)

12. Investigating wrist guard design Length Length Short Short Long Long Stiffness Stiffness Soft Soft Stiff (some flex) Stiff (some flex) Rigid (no flex) Rigid (no flex) Protection Protection Palm-side only Palm-side only Back of wrist only Back of wrist only Both sides Both sides Position Position Built into glove/mitten Built into glove/mitten Inside glove/mitten Inside glove/mitten Outside glove/mitten Outside glove/mitten

13. Wrist guard design Cases (n=17) % Controls (n=110) % Chi-squared p value Length:Short Long 88 12 67 33.079 Stiffness: Soft Stiff (some flex) Rigid (no flex) 10 45 6 55 39.501 Protection: Palm-side only Back of wrist only Both sides 65 5 30 37 4 59.017 Position:Built into glove/mitten Inside glove/mitten Outside glove/mitten 5 47 8 44 48.873

14. Wrist guard design cont’d The only aspect of wrist guard design where there was a significant difference was palm-side vs both sides (p =.000) The only aspect of wrist guard design where there was a significant difference was palm-side vs both sides (p =.000) Of the 17 wrist fractures incurred while wearing wrist guards: Of the 17 wrist fractures incurred while wearing wrist guards: Palm-side only wrist guards accounted for 65% of wrist fractures while wearing wrist guards Palm-side only wrist guards accounted for 65% of wrist fractures while wearing wrist guards Short, palm-side designs (52.9%), OR = 3.13 (CI 0.80 to 12.19) Short, palm-side designs (52.9%), OR = 3.13 (CI 0.80 to 12.19) Long, palm-side designs (11.8%) Long, palm-side designs (11.8%) cf Short, both –side designs ( ), OR=0.41 (CI 0.08 to 2.09) cf Short, both –side designs ( ), OR=0.41 (CI 0.08 to 2.09) Nobody wearing a long, back -of-wrist or both-sides designs experienced a wrist fracture Nobody wearing a long, back -of-wrist or both-sides designs experienced a wrist fracture

15. Conclusion Based on a small sample, this Australian study supports previous research that age, experience (intrinsic factors) and wrist guard usage (extrinsic factor) are risk factors in snowboarding wrist fractures Based on a small sample, this Australian study supports previous research that age, experience (intrinsic factors) and wrist guard usage (extrinsic factor) are risk factors in snowboarding wrist fractures The data also suggests that wrist guard design (short, palm- side) and being a visitor to the alpine region (i.e. tourist) are risk factors The data also suggests that wrist guard design (short, palm- side) and being a visitor to the alpine region (i.e. tourist) are risk factors The compounding effects of risk factors is demonstrated in that tourists who are <16 years of age, on their first day of snowboarding are more than 8 times more likely to break their wrist The compounding effects of risk factors is demonstrated in that tourists who are <16 years of age, on their first day of snowboarding are more than 8 times more likely to break their wrist

16. What’s next? Further co-ordinated research needs to be conducted: Further co-ordinated research needs to be conducted: Into the impact of wrist guard design on wrist injuries, e.g. Into the impact of wrist guard design on wrist injuries, e.g. Length of wrist guard in relation to injury position (measure, photograph) Length of wrist guard in relation to injury position (measure, photograph) The availability and design of wrist guards in rental shops The availability and design of wrist guards in rental shops The snowsport safety and wrist guard usage messages in resorts, magazines, TV shows, shops, online (e.g blogs, Youtube, Facebook) The snowsport safety and wrist guard usage messages in resorts, magazines, TV shows, shops, online (e.g blogs, Youtube, Facebook) Improved snowsport safety messages (targetting their communication channels and in their language) need to be developed to reach the at-risk populations (especially young, first-time participants, tourists) about: Improved snowsport safety messages (targetting their communication channels and in their language) need to be developed to reach the at-risk populations (especially young, first-time participants, tourists) about: The benefits of wrist guard usage The benefits of wrist guard usage What to look for in wrist guard designs What to look for in wrist guard designs

17. Acknowledgements Drs Mark Zagorksi and Mark Binet for advice on the questionnaire design Drs Mark Zagorksi and Mark Binet for advice on the questionnaire design Dr Mark Zagorski for assistance in data collection Dr Mark Zagorski for assistance in data collection Ms Margot Hurrell for data entry and feedback on results Ms Margot Hurrell for data entry and feedback on results

18. Contact: Tracey J. Dickson, PhD Senior Research Fellow Centre for Tourism Research University of Canberra Australia Tracey.Dickson@canberra.edu.au Tracey.Dickson@canberra.edu.au

19. References Bladin C, McCrory P, and Pogorzelski A. Snowboarding injuries: current trends and future directions. Sports Medicine (Auckland, N.Z.). 2004;34(2):133-9. Hagel BE. Skiing and snowboarding injuries. Medicine And Sport Science. 2005;48:74-119. Hagel BE, Pless IB, and Goulet C. The effect of wrist guard use on upper-extremity injuries in snowboarders. American Journal Of Epidemiology. 2005;162(2):149-56. Russell K, Hagel BE, and Francescutti LH. The effect of wrist guards on wrist and arm injuries among snowboarders: a systematic review. Clinical Journal Of Sport Medicine: Official Journal Of The Canadian Academy Of Sport Medicine. 2007;17(2):145-50.