Catastrophic Injuries in Sports and Recreation : Causes and Prevention - a Canadian Study [1 ed.] 9781442687561, 9780802089670

Citation preview

Recto Running Head i

CATASTROPHIC INJURIES IN SPORTS AND RECREATION: CAUSES AND PREVENTION – A CANADIAN STUDY Edited by Charles H. Tator

Injuries sustained in connection with sports and recreational activities are a major cause of all injuries and, of these, the catastrophic ones – those resulting in death or lifelong disability – comprise a significant proportion. Catastrophic injuries take a tremendous personal toll on individuals and their families, and result in major financial costs to society for medical care, supports and services, and for the replacement of lost earnings. However, the risk factors associated with injuries acquired in sports and recreational activities, and the particular causes of such injuries, have not been given a great deal of attention in terms of systematic documentation and assessment. This book is unique in that it presents a comprehensive description and analysis of all catastrophic injury cases reported during four 12month periods over the course of a decade for more than 100 sports and recreational activities in Ontario, Canada’s most populous province. Included are personal and population risk data and injury prevention strategies and tips for each activity. The book begins with a summary of the overall results of the study and the various epidemiological factors addressed throughout the book. The introductory chapters also discuss general matters such as principles of injury prevention, types of injuries, and demographic concerns. The next 55 chapters are devoted to detailed analysis of catastrophic injuries incurred in separate categories of sports and recreational activities. Catastrophic Injuries in Sports and Recreation provides a wealth of information in a clear and accessible manner. It will be an invaluable resource for researchers, policy-makers, administrators, medical personnel, coaches, league officials, and others concerned with injury prevention in sports and recreation. charles h. tator is a professor of neurosurgery at the University of Toronto.

This page intentionally left blank

Recto Running Head iii

Catastrophic Injuries in Sports and Recreation Causes and Prevention – A Canadian Study

EDITED BY CHARLES H. TATOR

UNIVERSITY OF TORONTO PRESS Toronto Buffalo London

iv

Verso Running Head

© University of Toronto Press Incorporated 2008 Toronto Buffalo London www.utppublishing.com Printed in Canada ISBN 978-0-8020-8967-0

Printed on acid-free paper

Library and Archives Canada Cataloguing in Publication Catastrophic injuries in sports and recreation : causes and prevention : a Canadian study / edited by Charles H. Tator. ISBN 978-0-8020-8967-0 (bound) 1. Sports injuries. RD97.C373 2008

2. Sports injuries – Prevention. 617.1′027

I. Tator, Charles H.

C2008-902858-9

University of Toronto Press acknowledges the financial assistance to its publishing program of the Canada Council for the Arts and the Ontario Arts Council. University of Toronto Press acknowledges the financial support for its publishing activities of the Government of Canada through the Book Publishing Industry Development Program (BPIDP).

Recto Running Head v

Contents

Editor’s Acknowledgments xiii Contributors xv SECTION 1. INTRODUCTION AND OVERVIEW 1 Description of the Study 3 charles h. tator Methods 8 / The McLaren Report 15 / Explanation of Calculations and Derived Values 17 2 Overview of the Results of the Ontario Study, 1986–1995 21 charles h. tator Number of Injured Participants 21 / Age and Gender of the Injured Participants 22 / Sports and Recreation Activities in Which the Injuries Occurred 23 / Age of Injured Participants in Each Activity 29 / Month of Injury 31 / Injury Sites – Terrain 32 / Anatomical Locations and Types of Injuries 33 / Supervision and Organizations Involved 34 / Alcohol Consumption 37 / Prevention 37 / Relative Risks of Catastrophic Injury 40 3 Sports Injury Prevention: General Principles 58 christine provvidenza and charles h. tator 4 Geographical Locations Where 2,154 Catastrophic Sports and Recreation Injuries Were Sustained 79 charles h. tator

vi Contents

5 Anatomical Locations and Types of Ontarians’ Catastrophic Injuries 119 alun ackery and charles h. tator SECTION 2. WATER SPORTS 6 Canoeing 121 yusra ahmad and charles h. tator 7 Sailing 139 pemma muzumdar 8 Personal Watercraft 148 douglas j. cook and charles h. tator 9 Other Boating Activities 158 pemma muzumdar and charles h. tator 10 Fishing 169 yusra ahmad and charles h. tator 11 Diving 180 sheila heinicke and charles h. tator 12 Scuba-Diving 192 sheila heinicke 13 Swimming 201 alun ackery 14 Waterskiing 209 pemma muzumdar 15 Other Water Sports: Parasailing, Parachute-Skiing, Sailboarding, Sea-Biscuit Riding, Surfing, Water-Tubing, Water Polo, Watersliding, Water Play, Windsurfing 221 michael detsky and mark o. baerlocher

Contents vii

SECTION 3. MOTOR SPORTS 16 Snowmobiling 229 sheila heinicke and charles h. tator 17 All Terrain Vehicle Riding 243 sheila heinicke and charles h. tator 18 Motorbiking 257 vanessa i. paesani and charles h. tator 19 Dirt-Biking (Off-Road Motorcycling) 268 daniel h. ovakim 20 Other Motor Sports: Mopedding, Motorcycling, Mini-biking, Trail-Biking, Stock Car Driving, Go-Carting 279 pemma muzumdar SECTION 4. WINTER SPORTS 21 Ice Hockey 291 fady saleh and charles h. tator 22 Ice Skating 305 adnan jalal and charles h. tator 23 Alpine Skiing 318 helen simson and charles h. tator 24 Snowboarding 333 alun ackery 25 Cross-Country Skiing 342 daniel r. ricciuto 26 Tobogganing and Sledding 353 mark o. baerlocher and charles h. tator

viii Contents

27 Other Winter Sports: Ringette, Curling, Boot Hockey, Broomball 363 pemma muzumdar and charles h. tator SECTION 5. BICYCLING AND OTHER STREET ACTIVITIES 28 Bicycling 371 fady saleh, helen simson, and charles h. tator 29 In-Line Skating 382 mark o. baerlocher, cynthia koch, and fady saleh 30 Skateboarding 395 bilal butt and charles h. tator 31 Running and Jogging 405 fatima butt and charles h. tator SECTION 6. AIR SPORTS 32 Flying Small Aircraft 419 meredith giffin and mark o. baerlocher 33 Other Air Sports: Ultralight Air Sports, Hang-Gliding, Para-gliding, Gliding 428 sana rahman and charles h. tator 34 Parachuting 436 mark o. baerlocher SECTION 7. FIELD SPORTS 35 Baseball 449 alun ackery 36 Football 457 fady saleh

Contents ix

37 Soccer 470 fady saleh and adnan jalal 38 Rugby 483 fady saleh 39 Other Field Sports: Track and Field, Field Hockey, Lacrosse 496 pemma muzumdar SECTION 8. RACQUET SPORTS 40 Badminton 505 sana rahman and charles h. tator 41 Racquetball 515 kashif pirzada 42 Squash 521 ishtiaq ahmed 43 Tennis 531 adnan jalal SECTION 9. EQUESTRIAN SPORTS 44 Horseback Riding 547 christine provvidenza SECTION 10. FLOOR SPORTS 45 Basketball 563 marium fatima and charles h. tator 46 Floor Hockey 573 bilal butt, prakash motwani, and charles h. tator

x Contents

47 Gymnastics 580 adnan jalal 48 Wrestling 593 fady saleh 49 Martial Arts: Karate and Tae Kwon Do 604 mark o. baerlocher 50 Other Floor Sports: Weightlifting, Volleyball, Handball, Gym, Boxing, Kick-Boxing 615 sana rahman SECTION 11. PLAYGROUNDS AND PLAY 51 Playgrounds and Play: Tree Climbing, Slides, Monkey Bars 623 christine provvidenza and charles h. tator SECTION 12. MISSILE SPORTS AND RECREATIONAL ACTIVITIES 52 Hunting 637 fady saleh and adnan jalal 53 War Games (Paintball) 651 alun ackery 54 Air Guns 658 fady saleh and ishtiaq ahmed 55 Other Missile Sports: Darts, Archery, Target Practice, Slingshot 667 sana rahman SECTION 13. SUMMER SPORTS 56 Golf 677 alun ackery

Contents xi

57 Ball Hockey 684 prakash motwani, bilal butt, and charles h. tator 58 Camping and Hiking 693 alun ackery 59 Mountain Climbing 701 maia von maltzahn, mark o. baerlocher, and charles h. tator 60 Other Summer Sports: Roller Skating, Walking, Billiards, Tree Climbing, Kite Flying, Steer Wrestling, Fairgrounds 711 sana rahman 61 Conclusion 719 charles h. tator APPENDIXES Appendix l: Survey Questionnaire 726 Appendix 2: Participation and Injury Rates – Males, Females, and by Sport, from the McLaren Report 728 Appendix 3: Population of Ontario 730 Index

731

This page intentionally left blank

Contents xiii

Editor’s Acknowledgments

Fady Saleh, MD, played a major role in helping to compile and analyse the data, as a medical student engaged in scholarships for two successive summers. Lillian Lapczak, B.Sc., was responsible for data input, tabulation, and display. Maria Vespa helped with chapter formatting and word-processing. Sarah Lord helped with the locations chapter. Funds for the project including data capture, data entry, and analysis, and for sponsorship of this publication were provided by research grants from the Sport and Recreation Programs Branch, Sport and Recreation Division, of the Ontario Ministry of Tourism and Recreation. The sports safety responsibilities of this ministry have since been transferred to the Ministry of Health Promotion, Ontario, which has continued to encourage publication of this book. The staff of the ThinkFirst Foundation, Canada, and especially previous executive directors Jim Russell, Virginia Edmonds, and Eleanor Sam, and former sports injury prevention coordinator Christine Provvidenza, were very helpful in completing this project. Their support is greatly appreciated. I wish to acknowledge the support of ThinkFirst by its major donors: TD Bank Financial Group, Ronald McDonald House Charities, Aviva Insurance, J & H Medical Products, Tridel, and the Krembil Foundation. The Ontario Medical Association provided strong support for this study through dissemination of questionnaires to its members and by encouraging the cooperation of its members. Tom Pashby, MD, was very helpful in providing information on eye injuries. I am grateful to my wife, Carol Tatot, for her support and advice.

xiv Editor’s Acknowledgments

Finally, I wish to thank the many chapter authors who put forth a major effort towards prevention of these catastrophic injuries. Many of the authors were medical students in the Faculty of Medicine, University of Toronto, when they wrote these chapters. They devoted their scarce time to this project because they understand its importance.

Contents xv

Contributors

Alun D. Ackery, BSc (Hon.), MD, MSc Emergency Medicine Resident University of Toronto Marium F. Ahmad, BSc MD Family Medicine Resident, McMaster University Ishtiaq Ahmed, BSc (Hon.), MD Resident Physician Yusra N. Ahmed, BA, MD Resident Physician, University of Alberta Mark Otto Baerlocher, BScH, MD Resident Physician, University of Toronto Bilal Butt, BSc Medical Student, Ross University School of Medicine Fatima T. Butt, BSc High School Teacher Douglas J. Cook, BSc, MD Resident in Neurosurgery, University of Toronto Michael E. Detsky, BSc, MD Resident Physician, University of Toronto Meredith Giffin, BSc (Hon.) Medical Student, University of Ottawa

xvi Contributors

Sheila V. Heinicke, BSc OT Reg., MEd Occupational Therapist, Regional Mental Health Care, St Joseph’s Health Care – London Adnan Jalal, BSc, MD Medical Student, University of Toronto Alana Kalyniuk, BSc (Hon.) Cynthia R. Koch, BSc Health Sciences Prakash (Paul) Motwani, BSc Medical Student, St Matthew’s University Pemma Muzumdar, BSc Educator, Health Promotion Daniel H. Ovakim, BSc, MD, MSc Resident Physician, University of Western Ontario Vanessa Paesani, BSc Mount Allison University Kashif Pirzada, BSc, MD Resident Physician, McGill University Christine F. Provvidenza, BPHE, MSc Neurology Services, Toronto Rehabilitation Institute, Past Research and Program Manager, ThinkFirst, Canada Sana Rahman, BSc Medical Student, University of Ottawa Daniel R. Ricciuto, MSc, MD Resident Physician, University of Toronto Fady Saleh, BSc, MD Resident Physician, McMaster University Helen Simson Research Consultant Charles H. Tator, CM, MD, PhD Professor of Neurosurgery, University of Toronto, Founder, ThinkFirst, Canada Maia E. von Maltzahn, BSc Medical Student, Dalhousie University

Canoeing 1

SECTION 1 Introduction and Overview

This page intentionally left blank

Recto Running Head

3

1 Description of the Study charles h. tator

For any given population, injuries sustained in connection with sports and recreational activities account for a significant proportion of all injuries, and of these, the catastrophic ones – such as brain or spinal cord trauma and fatalities – comprise a significant proportion.1–7 Catastrophic injuries can result in death or lifelong disability, with major effects of all kinds on the injured individuals and their families, and major financial costs to society for medical care, supports, and services, and for the replacement of lost earnings. The risk factors associated with injuries acquired in sports and recreational activities, and the particular causes of such injuries, are not well understood.8 This book presents a comprehensive description and analysis of all catastrophic injuries sustained during the period 1986–95 by the residents of Ontario, Canada. In 55 chapters we examine catastrophic injuries, and their prevention, for 55 separate sports and recreational activities (or groups of similar activities, where participation numbers for any one of them are very small) based on the data from four 12month prospective surveys undertaken by our research team. We begin, however, with a summary of our overall results and the various epidemiological factors that we address throughout this book (Chapter 2), the general principles of sports injury prevention (Chapter 3), the locations in Ontario where participants in sports and recreational activities sustained catastrophic injuries during our study period (Chapter 4), and the parts of the anatomy that were injured (Chapter 5). The data and analysis presented in this book are based on four 12month prospective surveys of catastrophic sports and recreation injuries sustained by Ontarians, undertaken by our research team between 1986 and 1995; a one-time survey, undertaken by others in 1995, for all of Ontario, of participation rates for and the injuries

4 Introduction and Overview

incurred in connection with a wide range of sports and recreational activities (see ‘The McLaren Report,’ below9); and a review of the available worldwide literature on sports injuries and their prevention. Chapter 2 introduces and summarizes the following epidemiological factors: the annual number and proportion of participants and of participants injured in sports and recreational activities in Ontario, their age and gender, the particular sports and recreational activities involved, the months in which the injuries occurred (see also Chapter 4, Table 4.1), the injury sites (e.g., lakes and rivers, playing fields), the anatomical locations of injuries (e.g., the head or spine) and the types of injuries sustained at each location (e.g., a skull fracture or a herniated cervical disc), fatalities, the organizations in which the injured participants were involved at the time of injury (e.g., school or community leagues), prevention issues (e.g., supervision, alcohol consumption), and the relative personal and population risk ratios (percentages and per 100,000) of participating in the various specific sports and recreational activities. While Chapter 2 presents and explains the overall results, in chapters 6 through 60 epidemiological data are examined sport by sport, for example, Chapter 6 is about canoeing and Chapter 37 is about soccer. Most of the sport-specific chapters have four tables each; however, because some chapters reflect groups of activities where the number of participants in any one of them was too small to yield enough usable information for such tabulation and/or the chapter examines a sport or recreational activity that was not addressed in the McLaren Report, some do not have these four ‘standard’ tables. Table 1 in the majority of chapters 6 through 60 shows the number of catastrophic injury cases for that sport or recreational activity during the four 12-month periods that we surveyed, distinguishing fatalities and survivors, males and females. For example, Chapter 28 is about bicycling. During the 4 years that we surveyed, as summarized on Table 28.1, a total of 289 Ontario bicyclists suffered catastrophic injuries: 62 of them were females and 226 were males (in one, gender unknown). Most of the injured bicyclists survived their catastrophic injuries (221 or 76.7%), but 67 (23.3%) of the cases were fatalities, 15 females and 52 males. Each chapter’s Table 1 also shows the age groups (age decades), by gender, to which participants belonged at the time their injuries were sustained, as well as the proportion of catastrophic injury cases represented by each decade of life, again, by gender. Almost one-quarter of the cases of catastrophic bicycling injuries (70 or 24.4%) were sustained by children under the age of 11 years, as can be seen in Table 28.1, and about 80% of the injured in this age group were boys; a good third of the bicycling injury

Introduction 5

cases were aged 11–20 at the time, and again, 80% of the injured in this age group were males. Information regarding age was not reported for two bicyclists who sustained catastrophic injuries; this fact is indicated on Table 28.1, and on all other tables where data were missing. Each Table 2 in chapters 6 through 60 shows, first, the estimated annual participation numbers and rates (percentages) for that chapter’s sport or recreational activity and the estimated annual numbers (and rates) of injury cases of all types for that activity (see below for how these were calculated), as well as the ratio of male-to-female injury cases. Data for both participation and injuries of all types are shown overall and by gender. For example, Chapter 13 is about swimming. We can see from Table 13.2 that every year 3 in 10 (29.30%) Ontarians swim at least once, a proportion that represents more than 3 million individuals, or 1,323,034 males and 1,681,479 females. The participation percentage, or rate, is somewhat higher for females (32.30%) than for males (26.10%). When calculated to two decimal places, it is estimated that 0.29% of Ontarians who go swimming in any given year will sustain an injury of some type while doing so; with regard to swimming, this estimated percentage for injuries of all types is the same overall, for males, and for females. This means that every year an estimated 8,584 Ontarians will sustain injuries while swimming, and of these 3,779 will be males and 4,787 will be females, giving a male-to-female injury ratio of 0.79. The remaining data in each Table 2 present and analyse our findings about catastrophic injuries for that sport or recreational activity. Continuing the example of swimming, Table 13.2 shows that the 100 catastrophic injury cases (79 males, 21 females) for our 4 study years (designated as 4 surveys) convert to a total of 25 catastrophic injury cases annually, or 19.75 male and 5.25 female cases. Thus, catastrophic injuries accounted for 0.291% of swimming injuries of all types. Only 14 of the 100 participants who sustained catastrophic swimming injuries survived, 86 sustained fatal injuries. Nineteen (21%) of the fatalities were females, 67 (79%) were males; annually, 4.75 females and 16.75 males sustained fatal injuries while swimming. The personal risk of catastrophic injury is shown in each Table 2 (in most of the chapters 6 through 60), as a percentage and per 100,000 participants in that sport or activity. The population risk per 100,000 population is shown, and finally, the risk of fatality. Although for swimming the estimated annual participation rates are similar for males and females (approximately 30%), and the rates for injuries of all types incurred in connection with swimming are also similar for males and females (approximately 0.3%), the catastrophic

6 Introduction and Overview

injury rates (0.001% vs 0.0003%) – let alone the fatality rates – are considerably higher for males than for females. In the chapters devoted to specific sports or recreational activities (chapters 6 through 60), the Table 3s show the kinds of catastrophic injuries that were sustained – according to anatomical location (e.g., the head) and type (e.g., skull fracture). This injury analysis is based on the data in our four 12-month surveys. In each Table 3 the numbers of fatal and non-fatal catastrophic injury cases correspond to the numbers shown in Table 1 of that chapter, but the number of actual injuries reported can, and very often does, exceed the number of injured individuals (cases). This is because an individual might easily sustain more than one injury in a single incident, and more than one injury to a single location, for example, a participant might sustain several injuries to the head and spine or chest. For example, Chapter 21 is about ice hockey. During the 4 years that we surveyed, as can be seen on Table 21.1, 190 Ontarians sustained catastrophic injuries while playing ice hockey; among them, were two fatalities (both males). Table 21.3 shows that the 190 catastrophically injured hockey players represented a total of 206 injuries, when considering the anatomical location (part of the body) that was injured – among them one of the head injury cases and one of the chest injury cases was fatal – but 321 injuries of various types at these locations (e.g., a location such as the head could sustain different types of injuries). The eye was a frequent site of injury: 69 hockey players sustained 100 catastrophic eye injuries, 10 injured the conjuctiva, 39 had hyphema, 16 incurred intraocular injuries, and 35 sustained other eye injuries. Injury prevention, and especially the prevention of catastrophic injuries, is an extremely important issue in sports and recreation. Measures taken to prevent such injuries, for example, enforcing helmet use or the wearing of a personal flotation device, have been enormously successful in reducing the numbers of deaths involving various sports such as motorcycling or swimming and in reducing the numbers of individuals left with lifelong disabilities or impairments as a result of engaging in such activities. In an effort towards reducing and mitigating cases of catastrophic injuries incurred during participation in sports and recreational activities, this book offers injury prevention strategies and tips geared specifically for each of the more than 100 activities examined here. While Chapter 3 describes in detail the general principles of sports injury prevention, in the chapters devoted to a single sport or recreational activity (or a group of similar activities, where participation numbers are very small for any one of them), we present the recom-

Introduction 7

mended injury prevention strategies and tips for that activity. The prevention strategies and tips are culled from reports and studies of sports injuries from all countries for which data are available. We recommend these prevention strategies to and suggest that they be implemented by a broad range of both public and private institutions, as well as by individuals, including professionals (e.g., coaches, trainers, facility managers, educators) and the participants in the various sports and recreational activities themselves and their families. Moreover, for evaluation of the effectiveness of new strategies for the prevention of sports and recreation injuries, this book should serve as a valuable source of comprehensive overall, as well as activity-specific data. In our four prospective surveys, we asked that primary physicians respond to three questions about prevention. We wanted to know whether the consumption of alcohol was involved with the incident during which catastrophic injury occurred, whether the activity during which the injury incident occurred was being supervised, and whether the physician thought the injury might have been prevented. The answers to these questions, for each activity, are summarized in Chapter 2, as well as in the Table 4s of the chapters 6 through 60. There are many published studies that examine the epidemiology of injuries associated with athletic activities, for example, water sports or bicycling, but only very few of them focus on catastrophic injuries. To date, the tendency has been to examine all the recorded injury cases – of which the overwhelming proportion are non-catastrophic – that resulted from participation in a particular sport, during some determined period of time (say, a few years or a decade), and in some named jurisdiction (a state, province, or country), and the emphasis has principally been on issues like the number of games missed because of injury. This book is unique in the sports and recreation injuries field in that it presents detailed data and analyses covering: • All catastrophic injury cases reported during four 12-month

periods over the course of a decade • All sports and recreational activities (more than 100 specific ones)

in which the population participates • A large, defined geographical region with a large population,

namely, the entire province of Ontario, Canada, which has more than 10 million inhabitants • Personal risk and population risk data, overall and for each sport or recreational activity • Injury prevention strategies and tips for each sport or recreational activity.

8 Introduction and Overview

Governments at all levels, health care planners, insurance underwriters, individuals in the public and private organizations that administer sports and recreation facilities and activities, and those who are in the industries involved with the production and maintenance of sports and recreation equipment and facilities, not to say participants and their families, might all benefit from attention to the findings presented in this book. Although the original data reported are all from Ontario, this book should be useful to a wide variety of interested individuals in other parts of Canada as well, and, indeed, to people in other countries and jurisdictions around the world. The safety and risk analysis and prevention strategies and tips are applicable in any locality in which there are participants in any of the 100 sports and recreational activities that we examine here. Methods Concern about an apparent rise in the incidence of catastrophic injuries to the nervous system sustained during certain sports and recreational activities, especially diving10,11 and ice hockey,12 prompted the Canadian Sports Spine and Head Injuries Research Centre – and its successor organizations SportSmart, Canada, and ThinkFirst, Canada – to sponsor four prospective 12-month surveys to gather epidemiological data. These surveys were conducted in 1986, 1989, 1992, and 1995, and their purpose was to document all of the catastrophic injury cases (n = 2,154) attributable to all sports and recreational activities involving residents of Ontario, which during the study period had a population of approximately 10 million. The surveys were especially designed to identify epidemiological factors that could inform the development of injury prevention programs. This book is the first publication that presents the combined data from all four of our surveys. (Since their completion SportSmart, Canada, has been incorporated into ThinkFirst, Canada, as a subsidiary known as ThinkFirst-SportSmart.) Participants The sample of participants in this study included the entire population of Ontario residents who took part in any sport or recreational activity during the study period. The four prospective surveys on which our

Introduction 9 Table 1.1 Methodology of Four 12-Month Surveys of Catastrophic Injuries Sustained in Sports and Recreational Activities in Ontario, Canada, 1986–1995 Method of Data Collection

1986a

1989b

1992c

1995d

Prospective Questionnaires

3,500 physicians

3,500 physicians

4 4

Data coordinators, 13 RTCs

Coroner’s System Media Reports

4 4

Data coordinators, 11 RTCs

4 4

4 4

Physicians = physicians and surgeons; RTC = regional trauma centre. a 1 Jan. to 31 Dec. 1986. b 1 Oct. 1988 to 30 Sept. 1989. c 1 July 1991 to 30 June 1992. d 1 Jan. to 31 Dec. 1995.

findings are based were administered by our research team and, for simplicity, are referred to here as the 1986, 1989, 1992, and 1995 surveys (see Table 1.1). These surveys identified all reported cases of catastrophic injuries incurred during participation in a sport or recreational activity in Ontario during four 12-month periods, together with epidemiological details about each one of them. All catastrophic sports and recreation injuries sustained by Ontarians, whether while they were actually in Ontario or while they were in other provinces of Canada or in other countries of the world are included in this study; catastrophic injuries sustained by people who were visitors to Ontario but not residents of Ontario are not included in this study. We also present estimated annual numbers and percentages for participation and for injuries of all types in each sport and recreational activity, as shown in the discussion above of the Table 2s in chapters 6 through 60. These were calculated from data obtained from what, for simplicity, is referred to here as the McLaren Report (see below). Furthermore, from these calculations we were able to derive the personal risk (per cent and per 100,000) and the population risk (per 100,000) for each sport or activity. Definitions of Non-Fatal and Fatal Catastrophic Injuries In this book we examine all reported fatal and non-fatal catastrophic injuries incurred by Ontarians during the four survey periods. A non-

10 Introduction and Overview

fatal catastrophic sports or recreation injury, referred to simply as a catastrophic injury for the purposes of this study, is any injury that causes permanent or long-term disability as a result of participation in a sport or recreational activity. Injuries such as a blood clot on the surface of the brain (extradural hematoma) that have the potential to cause permanent injury, long-term disability, or death are also included within the definition of non-fatal catastrophic injury. A fatal catastrophic injury is an injury incurred while participating in a sport or recreational activity where the result is death. These definitions for catastrophic injury were used consistently in all four of our surveys. Kinds of Injuries Included and Excluded in This Study The following injuries, both fatal and non-fatal, are included in this study: • Drowning • Head injury of severity greater than a simple concussion • Spinal injury with fracture, or spine ligament injury leading to • • • • • • • •

instability, or herniated disc Spinal cord injury, even if transient Nerve root injury Eye injury Facial fracture, except nasal fracture Internal injury to the thoracic, abdominal, or pelvic organs Arterial injury to the neck or limbs Laryngeal injury Major nerve or brachial plexus injury

In cases where an individual sustained more than one catastrophic injury in a single incident, all accompanying catastrophic injuries were recorded (see the discussion above of the Table 3s in chapters 6 through 60). Indeed, multiple injuries were reported in most of the cases of catastrophic injuries examined in this study, and thus there are often more catastrophic injuries for a given sport or recreational activity than the number of participants who sustained such injuries (see Chapter 5 and also the above discussion of the Table 3s in chapters 6 though 60). The following injuries are not included in this study if they occurred in the absence of an accompanying catastrophic injury:

Introduction 11 • Simple, uncomplicated concussion • Musculoskeletal injury to the limbs, including fractures • Soft tissue injury such as contusion, sprain, or dislocation, except • • • •

those with actual or threatened loss of a limb Simple whiplash injury Neck or back strain Near drowning Nasal fracture

Sports and Recreational Activities Examined in This Study All individual or team sports and fitness programs, both supervised and unsupervised, both amateur and professional, are included in this study, as are all recreational activities, including motor sports, bicycling, diving, boating and other water sports, supervised or unsupervised. Bicycling injuries sustained while bicycling to work or bicycling for transportation rather than for sport or recreation are excluded. However, all bicycling injuries to children are included – under the assumption that children ride bicycles only for leisure and recreation. Injuries sustained by participants of entertainment events involving sports and recreational activities are included, but not injuries to spectators at such events. Instruments and Procedures Data for all four of our surveys were collected prospectively. The principal instrument used was a Survey Questionnaire (reproduced here as Appendix l) that was developed and tested by us with the help of the Ontario Medical Association (AMA). The questionnaire, a one-page sheet, describes the inclusion and exclusion criteria and asks that the following information be noted for each patient, examined by the respondent, who sustained a catastrophic sports or recreation injury: • The geographical location in Ontario where the injury incident

occurred • The site where the injury incident occurred (swimming pool, play-

ground, etc.) • The type of organization (school or community league, etc.) in

which the participant was involved at the time of the injury

12 Introduction and Overview • The anatomical location(s) and type(s) of injury, the medical man-

agement, and the outcome • Whether the activity was being supervised, whether alcohol was

involved, and whether – in the opinion of the physician – the injury could have been prevented Identical data collection procedures were used for the 1986 and 1989 surveys. Before the start of each quarter year, the Survey Questionnaire was mailed to 3,500 physicians and surgeons in 12 specialty sections of the OMA (i.e., there were four separate mailings in each of the two years to 3,500 physicians). The OMA actively participated in this project through official endorsements and reminders to its members about the questionnaire. Chosen on the basis of their involvement in the management of trauma patients, the 12 specialty sections involved the following: all the surgical specialties including general, plastic, orthopaedic, paediatric, thoracic, vascular, neurological, and urological surgery, and the specialties of ophthalmology, otolaryngology, emergency medicine, and physical medicine and rehabilitation. A special arrangement was made with Ontario’s ophthalmologists through Tom Pashby, MD, who at the time maintained the Eye Injury Registry of the Canadian Ophthalmological Society, a reporting bank for all eye injuries incurred throughout Canada. The office of Ontario’s chief coroner, within the Ministry of the Attorney General, provided our research team with access to its data on all deaths in the province that resulted from trauma – whether or not the trauma was initially sustained at a time that the individual was in Ontario (some individuals were fatally injured while abroad or in another province, but were returned to Ontario either for treatment or as corpses). Implementing the coroner’s system, our research team selected and reviewed, in the chief coroner’s offices, the records of fatalities associated with injuries incurred by Ontarians during sports and recreational activities. In each of the survey years, a media monitoring service was engaged to collect all media reports about catastrophic sports or recreation injuries in Ontario or to Ontarians, either while in Ontario or elsewhere. With regard to almost all of the incidents reported in the media, we obtained follow-up verification and further details directly from the treating personnel or institutions involved. Data for the latter two of our four surveys were obtained using a different procedure, primarily to reduce costs. During the 1980s the

Introduction 13

Ontario health ministry designated 11 Regional Trauma Centres, all of which were located in major hospitals geographically dispersed throughout the province, including paediatric hospitals. For the 1992 and 1995 surveys members of our research team provided data coordinators, people who were already employees of these trauma centres, with training regarding definitions, inclusion and exclusion criteria, and the completion of the Survey Questionnaire. Throughout the latter 2 survey years, there was continual communication between these data coordinators and our research team to ensure consistency and compliance. Because of the nature of the Ontario health care system, with its allocation of resources to major trauma centres, it could safely be assumed that – with few exceptions (see Limitations below) – all catastrophic sports and recreation injuries that were sustained in Ontario during 1992 and 1995 were referred to one of these centres. In all other respects the procedures and instruments used in the 1992 and 1995 surveys were identical to those for the 1986 and 1989 surveys, such as the content of the questionnaire and the use of the Eye Injury Registry of the Canadian Ophthalmological Society, the media, and records in the offices of the Chief Coroner of Ontario. The catchment population was similar in all four surveys, and comprised all Ontarians, a population of approximately 10 million. The actual dates of the four periods of patient accrual are shown in Table 1.1. They were determined by the receipt of research contracts from the Ministry of Citizenship, Tourism and Recreation of Ontario, as commissioned by the Minister’s Advisory Committee on Sports Safety and Fitness. Each survey was taken for a full consecutive 12 months, and thus ensures a true annual accrual of all the seasonal sports and recreational activities for that 12-month period. It was possible to detect duplicate reports on the basis of injured individuals’ initials, dates of injury, and other details. Missing values are not included in the calculations of totals, percentages, and other statistical information, and the number of missing values is indicated in each table or figure. The SAS statistics package from the SAS Institute Inc., in Cary, North Carolina, was used for data entry and analysis. Geographical Location in Which Injury Incidents Occurred The location in Ontario in which the catastrophic injury incident occurred, rather than the location of the residence of the injured par-

14 Introduction and Overview

ticipant, was recorded on the questionnaire sheet. In identifying the nearest city, town, or village where a person sustained catastrophic injuries while engaged in a sport or recreational activity, our aim was to demonstrate the regional usefulness of our data. This specific, regional information should be valuable to regional administrators and local health and safety groups throughout the province, especially those who are involved in programs for the prevention of sports and recreation injuries. Table 4.1 (in Chapter 4) shows the geographical location in Ontario where, for each case that was reported in the four surveys used in this study, a sports or recreational activity resulted in catastrophic injuries. As well as the location, Table 4.1 names the particular activity in which the victim was participating when the catastrophic injury (whether fatal or non-fatal) was sustained and the month in which the incident occurred. Confidentiality To maintain confidentiality, wherever possible we have avoided presenting data on individual cases, and have not used any personal identifying information such as the initials of the injured person. Similarly, when citing the geographical location of the incidents during which catastrophic injuries were sustained, we did not include age and gender data. To further minimize the risk of revealing any participant’s identity, we have omitted the age and gender data, usually given in the Table 1s, from those tables that represent fewer than 10 individuals in the chapters that describe the individual sports and recreational activities (chapters 6 through 60). The McLaren Report The Sports and Recreation Programs Branch, Sport and Recreation Division, of the Ministry of Citizenship, Culture and Recreation in Ontario, provided a grant to the Institute of Social Research at York University, in Toronto, to conduct a study to document the numbers, types, and consequences of injuries incurred by Ontario residents while participating in sports and other physical recreation activities during the entire calendar year of 1995. Data were obtained through a telephone survey of a sample of the Ontario population aged 6 years and older.

Introduction 15

We use the term ‘McLaren Report’ in this book to distinguish the survey on which the report is based from our four surveys, and because the data for it, published in 1996, were gathered, analysed, and synthesized by Peter McLaren, PhD, a sports injury analyst at the ministry, the author of the report.9 We are grateful to Peter McLaren for providing us with copies of his report, which is described in detail as follows. Sample Design of the McLaren Report A telephone survey was conducted of a random sample of Ontario households in which a knowledgeable person was interviewed about all members of a household who were 6 years of age or older. There was no screening for those who had sustained injuries of any kind. Thus, the prevalence of injuries identified in McLaren Report survey is an unbiased estimate, as compared with data based only on households in which someone had been injured. The McLaren sample was stratified on the basis of the five service regions of the Ministry of Citizenship, Culture and Recreation at the time the survey was undertaken. The distribution of the sample was matched to the distribution of the population of Ontario, so the percentage of the sample cases in each service region is the same as the percentage of the total population of Ontario living in each service region. The survey of households produced both a sample of injuries and a sample of individuals and the sports in which they participated. The households were identified by randomly selecting residential telephone numbers in Ontario. The random digit dialing method was used to produce a sample of telephone numbers proportional to population size, and the goal was to obtain data on 8,365 individuals. Types of Information Obtained for the McLaren Report The findings of the McLaren Report include participation rates by sport or activity and injury rates – catastrophic and non-catastrophic injuries combined – for most of the high participation sports and recreational activities in Ontario. The summary of these rates is given here in Appendix 2, and also, for most of the individual sports and recreational activities or groups of activities, these rates are given in the Table 2s of chapters 6 through 60. The McLaren Report has been extremely useful for our study. Using McLaren’s rates and our empirical findings, and knowing the popula-

16 Introduction and Overview

tion of Ontario, we were able to calculate estimated annual participation numbers, estimated annual numbers of cases of injuries of all types, catastrophic injury rates, fatality rates, as well as the personal risk and the population risk of catastrophic injury for each sport or recreational activity, as will be explained in detail below. During the interviews for the McLaren Report, no distinction was made between catastrophic and non-catastrophic injuries. Since there is no accurate way to make this distinction retrospectively on the basis of the available information, McLaren’s results reflect a combination of both catastrophic and non-catastrophic (fatal and non-fatal) injuries. Basic Assumption in Using McLaren’s Findings The McLaren Report is based on research performed in 1995, and it generated participation data for that year. Unfortunately, participation data have not been generated for any other year covered by our study, neither by McLaren nor anybody else. We therefore made the decision to make our calculations using the assumption that the McLaren participation rates and rates for all types of injuries in 1995 could reasonably be applied in general terms for any of the years in our study (1986–95). Limitations in Using McLaren’s Findings We wanted to cover all the possible sports and recreational activities in which Ontarians participate. This meant facing some limitations in using McLaren’s findings, especially when it came to sports and recreational activities that lack major participation in Ontario. An example would be water polo. McLaren shows a participation rate for water polo of less than 1% of the population of Ontario, but he also shows that all 100% of these participants, all males and all females who played water polo, sustained an injury of some type while doing so. This finding was arrived at because the telephone survey uncovered only a very small number of individuals who had participated in water polo 1995, and it just so happened that all of the individuals in this small number had sustained a water polo injury in 1995. Thus, as we can see, it may be that data for specialized and less popular sports and recreational activities are skewed because of the much smaller chance of reaching individuals from these groups in a

Introduction 17

relatively small telephone survey. The reader should bear in mind that this can result in either an under- or an over-representation in the participation and the injury rates reported for some activities. Explanation of Calculations and Derived Values Average Ontario Population Numbers, 1986–1995 The population of Ontario changed somewhat over the decade 1986–95. Therefore, to use the same numbers for the populated in each year of our study, we used the average population numbers for the entire period, that is, average total population, average number of males, and average number of females (see Appendix 3). Values such as the estimated annual number of participants, estimated annual number of injuries of all types, and the catastrophic injuries per 100,000 population were calculated using these average population numbers. Participants and Cases of Injuries: Rates, Numbers, and Gender The Tables 2 in most of the chapters from 6 to 60 show the estimated percentage and number of Ontarians (overall and by gender), who participated at all, in any given year, in the sport or activity examined in that chapter. The Tables 2s also show the estimated annual rates and numbers of injury cases (catastrophic and non-catastrophic combined), overall and by gender. These findings for all of the sports and recreational activities examined in this book are summarized in Chapter 2. These numbers are derived using the percentages given in the McLaren Report for various sports and recreational activities. As already mentioned, McLaren did not cover all of the activities that our studies did, and for this reason we are not able to present participation and injury data for all activities. Because of cumulative roundings in the various stages and sources used in making these calculations (see the descriptions that follow), the rates and numbers do not always add up precisely but should be close enough (within 5%) to render a reasonably accurate picture. estimated annual number of participants The estimated annual number of participants for each sport or recreational activity was obtained by multiplying the Ontario population

18 Introduction and Overview

(as derived above) by the participation rates for the activities listed in the McLaren Report (see Appendix 2). We used the assumption that the participation rates and injury rates for 1995, as identified in the McLaren Report, were constant for the entire study period, from 1986 to 1995, and thus in our study the McLaren participation rates constitute the annual participation rates. The same assumption was applied in calculating the estimated numbers of male and female participants, that is, if the rates stayed the same year to year, so too did the numbers. estimated annual cases of injuries of all types The estimated annual rate of cases of injuries of all types (catastrophic and non-catastrophic combined) for each sport or recreational activity was calculated using the rate given in the McLaren Report for that activity, multiplying by the number of participants (calculated as described above), and then multiplying by 100 to obtain the estimated percentage of individuals who, in any given year, are likely to sustain an injury while participating in that activity. The same assumption as was applied in calculating the estimated annual numbers of participants, that is, if the rates stayed the same year to year, so too did the numbers, was used in calculating the estimated annual number of cases of injuries of all types, overall and for males and females. catastrophic injuries Our research focus is catastrophic injuries. From our surveys we obtained the number of catastrophic injuries for each activity or sport, and a total for the four survey years is given in Table 1 of each of the chapters on specific activities (chapters 6 through 60), and a summary for all of the sports and activities is to be found in Chapter 2. To calculate the annual number of catastrophic injuries, we divided by four. The 4-year totals and the annual numbers of catastrophic injuries, and separate 4-year totals and annual numbers – overall and by gender – are presented in the Table 2s of chapters 6 through 60, and summarized in Chapter 2. catastrophic injury rate The catastrophic injury rate was calculated by dividing the annual number of catastrophic injuries by the number of participants (both

Introduction 19

calculations explained above), and multiplying by 100. For each activity, this calculation was performed three times: for the activity as a whole, and then separately for the male participants and for the female participants. The catastrophic injury rates are presented as percentages in Table 2.17, for all sports and recreational activities examined in this study, as well as in the Table 2s of most of the chapters 6 through 60. Example: the overall annual catastrophic injury rate for skateboarding was found to be 0.007%. This means that, in any given year, 0.007% of all those who participate in skateboarding are likely to sustain a catastrophic injury.

Risk Analysis personal risk rate We present the catastrophic injury risk as a percentage (i.e., per 100 participants), for males and for females. But this can also be read as a personal risk rate, which we present as a rate per 100,000 participants. Thus, the above example of a catastrophic injury rate of 0.007% for skateboarding, represents a personal risk rate per 100,000 participants of 7. Put another way, we estimate that, in any given year, 7 of every 100,000 skateboarders will sustain a catastrophic injury. Examples: At 0.088% snowmobiling has one of the highest catastrophic injury rates of any sport or recreational activity. Put another way, in any given year, for every 100,000 snowmobilers 88 will likely sustain a catastrophic injury. For toboganning the annual risk of catastrophic injury is about 38 in 100,000 participants, or 0.38%, whereas every year for every 100,000 alpine skiers, about 3 will sustain catastrophic injuries per 100,000 skiers, or 0.003%.

population risk rate If we know the number of participants for any given sport or recreational activity, and we know the catastrophic injury rate, we can calculate the risk of catastrophic injury per 100,000 population represented by that activity for any given year. Example: For canoeing the annual risk of catastrophic injury per 100,000 population is 3.87. Put another way, this means that, in any given year, for

20 Introduction and Overview every 100,000 Ontarians there will be 3.87 who sustain catastrophic injuries while participating in canoeing.

The following chapters can be read consecutively, in the order in which they are presented here, or the reader may turn directly to the chapter examining the sport or recreational activity of greatest direct personal interest. References 1. Kurtzke JF. Epidemiology of spinal cord injury. Exp Neurol 1975;48:163–236. 2. Kraus J. Epidemiology of Head Injury. In: Cooper P, ed. Head Injury. 3rd ed. Baltimore: Williams and Wilkins, 1993, 1–25. 3. Tator C. Epidemiology and general characteristics of the spinal cord injury patient. In: Benzel E, Tator CH, eds. Contemporary Management of Spinal Cord Injury. Park Ridge: American Association of Neurological Surgeons, 1995, 9–13. 4. Tator C. Epidemiology and general characteristics of the spinal cord injured patient. In: Tator CH, Benzel E, eds. Contemporary Management of Spinal Cord Injury: From Impact to Rehabilitation. Park Ridge: American Association of Neurological Surgeons, 2000, 15–19. 5. Mueller FO. Catastrophic head injuries in high school and collegiate sports. J Athl Train 2001;36(3):312–15. 6. Mueller FO. Sports related head and brain trauma. N C Med J 2001;62(6):368–72. 7. Mueller FO. Catastrophic sports injuries: Who is at risk? Curr Sports Med Rep 2003;2(2):57–8. 8. Shephard RJ. Towards an evidence based prevention of sports injuries. Inj Prev 2005;11(2):65–6. 9. McLaren P. A Study of Injuries Sustained in Sport and Recreation in Ontario. Toronto: Publications Ontario, 1996. 10. Tator CH, Edmonds VE, New ML. Diving: A frequent and potentially preventable cause of spinal cord injury. CMAJ 1981;124(10):1323–4. 11. Tator CH, Edmonds VE. Acute spinal cord injury: Analysis of epidemiologic factors. Can J Surg 1979;22(6):575–8. 12. Tator CH, Provvidenza CF, Lapczak L, Carson J, Raymond D. Spinal injuries in Canadian ice hockey: Documentation of injuries sustained 1943–1999. Can J Neurol Sci 2004;31(4):460–6.

Recto Running Head 21

2 Overview of the Results of the Ontario Study, 1986–1995 charles h. tator

Number of Injured Participants The total number of catastrophic injuries in the 4 survey years (1986, 1989, 1992, and 1995) used in this study was 2,154, consisting of 1,523 (70.7%) survivors and 631 (29.3%) fatalities (Table 2.1). Although the total number of injuries in each survey year was similar, there were fewer fatalities in the first survey year, most likely because of difficulties in the identification of relevant cases in the coroner’s office, a problem that was corrected in the following three years surveyed. In the first two surveys (1986 and 1989, as noted in Chapter 1 and Table 1.1), prospective questionnaires were mailed to 3,500 selected physicians and surgeons in Ontario who would have potentially been involved in the management of catastrophic injuries; the response rate was about 20% in each of those two years. Although this is a low response rate, we are confident that the responses included a high percentage of the actual number of catastrophic injuries sustained in Ontario in connection with sports and recreational activities in those 2 survey years. First, there was a high likelihood that several different specialist physicians and surgeons would have treated each patient. A second reason relates to our strategy of employing a media clipping service, because catastrophic injuries in sports and recreation have a high probability of being reported in the media, and indeed, almost all of our cases were the subject of one or more media reports. We believe that the low response rate reflects the reluctance of physicians to return a survey questionnaire if they had no cases to report, and in fact, a high proportion of the returned surveys contained information about a catastrophic injury. In the later 2 survey years, 1992 and 1995, the potential for missed cases was minimal because the respondents at

22 Introduction and Overview Table 2.1 No. (%) of Fatal and Non-fatal Cases of Catastrophic Sports and Recreation Injuries Reported in Ontario in 1986–1995

Survivors Fatalities Totala a

1986

1989

1992

1995

Total

443 87 530

286 210 496

342 226 568

452 108 560

1,523 631 2,154

(70.7) (29.3) (100)

Annual incidence of fatal and non-fatal catastrophic injuries: 2,154 / 4 = 538.

Figure 2.1 Gender of individuals sustaining catastrophic injuries, both survivors and fatalities, 1986, 1989, 1992, and 1995. 2,000 1,800

1,756

1,600

Individuals (n)

1,400 1,200 1,000 800 600 368

400 200 0 Males

Females

all the major trauma centres throughout Ontario were employed by those centres to record all eligible cases, and these individuals provided us with the data. Age and Gender of the Injured Participants In general, the present study showed that catastrophic injuries in sports and recreation were sustained by young people, usually in their

The Ontario Study, 1986–1995

23

Table 2.2 Age and Gender of 2,154 Victims of Catastrophic Sports and Recreation Injuries Reported in Ontario, 1986–1995a (% in parentheses) Age group (years)

Femalesb

Malesc

Totald

< 11 11–20 21–30 31–40 41–50 51–60 61–70 71–80 >80 Total

88 (23.9) 121 (32.9) 68 (18.5) 44 (12.0) 29 (7.9) 10 (2.7) 7 (1.9) 1 (0.3)

188 (10.7) 552 (31.4) 431 (24.5) 264 (15.0) 166 (9.5) 80 (4.6) 49 (2.8) 20 (1.1) 6 (0.3) 1,756 (100.0)

276 (13.0) 673 (31.7) 499 (23.6) 308 (14.5) 195 (9.2) 90 (4.2) 56 (2.6) 21 (1.0) 6 (0.3) 2,124 (100.0)

368 (100.0)

a

Survivors and fatalities; 4 survey years (1986, 1989, 1992, 1995). Annual incidence of catastrophic injuries in female participants: 368/4 = 92. Mean age, 22.1 years; median age, 17.0 years. c Annual incidence of catastrophic injuries in male participants: 1,756/4 = 439. Mean age, 26.8 years; median age, 23.0 years. d Missing age and gender information for 30 participants. b

teens and twenties, and by males more than four times as frequently than by females (Figure 2.1). Table 2.2 (missing information for 30 injuries) shows that of 2,124 injuries, 1,756 (82.7%) were sustained by males and 368 (17.3%) were sustained by females, and that females were generally injured at a younger age: 56.8% of the females were 20 years of age or less, whereas only 42.1% of the males were aged 20 or less when the injuries occurred. Also, there were proportionally more injured males than females over the age of 50. Figure 2.1 shows that for both genders, injuries peaked in the decade 11 to 20 years, which accounted for 32.9% and 31.4% of the injuries in females and males, respectively. The mean and median ages for females who sustained injuries were 22.1 and 17 years, respectively, and for males 26.8 and 23 years, respectively (Table 2.2). For both sexes combined, the mean and median ages for the survivors were 23.6 and 20.0 years, respectively, and for fatalities, 31.6 and 29.0 years, respectively. Sports and Recreation Activities in Which the Injuries Occurred For some of the analyses, we found it helpful to group the sports and recreational activities into 12 broad groups (Figure 2.2). As a group, water sports (525 cases) represented the largest number of injuries, fol-

24 Introduction and Overview Figure 2.2 Incidence of catastrophic injuries (survivors and fatalities) in the 12 groups of sports and recreational activities (1986–95). 600 525 500 426

Injuries (n)

400

350 289

300 200

129 91

100

88

70

63

53

43

25

nt

in

g

n ria st

ue

Hu

or Flo Eq

ay Pl

t ue

ld

cq Ra

Fie

ll se

ba

isc Ba

M

r

cli

Bi

cy

in

te

or W

ot

er M

W at

ng

0

lowed by motor sports (426, including snowmobiling), winter sports (350), and bicycling (289). Most of the subsequent chapters contain data and analyses on each of 55 individual activities. The groups were arbitrarily selected to help injury prevention programs target their efforts on a seasonal basis. For example, we grouped water and winter sports, although we arbitrarily placed snowmobiling into the motor sports group rather than the winter sports group. Some activities such as bicycling were not grouped – to emphasize their importance, and because they are not restricted to one season. Tables 2.3 to 2.6 show the incidence based on the grouped and individual activities. Table 2.3 shows the data for the 12 groups of activities, and lists the total number of participants who sustained injuries and the number of survivors and fatalities, while Table 2.4 shows the activities in which the fatalities occurred. Table 2.5 shows the individual activities that comprise the various groups. Water sports as a group were the leading cause of catastrophic injuries, accounting for 24.4% of all such injuries. Motor sports were second (at 19.8%), winter sports third (at 16.3%), and bicycling fourth (at 13.4%) of all injuries (Table 2.3). With respect to the 631 fatalities, water sports accounted for 52.9% of all fatalities, while 23.1% involved motor sports,

The Ontario Study, 1986–1995 25 Table 2.3 Rank Order of 12 Groups of Sports and Recreational Activities According to No. (%) of Fatal and Non-fatal Catastrophic Injuries Reported, Ontario, 1986–1995a Rank

Activity Group

Catastrophic Injuriesb

1 2 3 4 5 6 7 8 9 10 11 12

Water sports Motor sports Winter sports Bicycling Miscellaneous Baseball Field sports Racquet sports Playgrounds / play Floor sports Horseback riding Hunting Total

525 (24.4) 426 (19.8) 350 (16.3) 289 (13.4) 129 (6.0) 91 (4.2) 88 (4.1) 70 (3.3) 63 (2.9) 53 (2.5) 43 (2.0) 25 (1.1) 2,152 (100.0)

a b

Survivors and fatalities; 4 survey years (1986, 1989, 1992, 1995). Missing information identifying the sport or recreational activity for two injured participants.

Table 2.4 Rank Order of 12 Groups of Sports and Recreational Activities According to No. (%) of Fatalities Reported, Ontario, 1986–1995a Rank

Activity Group

Fatalitiesb

1 2 3 4 5 6 7 8 9 10 11 12

Water sports Motor sports Bicycling Miscellaneous Hunting Winter sports Horseback riding Playground / play Field sports Floor sports Baseball Racquet sports Total

334 (52.9) 146 (23.1) 67 (10.6) 33 (5.2) 15 (2.4) 13 (2.1) 10 (1.6) 8 (1.3) 3 (0.5) 2 (0.3) 0 (0) 0 (0) 631 (100.0)

a b

For 4 survey years (1986, 1989, 1992, 1995). Annual incidence of fatalities: 631/4 = 157.

26 Introduction and Overview Table 2.5 No. (%) of Fatalities and No. (%) of Survivors of Non-fatal Catastrophic Injuries within 12 Groups of Sports and Recreational Activities, Ontario, 1986–1995a Activities 1

2

3

4 5

6 7

8

9 10 11 12 a b

Water sports Boating, canoeing Boating, sailing Boating, other Diving Fishing Scuba-diving Swimming Waterskiing Other Total Motor sports ATV riding Snowmobiling Other Total Winter sports Ice hockey Skiing, alpine Tobogganing / sledding Other Total Bicycling Miscellaneous Golf Other Total Baseball Field sports Football Rugby Other Total Racquet sports Badminton Squash Other Total Horseback riding Floor sports Playgrounds / play Hunting Total

Survivors

Fatalities

Totalb

(4.3) (1.1) (11.4) (0.8) (18.5) (1.6) (13.6) (0.3) (1.3) (52.9)

27 8 112 105 126 10 100 9 28 525

(1.3) (0.4) (5.2) (4.9) (5.9) (0.5) (4.6) (0.4) (1.3) (24.4)

1 40 100 9

(0.1) (2.6) (6.6) (0.6)

14 7 20 191

(0.9) (0.5) (1.3) (12.6)

27 7 72 5 117 10 86 2 8 334

67 170 43 280

(4.4) (11.2) (2.8) (18.4)

16 120 10 146

(2.5) (19) (1.6) (23.1)

83 290 53 426

(3.9) (13.5) (2.5) (19.8)

188 60 58 31 337 222

(12.4) (3.9) (3.8) (2) (22.2) (14.6)

2 5 4 2 13 67

(0.3) (0.8) (0.6) (0.3) (2.1) (10.6)

190 65 62 33 350 289

(8.8) (3) (2.9) (1.5) (16.3) (13.4)

20 76 96 91

(1.3) (5) (6.3) (6)

33 (5.2) 33 (5.2)

20 109 129 91

(0.9) (5.1) (6) (4.2)

31 16 38 85

(2) (1.1) (2.5) (5.6)

32 16 40 88

(1.5) (0.7) (1.9) (4.1)

21 (1.4) 20 (1.3) 29 (1.9) 70 (4.6) 33 (2.2) 51 (3.4) 55 (3.6) 10 (0.7) 1,521 (100)

1 (0.2) 2 (0.3) 3 (0.5)

10 2 8 15 631

(1.6) (0.3) (1.3) (2.4) (100)

21 20 29 70 43 53 63 25 2,152

For the 4 survey years (1986, 1989, 1992, 1995). Missing information identifying the sport or recreational activity for two injured participants.

(1) (0.9) (1.3) (3.3) (2) (2.5) (2.9) (1.2) (100)

The Ontario Study, 1986–1995 27 Table 2.6 Ranking by Number of Fatalities in Sports and Recreational Activities, 1986, 1989, 1992, 1995 Rank

Activity

Survivors n (%)

Fatalities n (%)

Total n (%)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38

Snowmobiling Fishing Swimming Boating, other Bicycling Boating, canoeing ATV riding Hunting Horseback riding Scuba diving Play, playground Boating, sail Flying Camping and hiking Water sports, other Diving Skiing, alpine Motor biking Parachuting Tobogganing and sledding Mountain climbing Dirt-biking Air sports Summer sports, other Hockey Waterskiing Personal watercraft Motor sports, other Floor sports Soccer Football Skating In-line skating Skateboarding Running and jogging Missile sports Field sports Winter sports, other

170 9 14 40 221 0 67 10 33 0 53 1 0 7 15 100 60 14 4 58 5 17 5 5 188 7 5 12 7 32 31 16 11 8 4 10 6 4

(11.2) (0.6) (0.9) (2.6) (14.6) (0.0) (4.4) (0.7) (2.2) (0.0) (3.5) (0.1) (0.0) (0.5) (1.0) (6.6) (3.9) (0.9) (0.3) (3.8) (0.3) (1.1) (0.3) (0.3) (12.4) (0.5) (0.3) (0.8) (0.5) (2.1) (2.0) (1.1) (0.7) (0.5) (0.3) (0.7) (0.4) (0.3)

120 117 86 72 67 27 16 15 10 10 8 7 7 7 6 5 5 5 5 4 4 3 3 3 2 2 2 2 2 1 1 1 1 1 1 1 1 1

290 126 100 112 289 27 83 25 43 10 61 8 7 14 21 105 65 19 9 62 9 20 8 8 190 9 7 14 9 33 32 17 12 9 5 11 7 5

(13.5) (5.9) (4.6) (5.2) (13.4) (1.3) (3.9) (1.2) (2.0) (0.5) (2.8) (0.4) (0.3) (0.7) (1.0) (4.9) (3.0) (0.9) (0.4) (2.9) (0.4) (0.9) (0.4) (0.4) (8.8) (0.4) (0.3) (0.7) (0.4) (1.5) (1.5) (0.8) (0.6) (0.4) (0.2) (0.5) (0.3) (0.2)

91 21 20 20

(6.0) (1.4) (1.3) (1.3)

0 0 0 0

91 21 20 20

(4.2) (1.0) (0.9) (0.9)

No Baseball deaths Badminton Squash Golf

(19.0) (18.5) (13.6) (11.4) (10.6) (4.3) (2.5) (2.4) (1.6) (1.6) (1.3) (1.1) (1.1) (0.5) (1.0) (0.8) (0.8) (0.8) (0.8) (0.6) (0.6) (0.5) (0.5) (0.5) (0.3) (0.3) (0.3) (0.3) (0.3) (0.2) (0.2) (0.2) (0.2) (0.2) (0.2) (0.2) (0.2) (0.2)

28 Introduction and Overview Table 2.6 (continued ) Rank

Activity

Rugby Racquetball Ball hockey Tennis Basketball Floor hockey Air gun use War games Gymnastics Martial arts Snowboarding Racquet sports, other Skiing, cross-country Wrestling Totals

Survivors n (%) 16 13 12 11 10 8 8 8 6 6 6 5 5 5

(1.1) (0.9) (0.8) (0.7) (0.7) (0.5) (0.5) (0.5) (0.4) (0.4) (0.4) (0.3) (0.3) (0.3)

1,521 (100.0)

Fatalities n (%) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 631 (100.0)

Total n 16 13 12 11 10 8 8 8 6 6 6 5 5 5

(%) (0.7) (0.6) (0.6) (0.5) (0.5) (0.4) (0.4) (0.4) (0.3) (0.3) (0.3) (0.2) (0.2) (0.2)

2,152 (100.0)

and 10.6 % resulted from bicycling (Table 2.4 and Figure 2.3). There were no fatalities in some activities such as baseball or racquet sports. In all activities except equestrian sports, catastrophic injuries to males outnumbered those to females, usually by a large percentage. In equestrian sports, there were 25 injuries to females, but only 18 to males (see Chapter 44). Table 2.5 shows the individual sports and recreational activities in which the fatal and non-fatal injuries occurred. In the water sports category, the major activities during which injuries were sustained were fishing, boating, swimming, and diving. Fishing had 117 fatalities (18.5% of all the fatalities) and was the highest cause of all fatalities in the water sports group, as well as second highest in fatalities in any group, after snowmobiling, which was responsible for 120 fatalities (19.0%). Most other fatalities in water sports resulted from swimming and boating. Snowmobiling was the cause of the highest total number of fatal (120) and non-fatal injuries (170), accounting for a total of 290 cases of injuries, representing 13.5% of the total number of injuries. Another cause of fatal injuries in motor sports was all terrain vehicle (ATV) crashes, which accounted for 16 fatalities. Bicycling caused 13.4% of all injuries, second only to snowmobiling, and accounted for 10.6% of all fatalities. Hockey was responsible for the highest number

The Ontario Study, 1986–1995 29 Figure 2.3 Number of fatalities in 10 of the 12 groups of sports and recreational activities during the 4 study years. There were no fatalities in baseball and racquet sports. 400 350

334

Fatalities (n)

300 250 200 146 150 100

67 33

50

15

13

10

8

3

2 or Flo

ld Fie

ay Pl

n st ue

Eq

W

in

ria

te

r

g in

isc M

nt Hu

cy

cli

or Bi

M

ot

er W at

ng

0

of injuries in the winter group (190 cases), although alpine skiing and tobogganing (and sledding) also produced large numbers of injuries. Field sports as a group were not associated with a large number of catastrophic injuries, and there were only small numbers of injuries in football and rugby. Although only 25 hunters sustained catastrophic injuries, 15 of these were fatal (2.4% of the total number of fatalities). Table 2.6 shows the incidence over the 4 survey years combined, ranked from the highest to the lowest numbers, and reveals that snowmobiling (290), bicycling (288), and hockey (190) were the top three individual activities for catastrophic injuries. Age of Injured Participants in Each Activity As expected, among the various types of activities there was considerable variation in the ages of the participants who sustained injuries (Table 2.7). On average those injured in some water sports such as fishing or in hunting, for example, were much older than those injured in bicycling and winter sports such as hockey. The average age of the 126 individuals injured while fishing was 40.3 years, while for the 190

30 Introduction and Overview Table 2.7 Age (Mean, Median, Minimum, Maximum) of 2,154 Participants Sustaining Catastrophic Injuries in 55 Sports and Recreational Activities in Ontario, 1986–1995a Age (years)b Activity

No. of Cases

Mean

Median

Minimum Maximum

Air guns Air sports Aircraft flying ATV riding Badminton Ball hockey Baseball Basketball Bicycling Boating, canoeing Boating, other Boating, sailing Camping / hiking Dirt-biking Diving Field sports Fishing Floor hockey Floor sports Football Golf Gymnastics Horseback riding Hunting Ice hockey Ice skating In-line skating Martial arts Missile sports Motor sports Motorbiking Mountain climbing Parachuting Personal watercraft Playground / play Racquet sports Racquetball Rugby Running / jogging Scuba-diving Skateboarding

8 8 7 82 21 12 90 10 288 27 110 8 14 20 105 7 123 8 9 31 19 6 42 24 187 17 12 6 11 14 19 9 9 7 60 5 12 16 5 10 9

18.3 42.5 46.7 27.0 22.5 16.5 21.5 17.7 23.3 30.6 36.7 29.0 22.6 19.0 24.1 15.1 40.3 21.3 25.9 19.3 25.9 12.7 31.9 32.6 24.3 31.9 24.1 23.5 12.9 18.4 25.8 30.9 29.8 28.9 8.7 31.8 30.8 20.6 46.4 37.1 13.6

14.0 42.5 49.0 25.0 18.0 14.5 20.0 15.5 16.5 27.0 36.5 26.0 20.5 16.5 21.0 13.0 38.0 18.0 27.0 17 23.0 12.5 36.5 28.5 22.0 35.0 13.0 20.0 13.0 17.5 22.0 30.0 30.0 27.0 8.0 35.0 31.0 19.0 46.0 38.0 13.0

10 24 31 2 8 4 3 11 2 15 5 6 1 10 7 10 5 9 45 14 7 8 4 15 11 6 11 14 4 6 7 16 14 18 2 7 16 14 36 17 10

44 57 69 76 49 36 49 33 86 56 74 58 48 41 60 29 84 50 10 29 77 17 72 84 54 66 79 45 19 33 62 48 43 47 34 47 44 46 57 54 20

The Ontario Study, 1986–1995 31 Table 2.7 (continued ) Age (years)b Activity Skiing, alpine Skiing, cross-country Snowboarding Snowmobiling Soccer Squash Summer sports, other Swimming Tennis Tobogganing / sledding War games Water play Waterskiing Winter sports, other Wrestling NA Total

No. of Cases 65 5 6 289 32 20 8 100 11 61 8 19 8 5 5 25 2,154

Mean

Median

Minimum Maximum

22.1 33.2 18.0 29.1 18.0 28.9 42.9 26.4 30.3 15.6 20.6 19.9 20.8 24.2 21.4

17.0 34.0 18.0 26.0 16.0 27.0 44.5 21.0 21.0 11.0 21.0 16.0 19.0 25.0 21.0

2 16 11 2 6 14 5 1 5 3 14 2 16 13 15

60 44 23 80 35 50 62 87 71 57 30 46 35 31 30

26.0

22.0

1

87

NA = not available. a Survivors and fatalities; 4 survey years (1986, 1989, 1992, 1995). b Missing information on age for 25 participants (NA).

injured hockey players the average age was 24.3 years, and for the 62 injured while tobogganing and sledding it was 15.6 years. The activity in which the oldest age group sustained catastrophic injury was flying (average, 46.7 years), and the other air sports also had older participants (average, 42.5 years) with catastrophic injury. Running and jogging (average, 46.4 years) also had older injured participants. Those injured on playgrounds comprised the youngest age group with catastrophic injuries (average, 8.7 years), and other activities in which young participants sustained catastrophic injuries included skateboarding (average, 13.6 years), tobogganing and sledding (average, 15.6 years), and snowboarding (average, 18.0 years; Table 2.7). Month of Injury Figure 2.4 and Table 2.8 show the months in which the injuries occurred. Peak months for injuries reflected participation in water

32 Introduction and Overview Figure 2.4 The number of injured in each month is shown for the 4 study years 1986, 1989, 1992, and 1995. 350

320

300

Injured (n)

250

217 190

200

188

214

198

152

150

143

134

150 104 81

100 50

c De

v No

t Oc

g

pt Se

Au

ly Ju

ne Ju

ay M

ril Ap

b M ar ch

Fe

Ja

n

0

sports during the summer and hockey, skiing, and snowmobiling during the winter months. July saw the largest number of injuries (320 or 15.3% of cases), January was second (217 or 10.4%), and August was third (214 or 10.2%). June and February also had large numbers of injuries, and November had the lowest (81 or 4%). Injury Sites – Terrain Figure 2.5 and Table 2.9 show where the injuries occurred in terms of the terrain. The most frequent site was lakes and rivers (497 cases), followed by roads and streets (377), and open terrain (294). Arenas, playing fields, and swimming pools were also frequent sites. It was of major interest that there were more diving injuries in pools (56) than in lakes or rivers (43). A large number of the snowmobiling injuries occurred in lakes and rivers (78), most of them drownings, as opposed to injuries on open terrain (99) and on streets and roads (65). The sites where other types of catastrophic injuries were sustained will be discussed in the chapters describing individual activities.

The Ontario Study, 1986–1995 33 Table 2.8 No. (%) of Fatal and Non-fatal Catastrophic Injuries in Sports and Recreational Activities Sustained in Each Month of the Year, Ontario, 1986–1995a Month

Injuries

January February March April May June July August September October November December Totalb

217 (10.4) 190 (9.1) 150 (7.2) 104 (5.0) 188 (9.0) 198 (9.5) 320 (15.3) 214 (10.2) 152 (7.3) 143 (6.8) 81 (3.9) 134 (6.4) 2,091 (100.0)

a

Survivors and fatalities; 4 survey years (1986, 1989, 1992, 1995). Missing information on month when incident occurred for 63 injured participants.

b

Anatomical Locations and Types of Injuries The main anatomical locations and types of injuries and the activities that caused them are shown in Figure 2.6 and Table 2.10. The most frequent injuries were to the head (640 cases), spine (433), and drowning (357). Eye injuries (301), abdominal injuries (291) and chest injuries (251) were also very frequent. Injuries in baseball occurred mainly to the eyes (40 cases), face (25), and head (23). Head injuries were the most frequent in bicycling (186) and motor sports (140; see Table 2.5). In racquet sports, eye injuries (11) predominated. Drowning was most frequent in water sports (310 cases), with spinal injuries (126) second, mainly resulting from diving (96). Winter sports produced mainly head (96 cases), spine (84), and eye (82) injuries. Drowning was the most frequent cause of death, followed by head, chest, and spinal injuries. Further details of the anatomical locations and types of injuries are provided in Chapter 5 and in the chapters describing the individual activities.

34 Introduction and Overview Figure 2.5 The number (and percentage) of injuries at various types of sites and terrain during the four study periods. Pool 78 (4%)

Play 172 (9%)

Lake 497 (24%)

Arena 204 (10%)

Open 294 (15%)

Other 391 (19%) Road 377 (19%)

Supervision and Organizations Involved Information was available about the extent of the supervision at the time of injury for 1,593 injured participants, and with regard to these, only 357 (22.4%) occurred under supervision (Table 2.11). The injuries most likely to occur in supervised settings are those associated with hockey, baseball, floor sports, and field sports, whereas many of the injuries that occurred in unsupervised settings were connected with water sports, bicycling, hunting, and motor sports (Table 2.12). Injury prevention organizations will be interested in the issue of supervision as a prevention strategy in some activities. Information was available in only 26.9% of the cases about the type of organization involved in the activities in which injuries occurred – such as a school, league, or club or fitness centre (Figure 2.7

The Ontario Study, 1986–1995

35

Table 2.9 No. of Catastrophic Injuries in 55 Sports and Recreational Activities According to Site or Terrain Where Incident Occurred, Ontario, 1986–1995a

Activity

Arena

Air guns Air sports ATV riding Badminton Ball hockey 1 Baseball Basketball Bicycling Boating, sailing Boating, other Boating, canoeing Camping / hiking Dirt-biking Diving Field sports Fishing Floor hockey Floor sports Flying Football 1 Golf Gymnastics Horseback riding Hunting Ice skating 9 Ice Hockey 188 In-line skating Martial arts 1 Missile sports Motor sports Motorbiking Mountain climbing Parachuting Personal watercraft Playground/play Racquet sports, other Racquetball Rugby Running / jogging Scuba-diving Skateboarding Skiing, cross-country

Pool

Lake/ River

2

Road/ Street

18

Play Field

1 2

7 75

43

3 5 43 1 1 2

235

13

8 1

2 5 1

7 107 26 1 56

Open Terrain

4

Other 1 2 6 15 1 5 10 19 1 2 11 3 3 2

123 1 1 1

27 4

5 1 2

4

1 1

25 12

1

2 3 9 4 8

4

2

4 2 10

1 2 6 3

1 6 3

2 1

7 7 2 9 5 8 7 4 1 1 5 8 4 5 3 1 47 11

16 5 7

3 8

1 3

2

Totalb 4 7 70 18 10 82 10 267 8 109 26 14 16 104 6 123 7 8 7 30 16 5 38 24 15 189 11 6 11 13 19 9 9 6 58 1 11 16 5 10 9 5

36 Introduction and Overview Table 2.9 (continued )

Activity

Arena

Skiing, alpine Snowboarding Snowmobiling Soccer Squash Summer sports, other 1 Swimming Tennis Tobogganing / sledding War games Water play Waterskiing Winter sports, other 3 Wrestling NA Total 204

Pool

Lake/ River

78

Road/ Street

65

Play Field

2 30

Open Terrain 11 3 99

3 18

64 1

4

78

1

3

1 20 4

14 6

497

377

172

294

Other

Totalb

52 3 28 2 16 4 16 7 34 1 2

63 6 272 32 16 8 98 8 59 5 20 6 4 4 141 2,154

1 4 141 532

NA = not available. NA numbers not included in calculating percentages. a For the 4 survey years (1986, 1989, 1992, 1995). b Missing information on type of site or terrain where the incident occurred for 141 injured participants.

and Table 2.13). The majority of hockey injuries and a large proportion of baseball injuries occurred in organized community league settings. This should be useful information to the sports administrators responsible for safe participation in those settings. In contrast, almost none of the water-related injuries occurred in organized settings. In badminton, field sports, floor hockey, football, rugby, and gymnastics, approximately half the incidents for which data are available occurred in schools, and this will be useful information for school administrators and their insurance associations (Table 2.13). Most injuries in motor sports such as snowmobiling and ATV riding occurred in nonorganized settings, and thus, these activities require completely different strategies for injury prevention.

The Ontario Study, 1986–1995 37 Figure 2.6 Incidence of the main anatomical locations of injuries during the 4 study years. 700 640 600

Injuries (n)

500 433 400

357 301

300

291 251 198

200

108 100 44 0 Head

Spine Drowning

Eye

Abdomen Chest

Face

Misc

Limb

Alcohol Consumption Information about alcohol consumption by the injured participants was available for 1,531 of the cases (Table 2.11), and in 346 (22.6%) there was evidence of alcohol consumption. Water and motor sports had the highest incidence of cases where alcohol had been a factor – almost 50% of the fatalities in the water sports group – whereas with other activities such as hockey there were virtually no instances of injuries involving individuals who had consumed alcohol (Table 2.14). Prevention The survey questionnaire contained several questions about the preventability of the reported injuries. These questions were answered

38 Introduction and Overview Table 2.10 Anatomical Locations of Catastrophic Injuries in 55 Sports and Recreational Activities, Ontario, 1986–1995a Anatomical Location Activity

Head Spine Drowning Eye Abdomen Chest Face

Air guns Air sports 2 Aircraft flying, small 2 ATV riding 36 Badminton Ball hockey 3 Baseball 23 Basketball 5 Bicycling 186 Boating, other 15 Boating, sailing Boating, canoeing 3 Camping / hiking 5 Dirt-biking 10 Diving 8 Field sports 3 Fishing 2 Floor sports 3 Floor hockey Football 6 Golf 11 Gymnastics 1 Horseback riding 19 Hunting 6 Ice hockey 23 Ice skating 13 In-line skating 8 Martial arts 1 Miscellaneous 4 Missile sports 1 Motor sports, other 7 Motorbiking 8 Mountain climbing 4 Parachuting Personal watercraft 3 Playgrounds / play 27 Racquet sports, other Racquetball Rugby 4 Running / jogging 3

8 4 18

2

1 2 50 15

1 7 96 1 1 9 1 3 10 1 46 2 1 1 1

2 65 7 24

5 20 9 40 3 12 1

3 110

2 4 7 2 4 1

2

3 69 1 2

4 3 22

1 4 3 20

7 1 58 8

1 1 60 9

1 5 1

1 2 2 1 4 2

3 1 11 1 7 3 23

6 7 3

2 1 1

1

2 3 2 5 2 9

3 2 2 1 1 4

Misc

1 7

3 7

25 41 4

0 1 1

11 10 3 2 6 1

1 1 1 1 2

4 1

5 1 37

2 4 4

2 3

1 1

1 7 1

1 1 2

1 1 2 5

1

2 1 1 1 6

5 11 1 1

1

6 1

3

1

10 4 7 2 2 1 9

Limb Totalb

6

7 4 1

2 1 1

2

1 1 1

9 15 11 120 20 13 99 10 427 131 11 29 14 28 111 7 130 9 8 33 21 6 49 28 206 17 12 6 8 11 18 20 13 10 11 68 5 12 18 7

The Ontario Study, 1986–1995 Table 2.10

39

(continued ) Anatomical Location

Activity

Head Spine Drowning Eye Abdomen Chest Face

Scuba-diving 1 Skateboarding 7 Skiing, cross-country Skiing, alpine 25 Snowboarding 3 Snowmobiling 97 Soccer 6 Squash 2 Swimming 2 Tennis Tobogganing / sledding 31 War games Water play 7 Waterskiing 2 Winter sports, other 1 Wrestling 1 Total 640 a b

9 1 2 18 2 74

7 1

1 7 38

3 433

8 13 17

1

9 1 87 3

6

5

1 1

28 6 1

21

13

7 9

4 1

357

Limb Totalb

1

82

14 4 2

3 1 1 17 1 61 5

Misc

3 8 3 4

1 13

3

5

1

1

1 1 1 1 301 291

1 1 1

1

2

1 1

2

251

198

108

44

14 10 5 88 7 427 33 20 98 11 71 8 24 12 5 5 2,623

Survivors and fatalities; 4 survey years (1986, 1989, 1992, 1995). Injury victims may have sustained more than one injury in any particular incident.

regarding 1,513 injuries, with 79.2% of the injuries classified as preventable (Table 2.11). Respondents provided specific suggestions for prevention in most cases. Information about injury prevention was also available for the individual activities (Table 2.15 and see Chapter 3); a large proportion of respondents concluded that there was a high probability that many of the injuries occurring in many activities could have been prevented. The elimination of alcohol consumption in sports and recreational activities was a frequent suggestion. Other frequent mentions were recommendations for the use of personal flotation devices (PFDs) in water sports, the use of helmets in activities such as bicycling and skiing, and the mandatory use of eye protection in certain racquet sports. In the subsequent chapters on individual activities, detailed injury prevention advice is given based on the responses received and the information obtained about each activity and each injury.

40 Introduction and Overview Table 2.11 Prevention Issues: Preventability, Alcohol Involvement, and Supervision – Summary of Responses of Physicians Who Treated Patients with Catastrophic Sports and Recreation Injuries (% in parentheses), Ontario, 1986–1995a Was the injury preventable?b Yes No Total

1,199 (79.2) 314 (20.8) 1,513 (100)

Was the injury alcohol-related?c Yes No Total

346 (22.6) 1,185 (77.4) 1,531 (100)

Was the activity supervised?d Yes No Total

357 (22.4) 1,236 (77.6) 1,593 (100)

a

Responses submitted by the primary attending physician. Survivors and fatalities; 4 survey years (1986, 1989, 1992, 1995). b Missing response about preventability for 641 injured participants. c Missing response about alcohol use in connection with incident for 623 injured participants. d Missing response about whether incident occurred in a supervised setting for 561 injured participants.

Relative Risks of Catastrophic Injury The relative risks of catastrophic injury in the individual sports and recreational activities were assessed in a number of ways. The risks to individual participants were calculated using the percentage of participants who sustained a catastrophic injury in one year (personal risk), and the number who sustained catastrophic injuries per 100,000 population in one year (population risk) (Table 2.16 and 2.17). The highest participant-risk activities were diving, snowmobiling, parachuting, hang gliding, water polo, tobogganing, with equestrian activities, scuba-diving, hunting, and fishing. The high risk of diving is mainly borne by recreational divers, and not by those engaged in the formal sport of diving. Activities with the lowest participant risk of catastrophic injury were aerobics, bowling, curling, golfing, tennis, and miscellaneous others. With respect to the population of Ontario (population risk), and the burden of injury to the province, Table 2.18 shows that on the basis of

The Ontario Study, 1986–1995 41 Table 2.12 Was activity supervised? Responses of Physicians Regarding Catastrophic Injuries Sustained in 55 Sports and Recreational Activities (% in parentheses), Ontario, 1986–1995a Responses Activity Air guns Air sports Aircraft flying, small ATV riding Badminton Ball hockey Baseball Basketball Bicycling Boating, canoeing Boating, other Boating, sailing Camping / hiking Dirt-biking Diving Field sports Fishing Floor sports Floor hockey Football Golf Gymnastics Horseback riding Hunting Ice hockey Ice skating In-line skating Martial arts Missile sports Motor sports Motorbiking Mountain climbing Parachuting Personal watercraft Playgrounds / play Racquet sports, other Racquetball Rugby Running / jogging Scuba-diving

Injury Cases 8 8 7 83 21 12 91 10 289 27 112 8 14 20 105 7 126 9 8 32 20 6 43 25 190 17 12 6 11 14 19 9 9 7 61 5 13 16 5 10

Total 6 6 4 72 14 9 64 9 236 17 67 6 9 17 84 5 85 6 6 25 10 3 31 15 141 14 9 5 10 14 16 7 7 4 47 1 10 12 4 3

Yes (75) (75) (57) (87) (67) (75) (70) (90) (82) (63) (60) (75) (64) (85) (80) (71) (67) (67) (75) (78) (50) (50) (72) (60) (74) (82) (75) (83) (91) (100) (84) (78) (78) (57) (77) (20) (77) (75) (80) (30)

1 10 2 46 8 6 2 3

No

(1) (71) (22) (72) (89) (3) (12) (4)

3 (4) 5 (100) 2 5 23 1 1 6

(33) (83) (92) (10) (33) (19)

123 (87) 1 (7) 5 1 6 2 2 6 1 4

(100) (10) (43) (13) (29) (86) (25) (9)

7 (70) 12 (100) 1 (25)

6 6 4 71 4 7 18 1 230 15 64 6 9 17 81

(100) (100) (100) (99) (29) (78) (28) (11) (97) (88) (96) (100) (100) (100) (96)

85 4 1 2 9 2 25 15 18 13 9

(100) (67) (17) (8) (90) (67) (81) (100) (13) (93) (100)

9 8 14 5 1 3 43 1 3

(90) (57) (88) (71) (14) (75) (91) (100) (30)

3 (75) 3 (100)

42 Introduction and Overview Table 2.12 (continued ) Responses Activity

Injury Cases

Total

Skateboarding Skiing, alpine Skiing, cross-country Snowboarding Snowmobiling Soccer Squash Summer sports, other Swimming Tennis Tobogganing / sledding War games Water play Watersking Winter sports, other Wrestling NA Total

9 65 5 6 290 33 20 8 100 11 62 8 21 9 5 5 2 2,154

8 47 4 6 246 22 14 5 41 8 55 4 12 4 3 4

Yes (89) (72) (80) (100) (85) (67) (70) (63) (41) (73) (89) (50) (57) (44) (60) (80)

1,593 (74)

No

6 (13)

6 (2) 20 (91) 8 (57) 7 1 4 1 4

(17) (13) (7) (25) (33)

2 (67) 3 (75) 357 (22)

8 41 4 6 240 2 6 5 34 7 51 3 8 4 1 1

(100) (87) (100) (100) (98) (9) (43) (100) (83) (88) (93) (75) (67) (100) (33) (25)

1,236 (78)

NA = not available. NA numbers not included in calculating percentages. a Responses submitted by the primary attending physician. Survivors and fatalities; 4 survey years (1986, 1989, 1992, 1995). b Missing response whether incident occurred in a supervised setting for 561 injured participants.

the number of catastrophic injuries each year per 100,000 population: snowmobiling was highest at 0.706 catastrophic injuries per 100,000 population per year, followed by bicycling at 0.701, hockey 0.462, and fishing 0.307. Table 2.19 shows the sports and recreational activities examined in this study in rank order (highest first) according to the number of catastrophic injuries (non-fatal and fatal) sustained in the 4 survey years 1986, 1989, 1992, and 1995.

The Ontario Study, 1986–1995 43 Table 2.13 Type of Organization in which Participant Was Involved When Injured, 55 Sports and Recreational Activities (% in parentheses), Ontario, 1986–1995a

Activity

All Injury Cases School

Air guns Air sports Aircraft flying, small ATV riding Badminton Ball hockey Baseball Basketball Bicycling Boating, canoeing Boating, other Boating, sailing Camping / hiking Dirt-biking Diving Field sports Fishing Floor hockey Floor sports, other Football Golf Gymnastics Horseback riding Hunting Ice hockey Ice skating In-line skating Martial arts Missile sports Motor sports, other Motorbiking Mountain climbing Parachuting Personal watercraft Playgrounds / play Racquet sports, other Racquetball Rugby Running / jogging Scuba-diving

8 8 7 83 21 12 91 10 289 27 112 8 14 20 105 7 126 8 9 32 20 6 43 25 190 17 12 6 11 14 19 9 9 7 61 5 13 16 5 10

10 1 8 5 1

College/ University

2

Sports/ Community Fitness League Club

1 1 40 2

2 2 2 1 1

1 4 4 2 14

1 1 1 2

4

4 1 9

2 1

3 1 1 5

7

90

4 1

Other Organizations

2 1 19 1 3 1 37 1 14 1 1 19 18 1 1 5 4 9 5 9 1

4 2 6 3 1 1

1 6

1

1

3 3 5 1

9 5

1

6 2 3

Total in Organized Activities

2 1 19 14 5 51 9 40 1 15

(25) (14) (23) (67) (42) (56) (90) (14) (3.7) (13)

1 23 6 18 6 6 26 5 4 15 5 119 1 1 4 2 6 3 2 5 3 12

(7.1) (5) (22) (86) (14) (75) (67) (81) (25) (67) (35) (20) (63) (5.9) (8.3) (67) (18) (43) (16) (22) (56) (43) (20)

1 9 12 2 3

(20) (69) (75) (40) (30)

44 Introduction and Overview Table 2.13 (continued )

Activity

All Injury Cases School

Skateboarding Skiing, alpine Skiing, crosscountry Snowboarding Snowmobiling Soccer Squash Summer sports, other Swimming Tennis Tobogganing / sledding War games Water play Waterskiing Winter sports, other Wrestling NA

9 65 5 6 290 33 20 8 100 11 62 8 21 9 5 5 2

College/ University

Sports/ Community Fitness League Club

3

2 6

16

1 1

11

1

2 1 11

1 1

1

2 1

2 1 29

2 8 1 6 1 5 2

1

2

Other Organizations

Total in Organized Activities 0 19 (29) 2 1 33 19 12

(40) (17) (11) (58) (60)

2 (25) 10 (10) 2 (18) 7 1 6 2 2 3

(11) (13) (29) (22) (40) (60)

Totalb 2,154 91 17 162 60 249 579 (27) NA = not available. NA numbers not included in calculating percentages. a Survivors and fatalities; 4 survey years (1986, 1989, 1992, 1995). b Missing information on type of organization involvement for 1,575 participants at the time of their injury. Missing information on type of activity for two injury victims (NA).

The Ontario Study, 1986–1995 45 Figure 2.7 There were identifiable organizations involved in 579 (26.9%) of the 2,154 catastrophic injuries during the 4 study years. The chart shows the percentage of injuries sustained while participating in five types of organizations. School 16%

University 3%

Other 43%

Community 28%

Fitness 10%

46 Introduction and Overview Table 2.14 Was injury alcohol-related? Responses of Physicians Regarding Catastrophic Injuries Sustained in 55 Sports and Recreational Activities (% in parentheses), Ontario, 1986–1995a Responses Activity Air guns Air sports Aircraft flying, small ATV riding Badminton Ball hockey Baseball Basketball Bicycling Boating, canoeing Boating, other Boating, sailing Camping / hiking Dirt-biking Diving Field sports Fishing Floor hockey Floor sports, other Football Golf Gymnastics Horseback riding Hunting Ice hockey Ice skating In-line skating Martial arts Missile sports Motor sports, other Motorbiking Mountain climbing Parachuting Personal watercraft Playgrounds / play Racquet sports, other Racquetball Rugby Running / jogging Scuba-diving

Injury Cases 8 8 7 83 21 12 91 10 289 27 112 8 14 20 105 7 126 8 9 32 20 6 43 25 190 17 12 6 11 14 19 9 9 7 61 5 13 16 5 10

Total 4 5 5 64 14 11 66 5 218 18 75 6 10 10 71 5 97 4 7 29 10 4 34 13 133 8 9 5 8 11 12 8 5 5 50 1 9 9 4 7

Yes (50) (63) (71) (77) (67) (92) (73) (50) (75) (67) (67) (75) (71) (50) (68) (71) (77) (50) (78) (91) (50) (67) (79) (52) (70) (47) (75) (83) (73) (79) (63) (89) (56) (71) (82) (20) (69) (56) (80) (70)

No

24 (38)

23 7 31 4 6 1 40

(11) (39) (41) (67) (60) (10) (56)

41 (42)

1 (3) 1 (1)

3 (25) 2 (25)

3 (6)

4 5 5 40 14 11 66 5 195 11 44 2 4 9 31 5 56 4 7 29 10 4 33 13 132 8 9 5 8 11 9 6 5 5 47 1 9 9 4 7

(100) (100) (100) (63) (100) (100) (100) (100) (89) (61) (59) (33) (40) (90) (44) (100) (58) (100) (100) (100) (100) (100) (97) (100) (99) (100) (100) (100) (100) (100) (75) (75) (100) (100) (94) (100) (100) (100) (100) (100)

The Ontario Study, 1986–1995 47 Table 2.14 (continued ) Responses Activity

Injury Cases

Total

Skateboarding Skiing, alpine Skiing, cross-country Snowboarding Snowmobiling Soccer Squash Summer sports, other Swimming Tennis Tobogganing / sledding War games Water play Waterskiing Winter sports, other Wrestling NA Totalb

9 65 5 6 290 33 20 8 100 11 62 8 21 9 5 5 2 2,154

7 43 5 4 219 25 12 4 66 8 42 4 11 4 3 4

Yes (78) (66) (100) (67) (76) (76) (60) (50) (66) (73) (68) (50) (52) (44) (60) (80)

1,531 (71)

124 (57)

31 (47) 3 (7)

1 (25) 346 (23)

No 7 43 5 4 95 25 12 4 35 8 39 4 11 4 3 3

(100) (100) (100) (100) (43) (100) (100) (100) (53) (100) (93) (100) (100) (100) (100) (75)

1,185 (77)

NA = not available. NA numbers not included in calculating percentages. a Responses submitted by the primary attending physician. Survivors and fatalities; 4 survey years (1986, 1989, 1992, 1995). b Missing response about alcohol use in connection with incident for 623 injured participants.

48 Introduction and Overview Table 2.15 Was injury preventable? Responses of Physicians Regarding Catastrophic Injuries Sustained in 55 Sports and Recreational Activities (% in parentheses), Ontario, 1986–1995a Responses Activity Air guns Air sports Aircraft flying, small ATV riding Badminton Ball hockey Baseball Basketball Bicycling Boating, canoeing Boating, other Boating, sailing Camping / hiking Dirt-biking Diving Field sports, other Fishing Floor hockey Floor sports Football Golf Gymnastics Horseback riding Hunting Ice hockey Ice skating In-line skating Martial arts Missile sports Motor sports, other Motorbiking Mountain climbing Parachuting Personal watercraft Playgrounds / play Racquet sports, other Racquetball Rugby Running / jogging Scuba-diving

Injury Cases 8 8 7 83 21 12 91 10 289 27 112 8 14 20 105 7 126 8 9 32 20 6 43 25 190 17 12 6 11 14 19 9 9 7 61 5 13 16 5 10

Total 5 3 3 66 16 11 69 5 219 20 73 5 7 15 91 3 95 5 6 23 8 4 28 12 135 8 7 6 11 10 11 7 6 3 41 1 10 10 4 4

Yes (63) (38) (43) (80) (76) (92) (76) (50) (76) (74) (65) (63) (50) (75) (87) (43) (75) (63) (67) (72) (40) (67) (65) (48) (71) (47) (58) (100) (100) (71) (58) (78) (67) (43) (67) (20) (77) (63) (80) (40)

No

4 (80) 1 59 14 11 38 5 188 19 62 5 4 14 89 2 90 4 4 6 6 2 7 12 104 2 7 4 11 7 9 5 4 3 28 1 9 5 1 3

(33) (89) (88) (100) (55) (100) (86) (95) (85) (100) (57) (93) (98) (67) (95) (80) (67) (26) (75) (50) (25) (100) (77) (25) (100) (67) (100) (70) (82) (71) (67) (100) (68) (100) (90) (50) (25) (75)

1 3 2 7 2

(20) (100) (67) (11) (13)

31 (45) 31 (14) 1 (5) 11 (15) 3 1 2 1 5 1 2 17 2 2 21

(43) (7) (2) (33) (5) (20) (33) (74) (25) (50) (75)

31 (23) 6 (75) 2 (33) 3 2 2 2

(30) (18) (29) (33)

13 (32) 1 5 3 1

(10) (50) (75) (25)

The Ontario Study, 1986–1995 49 Table 2.15 (continued ) Responses Activity

Injury Cases

Total

Skateboarding Skiing, alpine Skiing, cross-country Snowboarding Snowmobiling Soccer Squash Summer sports, other Swimming Tennis Toboggan / sledding War games Water play Waterskiing Winter sports, other Wrestling NA Totalb

9 65 5 6 290 33 20 8 100 11 62 8 21 9 5 5 2 2,154

8 32 4 3 223 20 16 6 64 9 34 4 12 4 4 3

Yes (89) (49) (80) (50) (77) (61) (80) (75) (64) (82) (55) (50) (57) (44) (80) (60)

1,513 (70)

8 11 1 1 206 5 14 2 54 6 20 4 11 3 2 1

No (100) (34) (25) (33) (92) (25) (88) (33) (84) (67) (59) (100) (92) (75) (50) (33)

1,199 (79)

21 3 2 17 15 2 4 10 3 14

(66) (75) (67) (8) (75) (13) (67) (16) (33) (41)

1 1 2 2

(8) (25) (50) (67)

314 (21)

NA = not available. NA numbers not included in calculating percentages. a Responses submitted by the primary attending physician. Survivors and fatalities; 4 survey years (1986, 1989, 1992, 1995). b Missing responses to this question for 641 cases (459 survivors, 182 fatalities).

50 Introduction and Overview Table 2.16 Annual Participation Rate (%) in 75 Sports and Recreational Activities and Personal Risk of Catastrophic Injuries by Gender (% and per 100,000 Participants), Ontario, 1986–1995a Annual Participation Rate (%)

Annual Catastrophic Injuries

Activityb

All

Per 100,000 Participants

All (%)

Males (%) Females (%)

Any activity Aerobics Archery, shooting Badminton Ball hockey Baseball Basketball Biathlon Bicycling, competitive Bicycling, recreational Bicycling, transportation Birdwatching Boating, kayaking/ canoeing Boating, sailing Bowling Boxing Broomball Camping / hiking Catch Cricket Curling Dancing Diving Field hockey Figure skating Fishing Floor hockey Football, tackle Football, touch Golf Gymnastics Handball Hang-gliding Horseback riding

75.5 78.4 18.4 12.1

6.9 NM

0.007 NM

0.011 NM

0.002 NM

11.1 3 2.4 1.4 0.3 NM

0.01 0.003 0.002 0.001 0.0002 NM

0.01 0.004 0.002 0.002 0.0004 NM

0.008 0.002 0.002 0 0.0001

0.2 1.7 1.2 16.1 8.2 0.02 0.2

Males Females 72.9 24.2

0.3 0.2 1.8 1.7 2.2 0.2 21.3 11.3 12 4.7 0.05 NM 0.3

0.1

NM

NM

NM

NM

29.8 31.1

28.5

2.4

0.002

0.004

0.001

0.7 0.1

NM NM

NM NM

NM NM

NM NM

3.9 4.9

0.004 0.005

0.006 0.006

0.001 0.004

5.7 NM 1.1 NM NM

0.006 NM 0.001 NM NM

0.007 NM 0.001 NM NM

NM 511 1 NM 11 1.8 0.007 NM 0.5 1.2 0.004 0.029 11.6

NM 0.51 0.001 NM 0.011 0.002 0.007 NM 0.0005 0.001 0.01 0.029 0.012

NM 0.65 0.002 NM 0.013 0.002 0.2 NM 0.0005 0.002

1.2 0.1 1.7 0.4 3.1 0.1 0.1 3.2 0.8 0.3 1.4 2.4 0.05 0.3 1.6 2.8 1.1 1 1.1 10 1.2 0.1 0.02 0.9

1.7 0.1

2 1.5 0.4 0.4 3.3 2.9 0.1 0.02 0.1 0.1 3.6 2.8 0.9 0.6 0.5 0.1 1.7 1.1 0.7 3.9 0.07 0.02 0.3 0.2 0.8 2.3 4.6 1.1 2.2 0.1 2.1 7.1 2 0.3 15.2 5.1 0.5 1.8 0.1 4.0 0.05 29.4 0.4 1.3

0.022

NM NM NM NM 0.29 NM 0.003 0.005 NM 0.0005

0.009

The Ontario Study, 1986–1995 51 Table 2.16 (continued )

Activityb Hunting Ice hockey Ice skating, recreational In-line skating Jogging/running Lacrosse Lawn bowling Martial arts Mountain climbing Orienteering Parachuting Race walking Racquetball Ringette Roller skating Rowing Rugby Sailboarding Scuba-diving Skateboarding Ski jumping Skiing, alpine Skiing, crosscountry Snowboarding Snowmobiling Soccer Softball Squash Swimming, competitive Swimming, recreational Swimming, synchronized Tennis Tobogganing / sledding Track and field Triathlon

Annual Participation Rate (%)

Annual Catastrophic Injuries

All

Per 100,000 Participants

All (%)

Males (%) Females (%)

12.2 6.3

0.012 0.006

0.015 0.006

2.5 2.8 4.6 4.6 8.7 6.8 0.4 0.05 0.1 0.2 2.1 1.3 0.7 0.1 0.1 0.05 0.07 62.9 0.1 0.6 1.1 0.2 0.2 0.3 NM 1.4 1.3 1.4 0.2 0.2 0.2 0.5 0.7 0.3 1.1 1.7 0.6 0.2 0.3 0.05 0.3 0.6 0.02 0.04 0.05 0.02 5 5.6 4.4

1.5 0.6 0.2 2.1 NM 0.9 5.5 NM 0.06 NM 5.3 NM 0.2 NM 7.8 0.8 12.2 7.3 NM 3.2

0.002 0.001 0.0002 0.002 NM 0.001 0.005 NM 0.06 NM 0.005 NM 0.0002 NM 0.008 0.0008 0.012 0.007 NM 0.003

0.002 0.001 0.0002 0.0002 NM 0.001 0.005 NM 0 NM 0.005 NM 0.0003 NM 0.01 0.0009 0.015 0.007 NM 0.004

NM 0.005

2.2 2.3 0.3 0.5 0.8 1.02 7.2 10.1 1.6 2 1.6 2.5

2.2 0.1 0.5 4.5 1.2 0.8

0.6 4.9 88.2 1.1 NM 3.0

0.0006 0.005 0.088 0.001 NM 0.003

0.0004 0.004 0.123 0.001 NM 0.004

0.0007 0.01 0.038 0.006 NM 0.001

0.3

0.2

0.3

NM

NM

NM

NM

29.3 26.1

32.3

0.8

0.001

0.001

0.0003

NM 0.4

NM 0.0004

NM 0.0006

NM 0.0002

37.7 0.9 NM

0.038 0.0009 NM

0.056 0.002 NM

0.027 0.0003

Males Females

0.5 0.8 7.3 14.3

0.1 0.9

2.7 4.6 7.7 0.2 0.2 1.7 0.4 0.1 0.04

0.05 0.05 6.4 7.8

0.05 5.1

0.4 0.3 0.5 1.1 0.8 1.4 0.04 0.05 NM

0.003 0.001 0.0003 0.00007 NM 0.01 NM

NM 0.003 0.0007

NM 0.002

52 Introduction and Overview Table 2.16 (continued ) Annual Participation Rate (%)

Annual Catastrophic Injuries

Activityb

All

Males Females

Per 100,000 Participants

All (%)

Volleyball Walking Water polo Weightlifting Wrestling

5.1 28.2 0.01 3.4 0.2

4.5 5.7 22.7 33.3 0.02 24.5 5.4 1.7 0.3 0.1

0.05 0.009 0.024 0.3 6.1

0.00005 0.0001 0.000008 0.00002 0.024 0.0003 0.0004 0.006 0.008

Males (%) Females (%)

NM = not measured or not measured separately in the present study a Survivors and fatalities; 4 survey years (1986, 1989, 1992, 1995) and McLaren Report (for 1995). b Not all activities in the McLaren Report are presented in this study of catastrophic injuries in sports and recreation, usually because no catastrophic injuries in that activity occurred during the survey years used in the present study. See Chapter 1 for explanation of calculations.

The Ontario Study, 1986–1995 53 Table 2.17 Personal Risk, 27 Highest-Ranking Sports and Recreational Activities According to Annual Rate (%) and No. of Catastrophic Injuries per 100,000 Participants, Ontario, 1986–1995a Annual Catastrophic Injuries Rankb

Activity

Rate (%)

Per 100,000 Participants

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

Diving Snowmobiling Parachuting Tobogganing/sledding Hang gliding Water polo Horseback riding Scuba Hunting Fishing Archery, shooting Rugby Skateboarding Football Ice hockey Wrestling Boxing Mountain climbing Racquetball Snowboarding Sailing Kayaking, canoeing Skiing, alpine Squash Badminton Ball hockey Bicycling

0.511 0.088 0.06 0.038 0.029 0.024 0.012 0.012 0.012 0.011 0.01 0.008 0.007 0.007 0.006 0.006 0.006 0.005 0.005 0.005 0.005 0.004 0.003 0.003 0.003 0.002 0.002

511.0 88.2 62.9 37.7 29.4 24.5 11.6 12.2 12.2 11.0 11.1 7.8 7.3 7.1 6.3 6.1 5.7 5.5 5.3 4.9 4.9 3.9 3.2 3.0 3.0 2.4 2.4

a

Survivors and fatalities; 4 survey years (1986, 1989, 1992, 1995). Some risky activities such as motorbiking could not be included because of the absence of participation data in the McLaren Report. b

54 Introduction and Overview Table 2.18 Population Risk, 55 Sports and Recreational Activities According to Annual No. of Fatalities and Survivors of Catastrophic Injuries per 100,000 Population, Ontario, 1986–1995a Rank

Sport

Survivors

Fatalities

Total

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42

Snowmobiling Bicycling Hockey Fishing Boating, other Diving Swimming Baseball ATV riding Skiing, alpine Tobogganing/sledding Horseback riding Play Soccer Football Canoeing Hunting Badminton Dirt-biking Squash Golf Motorbiking Skating Rugby Camping/hiking Motor sports, other Racquetball Ball hockey In-line skating Missile sports Tennis Basketball Scuba Water play Mountain climbing Parachuting Skateboarding Waterskiing Air sports Boating, sailing Floor hockey Air guns

0.414 0.538 0.458 0.022 0.097 0.243 0.044 0.217 0.163 0.146 0.141 0.08 0.080 0.078 0.075 0.000 0.024 0.051 0.041 0.049 0.046 0.034 0.039 0.039 0.022 0.034 0.032 0.029 0.027 0.027 0.027 0.024 0.002 0.017 0.015 0.017 0.019 0.017 0.012 0.002 0.019 0.019

0.292 0.163 0.005 0.285 0.175 0.012 0.200 0 0.039 0.012 0.010 0.024 0.000 0.002 0.002 0.066 0.037 0 0.007 0.000 0.000 0.012 0.002 0.000 0.012 0.000 0.000 0.000 0.002 0.000 0.000 0.000 0.022 0.007 0.007 0.005 0.002 0.005 0.007 0.017 0.000 0.000

0.706 0.701 0.462 0.307 0.273 0.256 0.243 0.217 0.202 0.158 0.151 0.105 0.080 0.08 0.078 0.066 0.061 0.051 0.05 0.05 0.046 0.046 0.041 0.039 0.034 0.034 0.032 0.029 0.029 0.027 0.027 0.024 0.024 0.02 0.02 0.022 0.022 0.022 0.019 0.019 0.019 0.019

The Ontario Study, 1986–1995 55 Table 2.18 (continued ) Rank

Sport

Survivors

Fatalities

Total

43 44 45 46 47 48 49 50 51 52 53 54 55

Field sports Floor sports Flying Personal watercraft War games Gymnastics Martial arts Snowboarding Running/jogging Racquet sports, other Skiing, cross-country Winter sports, other Wrestling

0.017 0.017 0.000 0.012 0.017 0.015 0.015 0.015 0.010 0.012 0.012 0.012 0.012

0.000 0.000 0.017 0.005 0.000 0.000 0.000 0.000 0.002 0.000 0.000 0.000 0.000

0.017 0.017 0.017 0.017 0.017 0.015 0.015 0.015 0.012 0.012 0.012 0.012 0.012

a

Survivors and fatalities; 4 survey years (1986, 1989, 1992, 1995).

56 Introduction and Overview Table 2.19 Ranking by Total Number of Catastrophic Injuries (Survivors and Fatalities) for 56 Sports and Recreational Activities, Ontario, 1986–1995a

Rank

Activity

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41

Snowmobiling Bicycling Hockey Fishing Boating, other Diving Swimming Baseball ATV riding Skiing, alpine Tobogganing/sledding Playground/play Horseback riding Soccer Football Boating, canoeing Hunting Water sports,other Badminton Dirt-Biking Squash Golf Motorbiking Skating Rugby Camping/hiking Motor sports, other Racquetball In-line skating Ball hockey Missile sports Tennis Scuba Basketball Parachuting Mountain climbing Waterskiing Floor sports Skateboarding Boating, sailing Air sports

Survivors

Fatalities

Totalb

n

(%)

n

(%)

n

(11.2) (14.6) (12.4) (0.6) (2.6) (6.6) (0.9) (6) (4.4) (3.9) (3.8) (3.5) (2.2) (2.1) (2) 0 (0.7) (1) (1.4) (1.1) (1.3) (1.3) (0.9) (1.1) (1.1) (0.5) (0.8) (0.9) (0.7) (0.8) (0.7) (0.7) 0 (0.7) (0.3) (0.3) (0.5) (0.5) (0.5) (0.1) (0.3)

120 67 2 117 72 5 86

(19) (10.6) (0.3) (18.5) (11.4) (0.8) (13.6)

16 5 4 8 10 1 1 27 15 6

(2.5) (0.8) (0.6) (1.3) (1.6) (0.2) (0.2) (4.3) (2.4) (1)

170 222 188 9 40 100 14 91 67 60 58 53 33 32 31 0 10 15 21 17 20 20 14 16 16 7 12 13 11 12 10 11 0 10 4 5 7 7 8 1 5

3 (0.5)

5 (0.8) 1 (0.2) 7 (1.1) 2 (0.3) 1 (0.2) 1 (0.2) 10 (1.6) 5 4 2 2 1 7 3

(0.8) (0.6) (0.3) (0.3) (0.2) (1.1) (0.5)

(%) 290 289 190 126 112 105 100 91 83 65 62 61 43 33 32 27 25 21 21 20 20 20 19 17 16 14 14 13 12 12 11 11 10 10 9 9 9 9 9 8 8

(13.5) (13.4) (8.8) (5.9) (5.2) (4.9) (4.6) (4.2) (3.9) (3) (2.9) (2.8) (2) (1.5) (1.5) (1.3) (1.2) (1) (1) (0.9) (0.9) (0.9) (0.9) (0.8) (0.7) (0.7) (0.7) (0.6) (0.6) (0.6) (0.5) (0.5) (0.5) (0.5) (0.4) (0.4) (0.4) (0.4) (0.4) (0.4) (0.4)

The Ontario Study, 1986–1995 57 Table 2.19 (continued ) Survivors

Fatalities

Totalb

n

n

(%)

8 8 8 8 7 7 7 6 6 6 5 5 5 5 5 2,152

(0.4) (0.4) (0.4) (0.4) (0.3) (0.3) (0.3) (0.3) (0.3) (0.3) (0.2) (0.2) (0.2) (0.2) (0.2) (100)

Rank

Activity

n

(%)

42 43 44 45 46 47 48 49 50 51 52 53 54 55 56

Summer sports, other Floor hockey Air guns War games Flying Personal watercraft Field sports Gymnastics Martial arts Snowboarding Running/jogging Winter sports, other Racquet sports, other Skiing, cross-country Wrestling

5 8 8 8 0 5 6 6 6 6 4 4 5 5 5 1,521

(0.3) (0.5) (0.5) (0.5) 0 (0.3) (0.4) (0.4) (0.4) (0.4) (0.3) (0.3) (0.3) (0.3) (0.3) (100)

a b

Four survey years (1986, 1989, 1992, 1995). Missing information for 2 cases.

(%) 3 (0.5)

7 (1.1) 2 (0.3) 1 (0.2)

1 (0.2) 1 (0.2)

631 (100)

Recto Running Head 58

3 Sports Injury Prevention: General Principles christine provvidenza and charles h. tator

Definitions of Catastrophic Injury More people today are participating in sports and recreational activities not only for enjoyment, but to improve their health and physical fitness. Others participate for leisure and competition, and for some, sports and recreation are professions. Unfortunately, these activities involve the risk of injury. An injury may arise when unintentional or intentional damage occurs to the body from activities involving physical effort, carried out for enjoyment or relaxation purposes.1 For minor injuries, the severity is often measured by time lost from participation, whereas catastrophic injuries are usually classified as either fatal or non-fatal. Catastrophic injury is a serious problem in sports and recreation. As noted in Chapter 1, fatal catastrophic injury is defined as any injury causing death suffered as result of participation in sports or recreational activity. Non-fatal catastrophic injury is defined as any injury causing permanent or long-term disability, or known to potentially cause death or permanent or long-term disability. Similar definitions have been used by others. The U.S. National Center for Catastrophic Sport Injury Research, for example, has classified catastrophic injuries as fatal, non-fatal, and serious.2 Non-fatal catastrophic injury may involve permanent severe brain or spinal cord functional disability, for example, quadriplegia. Serious catastrophic injuries do not involve permanent functional disability, but include those causing transient brain or spinal cord disability; a fractured cervical vertebra with no permanent paralysis is an example. Our definition of a non-fatal catastrophic injury includes both the non-fatal and serious categories of the U.S. classification. Fatalities may be direct,

Sports Injury Prevention: General Principles 59

resulting from participation in the specific sport or recreational activity itself, or indirect, where systemic failure results from exertion or a complication that is secondary to a non-fatal injury incurred while partaking in a sport or recreational activity. Principles of Injury Prevention Injury prevention involves taking actions towards reducing the probability of suffering injury, by minimizing or eliminating risk factors. This chapter discusses the essential components of injury prevention and provides an overview of strategies to avoid catastrophic injuries in sports and recreational activities. Prevention has three components: primary, secondary, and tertiary. Primary prevention involves taking appropriate actions before an event to prevent injury from occurring.3,4 Examples of primary prevention include following rules and regulations, the use of appropriate equipment, and educational efforts. Secondary prevention involves actions during or after an injury-causing event taken to reduce its severity, such as the provision of first aid to the injured participant. Tertiary prevention encompasses actions taken after an event to minimize the consequences of the injury, such as assessment and treatment, including adherence to appropriate return-to-play guidelines.4,5 Thus, prevention involves various steps to reduce the risk or severity of injury. Through the use of specific strategies, circumstances may be altered to minimize the impact of events leading up to injury or ultimately, prevent injury from taking place.6 The goal of injury prevention strategies is to reduce the burden of injury to the individual and to society. Burden includes morbidity, mortality, disability, and economic cost.7 Effective injury prevention programs have traditionally involved the ‘three E’s’ – education, engineering, and enforcement or legislation. The goal of education is to facilitate behavioural change. In sports and recreation, knowledge of injury prevention disseminated by parents, coaches, personal trainers, athletic therapists, and educators helps participants make appropriate decisions and encourages them to be cautious and avoid risk. Through education, they become aware of the causes of and factors contributing to injury and can therefore take the appropriate steps to enjoy their activities and remain injury free. Engineering involves modifying the environment to create safer surroundings. By modifying the dimensions of hockey arenas;

60 Introduction and Overview

maintaining the quality of the playing fields for soccer, football, and lacrosse; or enhancing the design, construction, and structure of protective gear such as helmets or eyewear, sports and recreation participants can play more safely. The final ‘E’ involves enforcement or legislation: through enforcement, legal requirements and rules are upheld, and risk is minimized. With the help of sporting officials, existing rules and regulations can be enforced in an effort to promote safe play, and new rules can be introduced as required. Epidemiology and the tracking of injuries could be considered a fourth ‘E.’ Exact information about ‘the who, how, and where’ of injuries is essential for the accurate and efficient targeting of prevention efforts. Similarly, without regular updates of injury statistics, we will not know whether prevention strategies are successful, nor will we know about new and emerging risks and risk-taking behaviours. A fifth ‘E’ is the evaluation of injury prevention programs to assess their effectiveness; the two categories are process and outcome evaluations. The former examines issues such as the effectiveness of the distribution of a strategy to reach the target audience, and the latter evaluates effectiveness in terms of enhancement of the knowledge of risks and the reduction of the incidence of injury. Study of Injury Prevention Researchers have developed scientific frameworks to examine how injuries can be prevented by education and by modifying the environment in which injuries occur. One example is the Haddon Matrix developed by William Haddon, who observed that injury is attributable to the uncontrolled release of physical energy, whether it be in the form of kinetic, chemical, thermal, electrical, or radiation energy.8 Haddon ascertained that an injury event occurs in three phases: the pre-event, during which the energy is controlled; the event, during which energy is transferred to the individual, and injury occurs, particularly if the energy transfer exceeds the ability of the individual’s body to absorb it; and the post-event, during which the event is dealt with to repair damage caused by injury.6 In our view, prevention measures taken in the pre-event, event, and post-event phases represent the primary, secondary, and tertiary prevention measures described above.5 Figure 3.1 shows the Haddon Matrix, which includes the following factors that interact to cause injury: the host, the agent, the physical environment in which the injury occurs, and the social envi-

Sports Injury Prevention: General Principles 61 Figure 3.1. The Haddon Matrix. Adapted from Haddon (8). Factors

Host Phase of Injury

{

Agent

Physical Environment

Social Environment

Pre-event Event Post-event

ronment (socioeconomic, political, and cultural context surrounding the injury). By dissecting the injury event into these phases and factors, the multiple points for intervention using preventive measures can be identified, thereby allowing interventions to be tailored specifically to the injury. Injury prevention efforts in sports and recreation require this type of multifaceted approach. Table 3.1 presents a modified version of the Haddon Matrix, specifically fashioned to depict the prevention strategies for ice hockey.3 Recognition of the Importance of Injury in Sports and Recreation Recognition of sports and recreation injuries as a significant public health concern is increasing. From a public health perspective, the injuries of most interest are those that are most common, severe, debilitating, or costly.1 Some national sports organizations may be more concerned with injuries because injuries prevent elite or highly paid athletes from performing and earning money for their sport. Sports and recreation organizations must also be attentive to catastrophic injuries because they discourage participation. On an individual level, injuries limit personal goals or achievements, ranging from participation on a regular basis to advancement to a competitive level of a sport.1 Current Responsibilities for Preventing Injuries From the perspective of the individual athlete, injury has commonly been thought of as ‘part of the game’ and an inherent consequence

62 Introduction and Overview Table 3.1 The Prevention Matrix for Ice Hockey Prevention Measures

Host

Physical Environment

Social Environment

• Protective equipment design, e.g., helmets • Ice maintenance • Rink temperature • Boards, glass, goal post/net design

• Age divisions and stratifications within divisions • Training of coaches, referees • Inform about the longevity of helmets • Improve protective quality of helmets • Implement initiatives to remind players not to hit from behind, e.g., viewing of Smart Hockey Video, STOP program • Make full face visor mandatory • Promote use of neck guards

Pre-event / Primary .

• Strength training, specifically neck musculature • Flexibility training, specifically lower extremities • Conditioning program • Replacing old equipment with new, properly fitting equipment • Age of introduction of bodychecking

Event / Secondary

• Coaches’ behav• Proper mainte- • Officiating – zero toleriour when team is nance of ice ance for illegal checks losing resurfacing and manoeuvres • Using or teaching equipment • Enforcing proper attitude proper technique • Maintaining and sportsmanship to deliver a bodyarena ventilation among parents check system • Wearing newer • Availability of and properly fitted trained personequipment nel for first aid

Post-event / Tertiary

• Suspension of players who hit from behind • Proper rehabilitation of injured players to avoid re-injury

• Repair of • Arena emergency damaged equipmedical procedures in ment after an place injury, e.g., • Trained medical staff on discard site or nearby damaged • Nearby medical facilities helmet and transport are available

Sports Injury Prevention: General Principles 63

of sports participation.1 Sports and recreation injury prevention researchers hold an opposing view: we believe that steps can be taken to prevent injury, thereby making injury prevention part of sports and recreation. Whether injury is short term, related to overuse, or catastrophic, efforts must be taken to prevent it. Through education, equipment, and other activity-specific strategies participants can maintain good health, increase their opportunity to remain injury free, and continue to be physically active in a safe manner. Sports and Recreation Participants People need to know the risks associated with the specific sport or recreational activity in which they participate. Risks are minimized when participants take responsibility for their actions before, during, and after engaging in the activity. Maintaining a healthy, wellbalanced dietary intake for essential energy and tissue repair can help minimize the consequences of injury. Implementing warm-up, stretching, conditioning, and cool-down exercises into training regimens is important, as these help to avoid muscle cramping and strain.9,10 Learning and maintaining proper technique, wearing and knowing how to fit protective equipment, and promoting good sportsmanship are all factors that participants must be aware of to prevent or minimize the risk of injury to themselves, their teammates, and their opponents. anatomy Warm-up, stretching, and cool-down exercises enhance flexibility of muscle, tendon, and connective tissue; muscle tightness has been associated with an increased incidence of muscle and tendon strain injuries.11 Exercises and strength and conditioning programs should be incorporated into training regimens by sports and recreation participants and their coaches. For example, we have advocated neck muscle strengthening exercises to prevent cervical spinal cord injuries in hockey.3 In addition, the use of orthotics, braces (elbow, wrist, knee, ankle), or the taping of joints can play a role in injury prevention. These devices may help stabilize weak joints before or after injury occurs, or during rehabilitation before return to activity.9

64 Introduction and Overview

nutrition Maintaining a proper, well-balanced diet is essential to maximize performance in sports and recreation, and for injury prevention. By following an appropriate diet, participants provide themselves with energy to perform at optimal capacity. In addition, nutrition assists recovery by the aiding repair of tissue damage after injury. Organizations (such as ThinkFirst) for Promoting Safety Education Education is a valuable tool for reducing the risk of injury and improving the outcome of injury. Knowledge about the types of potential injury, risk factors, and strategies for prevention that are associated with specific activities can be acquired through many routes, including information transfer from parents, teachers, coaches, athletic trainers, magazines, journals, books, conferences, workshops, media, and the Internet. Indeed, all these avenues are used by injury prevention organizations such as ThinkFirst and its subsidiary program, ThinkFirst-SportSmart. These agencies administer programs about national brain and spinal injury prevention, and they have a leadership role in the prevention of sports and recreational injuries in Canada. ThinkFirst-SportSmart has developed and distributed several activity-specific programs. Dive Smart and Sudden Impact are programs for elementary and high schools, respectively, about preventing diving injury. Their hockey injury prevention programs are entitled Smart Hockey with Mike Bossy and Smart Hockey: More Safety More Fun! For skiing and snowboarding, there is A Little Respect: ThinkFirst. For prevention of soccer injuries the program is entitled Smart Soccer, and for horseback-riding injuries Smart Equestrian. Through the use of real life experiences of the victims of catastrophic injuries (such as brain and spinal cord injuries) these programs inform participants about injuries, and some of the video and DVD programs such as Sudden Impact are accompanied by a Leaders’ Guide and instructional material for use in classroom or teaching settings such as lifeguard classes. During the 1990s, several thousand copies of this program were distributed free of charge to all high schools in Canada, and many other copies were distributed at cost to other organizations such as the Lifesaving Society of Canada. Sponsorship of the initial edition of Sudden Impact came from many sources, including the Ontario Ministry of Health Promotion, private industry, and other charities and foundations. Sudden Impact is

Sports Injury Prevention: General Principles 65

still widely used by high schools and by diving, swimming, and water safety organizations across Canada. Each of ThinkFirst’s injury prevention programs was developed by a consortium of sport-specific organizations, corporations, and experts. For example, development of the current Smart Hockey program involved a team of representatives from the National Hockey League Players Association, Hockey Canada, the Canadian Academy of Sports Medicine, ThinkFirst, The Hockey Company (JOFA-CCM), and media personalities. The revised program was designed to educate hockey players and their coaches on how to prevent head and spine injuries, as well as to provide information about the signs and symptoms of concussion, and recommendations for the management of concussion. To date, more than 35,000 free copies of Smart Hockey have been distributed. Injury prevention agencies such as ThinkFirst also conduct evaluation and epidemiological studies of sports and recreation injuries, the need for which was described above. For example, the effectiveness of Smart Hockey was evaluated particularly for knowledge transfer in 10to 12-year-old players, revealing that the players retained much useful information about concussions after viewing the video.12 There is excellent evidence that injury prevention programs in hockey have been effective in reducing the incidence of catastrophic spinal cord injuries.13 Other Agencies Organizations such as the Canadian Red Cross and the Lifesaving Society Canada have played a major role in promoting safety in sports and recreation. The Lifesaving Society14 has a Water Smart campaign, the purpose of which is to make Canadians ‘water smart,’ by encouraging targeted individuals to behave in a safe and responsible manner in and around water. Media campaigns, print and electronic communications, community initiatives, and special events and programs are some of the methods that the society has used to disseminate information to the public. Many other organizations have been active in presenting sports injury prevention programs to the public and in lobbying governments on behalf of injury prevention. The Canadian Paediatric Society and the Canadian Academy for Sport Medicine have submitted very useful position statements (available from its web site).

66 Introduction and Overview

Parents, Grandparents, and Other Family Members Parents and grandparents need to be informed of the risks associated with the sports and recreational activities in which their children take part. They should be knowledgeable about the factors associated with safe participation, such as proper nutrition, the use and fitting of equipment, learning and maintaining correct technique, rules and regulations, and sportsmanship. By asking the ‘coaching team’ questions, and learning by being informed about sports, recreation, and injury prevention, family members can become more prepared and help their children avoid the risk of initial or repetitive injury. Parents must be active in promoting fair play attitudes and respect for the rules of play, and they must insist on and exemplify an attitude of respect for all participants. Parental behaviour, especially at team events, is an essential factor in injury prevention. Parental supervision for certain sports such as tobogganing and water sports is essential, especially for children under 12 years of age. Coaches, Trainers, and Therapists Coaches, trainers, and athletic therapists play a critical role in the prevention of injury. Indeed, many believe that coaches are the most important factor in catastrophic injury prevention. Ideally, all coaches should be trained and certified by the National Coaching Certification Program (NCCP),15 which is offered across Canada for more than 60 sports; approximately 875,000 coaches have taken part since its inception.16 Through NCCP training, coaches learn about safety, skill development and training programs, equipment, and rules of play, all of which are essential to injury prevention.15 Furthermore, in developing athletes, coaches teach values, ethics, and sportsmanship, each of which is key to injury prevention. Coaches and trainers can influence what happens during play by maintaining control of the players and by stressing safety and respect. Athletic therapists employ strategies to help participants avoid or minimize the risk of injury. They provide immediate, expert care at the time of injury, as well as assistance during rehabilitation.17 Programs and courses are available to educate coaches, trainers, and athletic therapists about injury prevention, such as the Sports Injury Prevention and Care program (SIPAC) of the Sport Alliance of Ontario.16 The goals of SIPAC are to educate people about the fundamentals of

Sports Injury Prevention: General Principles 67

injury prevention, care, and safety; to develop plans for reducing precipitating factors that may lead to injury; and to improve the ability to care for injuries. ThinkFirst’s Concussion Road Show is a workshop for coaches, trainers, team doctors, and therapists that is designed to teach concussion management and return-to-play guidelines. People Who Administer, Maintain, and Supervise Sports and Recreation Properly maintained and equipped sports and recreational facilities are critical for the prevention of injury. Sporting structures should be designed to maximize safety and performance, while minimizing risk. For example, to avoid injury, arenas, pools, fences, goalposts, playing surfaces, and lighting need to be properly maintained, updated, and in conformity with professional and governmental standards. Proper signage for swimming pools about safe areas for diving is an important safety strategy. Choosing the correct terrain for outdoor activities involving specific age groups is essential for safety in activities such as hiking and skiing. The weather has a significant impact on injury prevention; thus, sports and recreation participants, parents, and coaches should all be aware of weather situations that increase the risk of injury. Hot and cold environments require specific preventive measures. During hot and humid weather, participants should have water or hydrating solutions of diluted carbohydrates and electrolytes easily accessible to avoid dehydration.9 Facilities such as arenas should provide access to hydrating solutions. Participants in some activities such as skiing and fishing are at risk for frostbite or hypothermia. Fishing in cold water is an extremely risky recreational activity, and death from hypothermia and subsequent drowning was a common cause of fatality observed in this study. Warm clothes should be worn in layers to help insulate the body. By being prepared for weather conditions, the risk of injury can be minimized. Lightning poses a risk for participants in certain sports and recreational activities, and education about avoidance of a lightning strike should be offered. Participants need to know that metal items such as golf clubs, fishing poles, bicycles, and shoes with metal cleats conduct electricity.18 By listening to weather forecasts, watching for severe weather, and knowing what to do when a storm occurs – such as avoiding open areas, seeking permanent shelter, keeping away from tall objects such as trees and towers, crouching in areas such as valleys and ditches – lightning strikes can be avoided.18

68 Introduction and Overview

Sports Governing Bodies Provincial and national sports governing bodies and organizations have an important role in injury prevention. On the Canadian Soccer Association website, for example, tips are provided by experienced soccer players on proper technique, which can facilitate safety and injury prevention in soccer. The association operates a program called Tide Mini Soccer designed to promote and teach aspiring soccer players basic soccer skills, fair play, and sportsmanship.19 The association also participated in the development of the Smart Soccer program. The Ontario Federation of Snowmobile Clubs is a good example of an organization that has played a strong role in injury prevention. The federation initiated a safety program entitled SledSmart in 1993–94,20 and it has been recognized as among the best snowmobile safety programs in North America. The objective of SledSmart is to reduce snowmobiling-related injuries and fatalities in Ontario, and this is achieved though educating participants about snowmobile-related safety issues, legislation, and policy. A popular component of the SledSmart Public Safety Education Campaign is the Sled Smart Team that delivers hands-on safety information to schools, clubs, events, and trail-side pit stops.20 Leagues and Associations for Rules and Officials To facilitate and enhance injury prevention, sporting leagues and associations should maintain comprehensive records of the frequency, types, severity, and outcome of injuries among participants. By maintaining an up-to-date database on their websites, for example, sporting leagues can make participants aware of the specific risks, types of injuries, how injuries occur, and tips for prevention. Websites should include specific links that provide information about the proper use and fitting of equipment, safety tips, injury facts, sportsmanship, current rules, rule changes, regulations, and contacts for medical information and assistance. The Hockey Canada website is an excellent example: in the Development and Programs section, participants and their parents can read about the Hockey Canada Safety Program. This is a volunteer hockey program initiated by Hockey Canada that emphasizes injury prevention and safety through risk management and education, with the goal of making hockey safe and enjoyable.21 Safety resources are provided, including a parents’ guide, an equipment

Sports Injury Prevention: General Principles 69

fitting guide, an emergency action plan, and a stretching information guide, as well as other safety messages ranging from facial to ear protection. Hockey Canada also provides links for safety and risk management. These links include the Ontario Brain Injury Association, the Dr Tom Pashby Sports Injury Prevention, and the ThinkFirst sites. In addition, Hockey Canada offers skill development camps for hockey players to learn about skills, fair play, respect, teamwork, leadership, and fitness.21 Sports administrators are responsible for translating the results of injury research into actions designed to prevent injury, such as rule changes. Good examples are rules against spearing and ‘clotheslining’ in football, which were instituted when research showed that these manoeuvres were responsible for broken necks. In ice hockey, we found that several mechanisms contributed to spinal injuries, including social and psychological factors. Improvements in protective equipment gave hockey players a sense of invincibility, and wearing this equipment made them feel bigger and stronger, less vulnerable to injury, and thus, more likely to play the game with aggression. Research showed that in many cases spinal injury occurred when players were pushed or checked from behind into the boards.3 As early as 1981, ThinkFirst-SportSmart identified checking and pushing from behind as major causes of spinal cord injuries in hockey, and as a result, the Canadian Amateur Hockey Association (now Hockey Canada) introduced specific rules in 1985–86 to make these plays illegal. Prior to 1985 there were no such specific rules against them. Recent studies13 have confirmed the effectiveness of these prevention measures. Even with appropriate rules, however, enforcement must occur if injuries are to be prevented. Inadequate enforcement is a major factor in the continuing occurrence of catastrophic spinal cord injury in hockey. Failure of leagues and referees to consistently penalize illegal plays has had an important impact on player safety. Rules that are developed should be uniform across geographical boundaries, and should address safety equipment, skill, and maturity level.9 Media The media are an important channel through which health education information can be disseminated to enhance knowledge and change behaviour and attitudes towards sports and recreation injury. The media are especially important for individual, non-team sports and

70 Introduction and Overview

recreation, such as diving, snowmobiling, swimming, and boating. National television campaigns, video simulations, public service announcements, billboards, local campaigns, and articles in newspapers are examples of how information can be relayed to society. In enlisting the media as an educational tool, it is essential to indicate the target populations and to provide correct information. Unfortunately, the media may emphasize the more sensational catastrophic injuries, especially those involving celebrities, and overlook the ‘good news’ stories, such as when injury prevention programs are successful. Federal and Provincial Governments Governments play an essential role in injury prevention through policy development, support for research, and implementation of prevention programs. More municipal, provincial, and federal government support is needed for research, education of the public, implementation of regulations, formulation of new legislation, delivery of established prevention programs, and development of new programs. Governments can maximize the effect of injury prevention programs by developing partnerships with non-governmental programs such as ThinkFirst and Safe Kids. For example, several effective partnerships have been developed between ThinkFirst and the former Ontario Ministry of Citizenship, Culture and Recreation, and currently the Ministry of Health Promotion. It is planned to distribute abstracts of the present study to sports and recreation governing bodies in Ontario, and to make some information available on the ThinkFirst website and other websites such as that of the publicly funded Leisure Information Network (www.lin.ca) or the ministry’s website (www.safeontario.org). This ministry initiated the Ontario Sports Medicine and Safety Advisory Board in the 1980s, and this body has been very useful for initiating a number of injury prevention strategies including one for snowmobiling. In other parts of Canada, provincial governmental bodies play a role in sports, including injury prevention. One of the most active was the Régie de la sécurité dans les sports du Québec, which was terminated in 1997, and is now part of the Secrétariat au loisir et au sport, of the Ministère de l’Éducation du Loisir et du Sport. Its work includes establishing safety rules and regulations, as well as conducting research investigating injury and safety in sport.22 An important role for governments is to provide funding for injury surveillance systems and registries to enhance the quality of injury

Sports Injury Prevention: General Principles 71

prevention programs.23,24 The Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) is a federal program involved in injury surveillance and prevention. Information provided by CHIRPP is useful for injury prevention programs and helps to target specific populations at risk. However, CHIRPP is not a comprehensive registry, and it mainly covers several major paediatric hospitals and a smaller number of adult hospitals. The Ontario and federal governments have supported the Ontario Trauma Registry (OTR) and the National Trauma Registry (NTR), respectively, which have provided some useful data about trauma in general, but they need to augment their data collection by including all the specific types of sports and recreational activities. These registries have been enhanced by being incorporated into the Canadian Institute for Health Information (CIHI), Canada’s major data collection agency for health information in general. However, there are still major shortcomings with respect to data collection about sports and recreation injuries. Ideally, specific data on injuries sustained in every activity listed in this book should be captured individually to maximize the usefulness of these government-supported data collection agencies. An example of the persisting deficiencies is diving injuries, which are not specifically captured by the current CIHI, NTR, or OTR systems. Other federal initiatives include the ParticipACTION program established in 1971 to promote the importance of physical activity for a healthy lifestyle. Injury prevention was one of its indirect objectives.25 Although ParticipACTION’s national office closed in 2001 because of decreased funding, the fitness initiatives that it promoted are continued through volunteers in some locations. Parks Canada plays a role in injury prevention by identifying site-specific hazards, performing risk analysis, operating search and rescue services, and its development of some targeted prevention programs that encourage self-reliance.26 Safety messages are on its website, and Parks Canada provides other educational materials about safety, hazards, and environmental advisories, such as avalanche control. Regional and Municipal Governments Intervention at the regional level can occur through public health units, police departments, district school boards, industries, and private organizations.23,24 Regions address injury prevention by establishing partnerships with injury prevention organizations, such as the

72 Introduction and Overview

Safe Communities Foundation or ThinkFirst. Knowledge transfer to promote injury prevention is provided to the community to address issues such as bicycle and playground safety. At the municipal level, injury prevention initiatives can be promoted by parks and recreation departments to foster safety and injury awareness by targeting different sports and recreational activities, often on a seasonal basis. For example, Bicycle Safety Awareness Week in Toronto encourages the use of bicycles as a form of transportation, and tips are provided on road and equipment safety. In addition, municipal parks and recreation websites have links to injury prevention programs in sports and recreation. Industry Steps have been taken by some industries to initiate safety in sports and recreation. In Ontario, Labatt Breweries has supported a variety of initiatives for responsible water activities and snow trails, such as the Labatt WaterWise Team, a boating safety campaign, that travelled across the province during the summer to provide water and boating safety demonstrations directly to boaters on the water. Their safety messages included: Don’t Drink and Boat, Always Wear a Personal Flotation Device, Get Properly Trained, Acquire a Pleasure Craft Operator’s Card, and Be An Environmentally Responsible Boater. Labatt also sponsored the Safe Trails Snowmobile Program, which is run by the Sled Smart Education Team of the Ontario Federation of Snowmobile Clubs. This program promoted moderation and safety while travelling on the province’s snowmobile trails.27 Other injury prevention efforts by industry include improving the safety of all terrain vehicles (ATVs). In the mid- to late 1980s, threewheel ATVs were withdrawn, apparently voluntarily, by the manufacturers from the American and Canadian markets because of safety concerns.28 Today’s new ATVs are four-wheelers built to stricter safety standards in areas such as vehicle stability and brake performance.28 Obviously, there is less risk of rollover, but these vehicles continue to cause many catastrophic injuries. Challenges for the Prevention of Injuries in Sports and Recreation Several challenges exist to improve injury prevention programs in sports and recreational activities. Additional targeted prevention pro-

Sports Injury Prevention: General Principles 73

grams are needed to address some of the high-risk activities, such as fishing, identified in this book, and greater funding is required to evaluate the effectiveness of several of the existing programs. Enhanced prevention programs are needed for catastrophic injuries such as drowning, but also for common, non-catastrophic sport specific injuries such as torn ligaments in the knees, which also cause considerable disability to individuals and significant cost to society. Registries and Surveillance Programs Effectively addressing catastrophic injuries in sports and recreation, and aiding the development of new or updated targeted prevention programs requires better injury monitoring through permanent registries and surveillance programs that encompass all the sports and recreational activities listed in this book. A good example of the usefulness of detailed, sport-specific data is ThinkFirst-SportSmart’s Canadian Registry of Spinal Injuries in Ice Hockey, which has monitored spinal injuries in hockey since the 1980s and reports its findings to Hockey Canada and to the general public through journal articles and media reports. The development and success of the targeted injury prevention programs in ice hockey is directly related to the data generated by this registry. As noted above, the OTR, NTR, and CIHI do not provide sufficiently specific information for injuries in sports and recreation. For example, these registries code ‘falls’ as a cause of injury, but in many cases it is impossible to determine the exact circumstances, such as whether the fall causing a broken neck happened to a roofer as an occupational injury or to a gymnast who fell off a trampoline in a backyard. Specific details are necessary if registries and surveillance systems are to be useful for injury prevention. To assist with monitoring injury, future analytical studies need to provide better methods or tools for assessing the frequency and duration of sports and recreation participation.29 More accurate estimates of injuries and injury rates will facilitate examination of the risks and protective factors associated with sports and recreation, as well as the identification of future prevention strategies.29 Evaluation of Program Effectiveness Evaluation of effectiveness is a key component of injury prevention programs because it provides information necessary for decisions

74 Introduction and Overview

about the expansion or contraction of current programs or development of new ones. This helps to refine interventions by determining their suitability to the target population. For example, evaluation of the distribution and usage of ThinkFirst’s diving injury prevention program entitled Sudden Impact indicated that the distribution mechanism used was not effective in ensuring that the free copies provided to schools actually reached them and were then being shown to the students.30 Such examination allows injury prevention programs to identify impediments that limit the effectiveness of their interventions, and can indicate the need for changes to optimize successful programs or withdrawal of unsuccessful ones.31 It is unfortunate that the prevention programs developed by many organizations have never been evaluated. Economic Burden of Sports and Recreation Injuries There is an enormous financial burden to individuals and to society in general from catastrophic injuries incurred during sports and recreational activities. Unfortunately, there is limited information available about the exact current costs of either catastrophic or non-catastrophic injuries in sports and recreation, but some information is available on which to base estimates. In the McLaren Report for 1995 it was estimated that the cost of non-catastrophic injuries in sports and recreation in Ontario was approximately $667 million. There has been no other similar study of the economic burden of catastrophic injuries in sports and recreation in Ontario. However, some information is available to allow estimates to be made. For example, it is known from settlements in court that each major catastrophic brain injury (e.g., persistent vegetative state) or major spinal cord injury (e.g., complete quadriplegia) costs approximately $7.5 million (extrapolated to 2006 dollars) in lifetime medical costs and lost earnings. There were a total of 1,073 catastrophic head and spine injuries documented in the present study (Table 2.10). Some participants suffered less severe injuries, although still catastrophic ones, and some participants sustained more than one of these types of injuries. A conservative estimate of the number of major brain and spinal cord injuries alone is 600 over the 4 years surveyed, approximately 150 per year, and this would potentially cost approximately $1.125 billion annually. Added to this would be the costs for the other 1,000 or so non-neurological catastrophic injuries, probably about another $1.0 billion. Thus, non-

Sports Injury Prevention: General Principles 75

catastrophic and catastrophic injuries in sports and recreation in Ontario represent costs of about $3 billion annually for lifetime care and rehabilitation and lost earnings. Future studies should attempt to quantify in detail the health care and other costs to society that are associated with such injuries. In doing so, society will have a better understanding of the public health burden of sports and recreation injuries.29 Conclusions Effective injury prevention education requires messaging through multiple channels, and therefore cooperation has to occur at a variety of levels to increase public awareness about injury prevention. Effectiveness is improved with the establishment of coalitions and partnerships between voluntary agencies, governments, activity associations, and corporations. Through increased funding, and by establishing partnerships with injury prevention organizations, injury prevention programs can help change behaviour, attitudes, values, and public policy and legislation associated with sports- and recreation-related injuries, and ultimately reduce their incidence. Research into the epidemiology of these injuries shows the important pre-injury, injury, and post-injury components, and has led to the development of targeted prevention programs, some of which have been successful. Emphasis on proper nutrition, equipment, strength training and conditioning programs, promoting sportsmanship, and adhering to rules and regulations are effective prevention strategies. For these initiatives to have a greater impact, however, additional partnerships need to be developed among governments, sports and recreation organizations and agencies, corporations, and sports and recreation participants, parents, coaches, sports medicine physicians, and athletic therapists. Efforts are being made by researchers to enhance the quality and effectiveness of injury prevention programs. Evaluation is a key component to determining the success of current programs, as well as to develop enhanced ones in the future. Programs promote safety by encouraging participants, as well as those who are essential to the injury prevention process, including administrators, coaches, parents, teachers, and the media, to take responsibility for their actions, thereby making injury prevention an integral part of the culture of sports and recreation.

76 Introduction and Overview

References 1. Chalmers D. Injury prevention in sport: Not yet part of the game? Inj Prev 2002;8(Suppl IV):iv22–iv25. 2. Cantu R, Mueller F. Fatalities and catastrophic injuries in high school and college sports, 1982–1997. Physician Sports Med 1999;27(8):35. 3. Tator C, Carson J, Edmonds V. Spinal injuries in ice hockey. Clin Sports Med 1998;17:183–94. 4. Watt G, Finch C. Preventing equestrian injuries: Locking the stable door. Sports Med 1996;22(3):187–97. 5. Tator C. Current primary to tertiary prevention of spinal cord injury. Topics Spinal Cord Inj Rehabil 2004;10(1):1–14. 6. Bonnie R, Fulco C, Liverman C. The injury field. In: Bonnie R, Fulco C, Liverman C, eds. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington: National Academy Press, 1999, 18–40. 7. Roberts I. Research priorities for injury prevention. Inj Prev 2001;7:1–3. 8. Haddon W. Options for the prevention of motor vehicle crash injury. Israel J Med 1980;16:45–8. 9. Weaver J, Moore C, Howe W. Injury prevention. In: Caine D, Caine C, Lindner K, eds. Epidemiology of Sports Injuries. Champlaign: Human Kinetics, 1996, 439–47. 10. Insel P, Roth W. Core Concepts in Health. Mountain View: Mayfield, 1991. 11. Ekstrand J, Gillquist J. Avoidability of soccer injuries. Int J Sports Med 1983;4:124–8. 12. Cook D, Cusimano M, Tator C, Chimpman M. Evaluation of the ThinkFirst Canada Smart Hockey brain and spinal cord injury prevention video. Inj Prev 2003;9(4):361–6. 13. Tator CH, Provvidenza CF, Lapczak L, Carson J, Raymond D. Spinal injuries in Canadian ice hockey: Documentation of injuries sustained from 1943–1999. Can J Neurol Sci 2004;31(4):460–6. 14. Lifesaving Society, Ontario. Water Smart. http://www.lifesavingsociety .com/na/reallife.asp?PageId=90&SectionId=5&LevelId=2. Retrieved 8 Sept. 2003. 15. Coaching Association of Canada. Program Overview: National Coaching Certification Program. 2003. http://www.coach.ca/e/nccp/index.htm. Retrieved 2 Oct. 2003. 16. Recreation MoTa. Volunteer Leadership. 2002. http://www.tourism.gov. on.ca/english/sportdiv/coaching/leader.htm. Retrieved 8 Aug. 2003.

Sports Injury Prevention: General Principles 77 17. Trainer’s Choice Sports Medicine Products. Trainer’s Choice: Our Philosophy. http://www.trainerschoice.on.ca/about_us.htm. Retrieved 9 Sept. 2003. 18. Environment Canada. Lightning Safety Tips: For the public. http://www.msc.ec.gc.ca/education/lightning/safetypublic_e.html. Retrieved 8 Sept. 2003. 19. Canadian Soccer Association. Tide Mini Soccer. 2003. http://www.canadasoccer.com/eng/minisoccer/index.asp?sub2=3. Retrieved 8 Sept. 2003. 20. Ontario Federation of Snowmobile Clubs. SledSmart Education Team. http://www.sledsmart.com. Retrieved 6 Oct. 2003. 21. Hockey Canada. Hockey Canada: Safety Program. http://www.canadian hockey.ca/e/develop/safety/index.html. Retrieved 9 Sept. 2003. 22. Turner S, Brown D, Buist A, Fafard M, Goulet C. Best Practices in Sport: A Vehicle for Positive Values and Ethic Conduct? Direction de la promotion de la sécurité du Sécretariat au loisir et au sport. http://www.cces .ca/pdfs/CCES-PAPER-DPS-E.pdf. Retrieved 21 Jan. 2008. 23. Barss P, Smith G, Baker S, Mohan D. Injury treatment and rehabilitation: The role of health services and other sectors. In: Barss P, Smith G, Baker S, Mohan D, eds. Injury Prevention: An International Perspective. Epidemiology, Surveillance, and Policy. New York: Oxford University Press, 1998, 307–22. 24. Barss P, Smith G, Baker S, Mohan D. Choice and development of injury prevention programs. In: Barss P, Smith G, Baker S, Mohan D, eds. Injury Prevention: An International Perspective. Epidemiology, Surveillance, and Policy. New York: Oxford University Press, 1998, 277–306. 25. Kisby R. Reflections on a Pioneer in Health Promotion. http://www.speakwell.com/well/2001_summer/3.shtml. Retrieved 28 Oct. 2003. 26. Parks Canada: Sharing the Responsibility for Safety. http://www.parks canada.pch.gc.ca/progs/np-pn/visit_secur/index_E.asp. Retrieved 3 Oct. 2003. 27. Labatt-Ontario. Labatt Breweries Ontario: Community Initiatives. http://www.labatt.ca/comp/lb_ont.html. Retrieved 8 Sept. 2003. 28. Canada Safety Council. The All-Terrain Vehicle Boom. Safety Canada 2003;47(2):1–8. 29. U.S. Centers for Disease Control. Preventing Injuries in Sports, Recreation and Exercise. http://www.cdc.gov/ncipc/pub-res/research_agenda/ 05_sports.htm. Retrieved 8 Aug. 2003.

78 Introduction and Overview 30. Bhide VM, Edmonds VE, Tator CH. Prevention of spinal cord injuries caused by diving: Evaluation of the distribution and usage of a diving safety video in high schools. Inj Prev 2000;6(2):154–6. 31. Dannenberg A, Fowler C. Evaluation of intervention to prvent injuries: An overview. Inj Prev 1998;4:141–7.

Recto Running Head 79

4 Geographical Locations Where 2,154 Catastrophic Sports and Recreation Injuries Were Sustained charles h. tator

This chapter focuses on the geographical locations where during the four survey periods (1986, 1989, 1992, and 1995) 2,154 individuals sustained catastrophic injuries while taking part in sports and recreational activities. Close examination of the relationship between location and injury events should be helpful to governments and organizations charged with the responsibility for planning, implementing, and monitoring injuries and injury prevention programs. Such knowledge should enable key individuals across Ontario to target the activities and age groups in their own locations who are particularly at risk for sustaining catastrophic injuries in sports and recreation. Thus, this chapter is directed especially to the people in local communities who are in a position to prevent injuries or for whom injury prevention is part of their jobs. The former include health care professionals, teachers, and the participants themselves, while the latter include recreation supervisors working for cities and towns; superintendents of municipal or provincial parks; police and firefighters; camp owners and counsellors; and facility operators such as arena managers, playground supervisors, lifeguards, lodge operators, and campground owners. With information about the exact circumstances of the injuries in their own communities, all of these people should be more effective in promoting injury prevention. Designation of the Geographical Location of the Injuries The places shown in Table 4.1 are the actual geographical locations where the injuries were sustained, rather than the places of residence of the injured persons. Injuries to Ontario residents that occurred in [Text continues on page 111

80 Introduction and Overview Table 4.1 Geographical Location, Sport or Recreational Activity, and Month Catastrophic Injury Sustained for 2,154 Ontario Participants between 1986 and 1995a Locationb Central LHIN Alliston

Aurora Bradford East Gwillimbury Georgina Island Jackson's Point Keswick Kettleby King City Kleinburg Markham

Mount Albert Newmarket

North York

Oak Ridges Pefferlaw

Activityc

Monthd

ATV riding Bicycling Canoeing Hunting Ice hockey Ice hockey Boating Soccer Boating Swimming ATV riding Snowmobiling Bicycling Boating Snowmobiling Motorbiking Bicycling Bicycling Flying small aircraft Golf Ice hockey Skateboarding Squash Diving Air sports, gliding ATV riding Baseball Bicycling Boating Ice hockey Snowmobiling Swimming Tobogganing Bicycling Football Motor, mountain-biking Play, swing Tobogganing Snowmobiling Boating Horseback riding

Apr May Sept Jan Jan Nov July July Nov Aug May Mar Feb June, July (4) Mar June July Aug Nov July, Aug Jan, Mar July Jan July July Jan July May, Aug June Apr, NA Jan, Feb Aug Jan May, June, July July Oct May Jan (2) Feb June May

Geographical Locations Where Injuries Were Sustained 81 Table 4.1 (continued ) Location b

Activity c

Month d

Richmond Hill

Baseball Bicycling Dirt-biking Pellet gun use Swimming ATV riding Swimming Windsurfing Baseball Bicycling Field hockey Horseback riding ATV riding Bicycling Ice hockey

May (2) Mar, Sept Jan, Sept Apr Aug May July (3) July Aug Apr Apr Oct Nov Sept Feb

Baseball Bicycling Boating Diving Ice hockey Play, slide Road hockey Sailing Snowmobiling Swimming Snowmobiling Diving Ice skating Snowmobiling Tobogganing Windsurfing ATV riding Diving Snowmobiling Snowmobiling Snowmobiling Snowmobiling Diving Fishing Golf Ice hockey Snowmobiling

July Mar, June (2) Oct June, July Dec Mar, Sept Dec Oct Jan Aug Feb, Apr (3) July Dec Feb, Mar Dec, Feb N/A Aug June Feb, Mar, Dec Mar Jan Feb (2) June Mar July Mar Feb

Sutton

Thornhill

Unionville Woodbridge Central East LHIN Ajax

Apsley Bowmanville

Burleigh Falls Campbellford

Cardiff Carnarvon Coboconk Cobourg

82 Introduction and Overview Table 4.1 (continued ) Location b

Courtice Fenelon Falls

Haliburton

Haliburton Lake Hastings Havelock Kirkfield Lakefield Lindsay

Minden

Mosport Newcastle Norwood Oshawa

Peterborough

Activity c

Month d

Bicycling Bicycling Ice hockey Snowmobiling Swimming Air sports, ultralight ATV riding Boating Camping Fishing Snowmobiling Water-tubing Snowmobiling Snowmobiling Snowmobiling Scuba-diving Fishing Snowmobiling ATV riding, 4 wheel Bicycling Boating Fishing Ice hockey Personal watercraft Skateboarding Snowmobiling Swimming ATV riding, 4 wheel Canoeing Diving Snowmobiling Motorbiking Motorcycling Bicycling Diving Baseball Bicycling War games Waterskiing ATV riding Baseball Bicycling Diving Fishing

Apr May Sept Feb, Mar June Mar May July Aug July Jan (2), Feb (2), Dec (2) Aug Apr Feb, Dec Jan Apr (2) June Jan June Sept July Oct Jan July May Jan (3), Feb, Apr, Dec (2) June Apr Sept, Oct May Jan (2), Feb (3), Dec May Oct Sept June May July, Aug, Sept Sept June Aug July Aug, Sept June, July Aug, Sept

Geographical Locations Where Injuries Were Sustained 83 Table 4.1 (continued ) Location b

Pickering

Port Hope Port Perry

Scarborough

Scugog Sprucehole / Peterborough Stoney Lake Uxbridge

Activity c

Month d

Golf Horseback riding Ice hockey Missile, darts Personal watercraft Scuba-diving Skateboarding Skiing Snowmobiling Steer wrestling Stock car driving Swimming Tobogganing Waterskiing ATV riding Bicycling Ice hockey Jogging Rugby Squash Snowmobiling Dirt-biking Fishing Horseback riding Snowmobiling Baseball Bicycling Diving In-line skating Skiing, cross-country Soccer Swimming Tennis Snowmobiling

Aug Apr Jan (3), Dec Apr June June July Jan, Mar (2) Jan (2), Mar June July July (2) Jan Aug Apr Aug, Oct Aug Sept May Apr Feb June Oct July Feb (3), Dec Aug May, Sept, Oct July Oct Mar Sept (2) July, Sept Aug Feb

Swimming Fishing ATV riding Bicycling Diving Motor, go-carting Rugby Skiing Snowmobiling

Sept July Oct Feb Aug June May Jan

84 Introduction and Overview Table 4.1 (continued ) Location b

Victoria County Whitby Woodville Central West LHIN Bolton Brampton

Caledon Orangeville

Activity c

Month d

Tobogganing Horseback riding Snowmobiling Boating Ice hockey

Feb Aug Dec Oct May

Baseball Snowmobiling Bicycling Diving Ice hockey Martial arts Swimming Flying small aircraft Ice hockey Hunting, duck Play, tree climbing Snowmobiling

Oct Dec June, Aug (4) June (2), July Oct, Nov, Dec (2) July July July Jan, Nov Sept July Feb

Central LHIN/Hamilton Niagara Haldimand Brant LHIN York City Bicycling York County Snowmobiling Swimming Champlain LHIN Alfred Arnprior

Ashton Barrys Bay

Brinston/Winchester Carleton Place Carp Carp/Ottawa Casselman Chesterville

Swimming Boating Ice hockey Parachuting Snowmobiling Tobogganing Horseback riding Hunting Boating, motor Diving Swimming Tobogganing Play, monkey bars Water, sea biscuit Play, on ice Bicycling Swimming Snowmobiling

June Feb Aug

July July Jan May Mar Dec July Feb Aug Aug July Feb Jan Aug Nov Mar June Feb

Geographical Locations Where Injuries Were Sustained 85 Table 4.1 (continued ) Location b

Activity c

Month d

Clarence Creek Cornwall

Golf ATV riding Bicycling Boating Scuba-diving Snowmobiling Soccer Swimming Missile, target practice Boating Snowmobiling Hunting Skateboarding Ice hockey Snowmobiling Tobogganing Bicycling Canoeing Snowmobiling Skiing Play, jungle gym Field, high jumping Snowmobiling Ice hockey Ice skating Sailing Swimming Football Martial arts Snowmobiling Air sports, hang-gliding Air sports, parachuting Badminton Baseball Basketball Bicycling

June Mar, Nov Aug July July Feb May Aug Dec Sept Jan June Nov Jan Jan Jan June, Aug June Dec Mar July June Feb Feb N/A May (3) Jan Oct May Feb (2) July Sept May, July, Sept (2) Apr, June (2), Aug Dec Feb, Mar, Apr, May (2), June (6), July (4), Aug, Sept (2), Oct (3) May, June June (2), July (5) July, Aug Jan Mar, Aug, Oct Jan

Crysler Dundas County Finch Gloucester

Hawkesbury

Hull/Ottawa Kanata Kemptville Limoges Nepean

Orleans

Ottawa

Dirt-biking Diving Fishing Flying small aircraft Football Football, touch

86 Introduction and Overview Table 4.1 (continued ) Location b

Ottawa Prov Park Pembroke

Perth

Petawawa

Activity c

Month d

Golf Gymnastics Gymnastics, trampoline Horseback riding Ice hockey

July Sept Apr July, Nov Jan, Feb (2), Mar (2), Apr, May (3), July, Sept, Oct, Dec Jan, Feb, Mar Apr Mar Apr, May June Feb, Mar May, July Jan, Feb (5), Mar Jan Jan Jan, Feb, Mar, Dec June, July (2), Oct (3) Apr, May July (2), Aug (2) Dec Jan, Feb, Mar (2), Dec (3) Sept July July Aug May Sept (2) Aug Oct (2) Oct Jan (2), Feb Feb, Mar Dec Apr, May, Sept July Aug Aug Oct Mar (2) Apr Aug Nov

Ice skating In-line skating Martial arts, karate Motorbiking Play, play structure Racquetball Rugby Skiing Skiing, cross-country Snowboarding Snowmobiling Soccer Squash Swimming Tennis Tobogganing Track and field Water, play Water, rowing Swimming Bicycling Boating Dirt-biking Football Hunting, moose Snowmobiling Tobogganing Winter, curling ATV riding Bicycling Canoeing Diving Football Ice hockey Motorbiking Water, play Air sports, parachuting

Geographical Locations Where Injuries Were Sustained 87 Table 4.1 (continued ) Location b

Activity c

Month d

Reid Lake Renfrew

Fishing Bicycling Fishing Ice skating Motorbiking Snowmobiling Fishing Tobogganing Snowmobiling Bicycling Fishing Jogging Softball Snowmobiling

June June May Dec May Feb (2), Mar May Jan Jan Dec May May May Feb

Verner Wendover Winchester

Winchester/Ottawa

Champlain LHIN/ South East LHIN Lanark Ice hockey Swimming Erie St Clair LHIN Amherstburg Belle River

Belle River Blenheim Bothwell Cedar Island Chatham

Erieau Essex Essex County Forest Grand Bend Harrow Kingsville

Baseball Bicycling Ice hockey Snowmobiling Snowmobiling Swimming Swimming Swimming Bicycling Boating Diving Fishing, ice Hunting Miscellaneous: Lacrosse Swimming Horseback riding Soccer Canoeing Fishing Swimming Boating Swimming Hunting Canoeing

Mar June

Sept Sept Nov Jan Jan July May July June, July, Oct July July, Aug Mar (2) Dec Aug Aug June Mar May Nov Aug July (5), Aug Aug (2) Dec June

88 Introduction and Overview Table 4.1 (continued ) Location b

La Salle-Windsor Lambton County Leamington Morpeth Petrolia Port Franks Rondeau Bay Rondeau Prov Park Sarnia

Southwood Tecumseh Tilbury Wallaceburg

Windsor

Activity c

Month d

Golf Waterskiing Swimming Boating Boating Bicycling ATV riding Boating Swimming Sailing Swimming Boating Diving Flying small aircraft Ice hockey Snowmobiling Water, parasailing Bicycling Baseball ATV riding Bicycling Air sports, gliding Horseback riding Hunting, duck Personal watercraft Soccer Baseball Bicycling Boating Dirt-biking Diving Floor, weight lifting Floor hockey Football Horseback riding Ice hockey

Feb Aug July June May Apr Oct June July, Aug Aug July Aug May (2) Sept (2) Jan Jan July May July Feb July July May Oct May June May, Aug Feb, May, July Aug Mar, Aug May, June, Aug Nov Feb (2), Sept Aug, Sept, Oct, Nov July Mar, Aug, Oct, Nov (3), Dec (5) Apr Dec Mar July Jan Jan (4), Dec Aug

In-line skating Play, ball Play, rides Play, tree climbing Play, wrestling Tobogganing Water, play

Geographical Locations Where Injuries Were Sustained 89 Table 4.1 (continued ) Location b

Activity c

Month d

Woodslee

Golf

Aug

Hamilton Niagara Haldimand Brant LHIN Ancaster Horseback riding Play, monkey bars Soccer Beamsville Badminton Brantford Badminton Baseball Bicycling Canoeing Diving Floor, volleyball Flying small aircraft Horseback riding Ice hockey In-line skating Snowmobiling Burford Ice hockey Burlington Basketball Bicycling Diving Football, touch Bicycling, mountain-biking Bicycling, mountain-biking, Bmx Mountain, rock climbing Play, monkey bars Tennis Caledonia Diving Fishing Swimming Water, water-tubing Cayuga Boating Fishing Motorbiking Copetown Swimming Crystal Beach Motor, go-carting Dundas Baseball Mountain, rock climbing Dunnville Boating Play, tree climbing Fort Erie Baseball Fishing Ice hockey

Mar Sept June Mar Apr Apr, July May June July July Oct May Oct Aug Nov Mar Oct Apr, May, Oct June, July (2) June Sept Dec Dec Sept Oct Apr Oct June Aug Aug June May June Mar July July July June July July, Aug Feb, Dec

90 Introduction and Overview Table 4.1 (continued ) Location b

Freelton Grimsby Hagersville Haldimand Hamilton

Activity c

Month d

Swimming Play, tree house Ice hockey Soccer Diving Motor, motocross biking ATV riding Badminton Baseball Baseball, slow pitch Bicycling

Aug Oct Feb June Aug June July Feb, Nov (2) Oct Oct Feb, Mar, June (3), July (2), Aug (4), Sept May, June (2), July (2), Sept, Dec Mar, Oct Sept, Oct (2) Jan, Feb (2), Apr, Aug, Nov (4) Jan Dec Mar Dec July, Sept Jan May Mar Jan Dec May Aug June, Sept Dec Nov Apr July June NA June (2) Oct July Apr Apr, Aug Jan Jan

Diving Horseback riding Football Ice hockey

Hamilton Wentworth Lowville Millgrove Mount Hope Niagara

Niagara Escarpment Niagara Falls

Niagara-Simcoe Norfolk Paris Port Colborne

Skiing Snowboarding Snowmobiling Squash Swimming War games Wrestling Horseback riding Tobogganing Ice skating Motor, mini-biking Boating Hiking Tobogganing Mountain, rock climbing Badminton Baseball Bicycling Snowmobiling Fishing Horseback riding Soccer Bicycling Bicycling Ice hockey Scuba-diving

Geographical Locations Where Injuries Were Sustained 91 Table 4.1 (continued ) Location b

Activity c

Month d

Port Dover Simcoe

Play, Frisbee Ice hockey Missile, sling shot Motor, motocross biking Bicycling Baseball Bicycling Diving Ice hockey Racquetball Track and field Swimming Bicycling Mountain, rock climbing Fishing Bicycling Diving Bicycling Swimming Baseball Bicycling Diving In-line skating Bicycling

June Feb Jan June May May, NA Aug, Oct, Nov Aug Jan, Feb Jan May July Aug, Sept Oct Oct, Dec July, Oct July Sept May, July, Aug June Aug July, Aug July June

Bicycling Ice hockey Baseball Bicycling Football Ice hockey Motor, go-carting Snowboarding Tobogganing Baseball Tobogganing Horseback riding Ice hockey Mountain climbing Ball hockey Baseball Basketball Bicycling

July Jan May June Oct Jan Aug Feb Jan July Jan July Dec Aug (2) Oct May, June Aug, Oct Mar, May, June, July, Oct, NA

St Ann's St Catharines

Stoney Creek Tewes Falls Turkey Point Vineland Waterdown Waterford Welland

York Mississauga Halton LHIN Acton Etobicoke

Georgetown Milton

Mississauga

92 Introduction and Overview Table 4.1 (continued ) Location b

Oakville

Port Credit North East LHIN Alban Algoma

Algoma Spragge Blind River

Britt Burks Falls

Activity c

Month d

Boating Diving Football Ice hockey In-line skating Play, Ferris wheel Play, playground Racquetball Rugby Swimming Tobogganing Water, play Badminton Baseball Bicycling Boating Football Horseback riding Ice hockey In-line skating Pellet gun use Play, bat Play, playground Rugby Skateboarding Snowmobiling Squash Boating

May July, NA July Jan, Nov May May Feb Feb May Sept Jan (2) May Mar, May Apr June, Nov Feb Sept Sept Dec (2) May Aug Aug Feb July May Feb Apr, June May

Play, outdoors ATV riding Fishing Snowmobiling Summer, kite-flying Baseball Bicycling Fishing, ice Snowmobiling Swimming Bicycling Fishing Snowmobiling Fishing

Jan May Oct Dec June Dec July Feb Jan July Aug Sept Feb Sept

Geographical Locations Where Injuries Were Sustained 93 Table 4.1 (continued ) Location b

Activity c

Month d

Burks Falls / North Bay Callander Capreol

Bicycling ATV riding ATV riding Diving Ice hockey Ice skating Tobogganing Fishing Snowmobiling Badminton ATV riding Canoeing Fishing Snowmobiling ATV riding Discus Hunting Canoeing Snowmobiling Swimming Snowmobiling Fishing Snowmobiling Snowmobiling Fishing ATV riding Snowmobiling ATV riding Snowmobiling Air sports, hang-gliding Bicycling Gymnastics Snowmobiling Bicycling Bicycling, 3 wheel Diving Hunting, moose Snowmobiling Fishing Fishing Boating ATV riding, 3 wheel Hunting, moose Diving

Oct May July July Jan Jan Nov May Dec Jan, Oct Oct Sept May (2) Jan (3), Apr May June Oct (2) May Jan, Feb, Mar Aug Jan, Feb Oct (2) Feb Feb Apr Aug Feb Oct Nov, Dec July Oct Aug Jan, Nov, Dec May Oct June Oct Feb (2), Dec June July June Sept Nov Aug

Chapleau Chapleau River Chelmsford Cochrane

Elliot Lake

Espanola

Fort Albany French River Garson Gogama Gore Bay Hagar Haileybury Hanmer

Hearst

Hornpayne Iron Bridge Iroquois Falls Kapuskaping Kearney

94 Introduction and Overview Table 4.1 (continued ) Location b

Activity c

Month d

Killarney Kirkland Lake

Snowmobiling Diving Floor, weight lifting Snowmobiling Swimming Fishing Swimming Bicycling Diving ATV riding Fishing Ice hockey Skateboarding Summer, tree climbing, fruit picking Swimming Fishing ATV riding Boating, power Diving Missile, target practice Fishing ATV riding Snowmobiling Snowmobiling Ball hockey Snowmobiling ATV riding Motorbiking Snowmobiling Canoeing Snowmobiling Bicycling Skiing Snowmobiling Canoeing Hunting Play, toy wagon Baseball Basketball Bicycling Diving Fishing Football Hunting

Mar June, Aug July Mar July Sept July July, Aug May May May Nov June

Lake Nipissing Lake Tamagamee Levack Little Current

Madawaska Manitoulin District Manitoulin Island

Marten River Massey Mattice Mckellar Mindemoya Moonbeam Moose Factory Moosonee New Liskeard

Noelville

North Bay

Oct Aug Sept Apr Oct June Oct May (2) Apr Feb Feb Jan Jan Nov Dec Jan (2) Sept Jan July Mar Mar July Nov Sept Sept Jan Apr July Aug Sept Nov

Geographical Locations Where Injuries Were Sustained 95 Table 4.1 (continued ) Location b

Parry Sound

Pointe Au Baril Pokei Lake Powasson Ramsey Lake Sault Ste Marie

Smooth Rock Falls Spanish River St Charles Sturgeon Falls

Activity c

Month d

Ice hockey Sailing Skiing Snowmobiling Swimming ATV riding Bicycling Boating Canoeing Fishing Hunting Hunting, deer Motorbiking Snowmobiling Swimming Boating Snowmobiling Fishing Snowmobiling Boating ATV riding Bicycling Boating Diving Fishing Floor, boxing Football Ice hockey Ice skating Motorbiking Motorcycling Play, tire swing Skateboarding Snowmobiling Swimming Tobogganing Canoeing Play, ball Snowmobiling ATV riding, 4 wheel Fishing Horseback riding Ice hockey Snowmobiling

Jan, Mar, Dec, NA June Jan, Feb, NA Jan (4), Feb (3), Mar (2) July, Aug July (2), Aug Aug June, July (3), Aug June May, June Oct Nov (3) Dec Jan, Feb, Apr, Dec (2) Aug Nov Apr May Feb Aug June, July , Aug June (2), Aug, Sept Feb May, June July (3) Sept Sept Feb, Mar Mar Dec Aug June July Jan, Dec July (2) Jan, Apr Sept Aug Nov Jan, Dec Aug Oct Jan Jan (2), Feb

96 Introduction and Overview Table 4.1 (continued ) Location b

Sudbury

Activity c

Month d

Soccer Water, parachute-skiing ATV riding ATV riding, 4 wheel Badminton Ball hockey Baseball Bicycling

Oct Sept Jan, May , Aug Oct Feb Jan (2), Mar, Dec July, Aug (2) May, June, July (3), Aug (3), Sept, Oct (2) May, June, Aug Aug June June, July May, June, July (4), Aug June May, June Nov Jan, Mar (3), Oct, Dec June Oct Mar, May, Oct Nov Jan (8), Feb (9), Mar (7), Dec (5) Aug Apr June Feb (2), Dec (3) Jan Feb Sept (2) July June (2) July Aug, Sept Mar July Sept Sept Sept Dec Jan, Mar, Nov (2), Dec Aug Aug

Boating Camping Dirt-biking Diving Fishing Golf Horseback riding Hunting Ice hockey Motorbiking Motor, motocross biking Pellet gun use Play, rough-housing Snowmobiling

Temagami Timmins

Val Caron

Soccer Squash Swimming Tobogganing Winter, boot hockey Wrestling Fishing Waterskiing Bicycling Diving Fishing Ice hockey Motor, motocross biking Motocross biking Play, playground Rugby Skiing Snowmobiling Baseball Bicycling

Geographical Locations Where Injuries Were Sustained 97 Table 4.1 (continued ) Location b

Activity c

Month d

Warren Wawa White River Wikwemikong

Dirt-biking Ice hockey Play, playground Play, tree climbing Baseball ATV riding Fishing Bicycling

Oct Mar Dec Dec Aug Aug June Nov

North Simcoe Muskoka LHIN Bala Fishing Snowmobiling Barrie Air sports, skydiving ATV riding Baseball Bicycling Boating Boating, raft Boating, power Camping Canoeing Diving Hunting, duck Ice hockey Play, monkey bars Rugby Skiing Snowmobiling Squash Swimming Winter, boot hockey Borden Missile, blow darts Bracebridge Boating Diving Motorbiking Rugby Scuba-diving Snowmobiling Soccer Squash Carson Baseball Cassidy Lake Fishing Collingwood ATV riding Bicycling

June Dec Mar July July May, June, Aug May July July Sept May July, Nov Oct Apr, Oct Apr May (2) Jan, Feb (3), Mar (2) Jan, Feb (3) May May Jan Apr Aug, Nov July Sept May June Jan, Feb (6), Dec (2) May NA May June May Aug, Oct

98 Introduction and Overview Table 4.1 (continued ) Location b

Dorset

Dwight Elmvale Honey Harbour Horseshoe Valley Huntsville

Lake Rousseau Lavender Falls MacTier Midland

Muskoka

New Lowell Orillia

Activity c

Month d

Diving Horseback riding Personal watercraft Skiing Skiing, cross-country Swimming Tobogganing Horseback riding Snowmobiling Swimming Tennis Diving Snowmobiling Skiing ATV riding Bicycling Bicycling, 3 wheel Boating Canoeing Dirt-biking Diving Ice hockey Parachuting Play, swing Snowmobiling

Aug July Sept Jan (3), Feb (3), Mar (3) Jan July Jan, Feb July Feb (2) June Aug July Jan, Feb Dec May, July, Sept July (3) Sept July, Oct Aug Sept July Feb Mar Oct Jan, Feb (3), Mar (3), Nov, Dec Mar Sept Oct Mar Sept July Mar Feb, Aug July June, July Jan, Mar, Oct Aug June May July July, Nov Sept May, July

Tobogganing Swimming Hiking ATV riding Boating Baseball Basketball Bicycling Boating Diving Ice hockey Missile, target practice Boating Boating, power Diving Fishing Bicycling ATV riding

Geographical Locations Where Injuries Were Sustained 99 Table 4.1 (continued ) Location b

Penetanguishene Port McNicoll Port Severn Sundridge Tiny Beaches Wasaga Beach Washago Washago Beach North West LHIN Atikokan

Balmertown Crooked Lake Dawson Dorion Dryden Dyment Ear Falls Fort Frances

Fort Hope Geraldton

Hudson

Activity c

Month d

Badminton Bicycling Boating Canoeing Diving Fishing Ice hockey Motor, mountain-biking Play, ball Play, tree climbing Skiing Snowmobiling Waterskiing Snowmobiling Snowmobiling Swimming Ice hockey Personal watercraft Snowmobiling Fishing Play, playground

Jan Aug Aug (2) Aug (2) July Mar Jan Oct May July Mar Jan (2), Feb, Mar, Nov, Dec (2) Sept (3) Feb, Dec Jan July Feb July Feb June Aug

Bicycling Fishing Snowmobiling Snowmobiling Snowmobiling ATV riding ATV riding Play, playground Snowmobiling ATV riding Play, climbing Bicycling Boating Fishing Missile, archery Hunting ATV riding Fishing Hunting Fishing

May July Feb (2), Mar (2) Mar Jan Apr Sept Dec Jan, Dec Sept Sept May, Sept July, Sept July May Mar Apr July Sept NA

100 Introduction and Overview Table 4.1 (continued ) Location b

Activity c

Month d

Ignace

Boating Snowmobiling Snowmobiling Boating Boating, power Canoeing Fishing Hunting Snowmobiling

July Feb, Dec Dec May Oct Aug, Sept July, Sept May Jan, Apr (2), Nov (2), Dec (2) July, Aug June July May, June, July (2) Dec NA Aug May Aug Jan Sept July Dec (2) Oct (2) Jan June Jan Apr May June Aug June June May July Nov May, June May Mar June Jan, Mar May (3) Aug Apr

Kakabeka Kenora

Lac La Croix Lake of the Woods Longlac

Longlegged Lake Madsen Manitouwadge

Marathon Mimimiska Lake-Lake Morson Nakina Otterskin Lake Pickle Lake-Kenora

Poplar Hill Rainy River

Red Lake

Silver Lake Sioux Lookout

Swimming Water, play Boating Boating Snowmobiling ATV riding Baseball Bicycling Boating Snowmobiling ATV riding, 3 wheel Bicycling Motorbiking Hunting Snowmobiling Fishing Snowmobiling Hunting, goose Fishing Boating Fishing Swimming Canoeing Bicycling Dirt-biking Hunting Boating Fishing Ice hockey Motorcycling Snowmobiling Fishing Boating Snowmobiling

Geographical Locations Where Injuries Were Sustained 101 Table 4.1 (continued ) Location b

Activity c

Month d

Sioux Narrows Sumach Lake Terrace Bay Thunder Bay

Fishing Boating Motor, mountain-biking ATV riding Bicycling

Swimming Tobogganing Water, waterslide Windsurfing Fishing

Sept (2) June July July July (2), Aug, Sept (2), Oct Oct May Oct (8) Sept Jan, Mar, Oct Dec Nov Mar Jan Jan (4), Mar (3), Nov (2), Dec (2) July Mar, Dec Oct Aug May

Camping Canoeing Fishing Fishing Snowmobiling Canoeing Boating ATV riding Baseball Fishing Horseback riding Ice hockey Squash Swimming Swimming ATV riding Bicycling Horseback riding Ice hockey

Oct (2) Sept May May Feb Aug Aug Jan, Apr May, July May Sept Jan, Feb July July (3) July June July July Jan, Mar, Nov, Dec

Boating Canoeing Fishing Football Ice hockey Jogging Play, playground Skiing Snowboarding Snowmobiling

Winnipeg River South East LHIN Algonquin Park

Bancroft Battersea Bay of Quinte Belleville

Brighton Brockville

102 Introduction and Overview Table 4.1 (continued ) Location b

Clarendon Desoronto Frontenac County Gananoque Harrowsmith Kingston

Landsdowne Lennox/Addington

Madoc Marmora Mazinaw Lake Merrickville Napanee

North Augusta Picton

Activity c

Month d

Soccer Fishing Fishing Mountain, rock climbing Fishing Baseball Baseball Bicycling Boating Dirt-biking Diving Fishing Floor hockey Golf Horseback riding Ice hockey In-line skating Jogging Rugby Scuba-diving Skiing Snowmobiling Swimming Tobogganing Baseball Bicycling Fishing Flying Snowmobiling Baseball Hunting Hunting, duck Mountain, climbing ATV riding Play, on ice ATV riding Bicycling Fishing Mountain, rock climbing Swimming Horseback riding ATV riding Fishing Hunting, duck

June Oct May Sept Oct (3) Apr June (3), Aug July, Aug June (2), July Mar July (2) July, Oct (2) July June May Jan (2) Apr May May June Dec Feb, Dec July, Aug Jan, Mar July Oct May Apr Jan (3) May Nov Nov Aug June Nov Feb June June May June June Mar Sept Nov

Geographical Locations Where Injuries Were Sustained 103 Table 4.1 (continued ) Location b

Activity c

Month d

Rideau Lake Sandbanks Provincial Park Shannonville Shorbat Lake Smith Falls

Fishing Swimming Motorcycling Snowmobiling Baseball Soccer Snowmobiling Snowmobiling Baseball Ice hockey

July Aug May Jan Apr Apr Dec Jan

Steenburg Lake Stirling Tweed

South East LHIN/ Central East LHIN Northumberland County Fishing South West LHIN Aylmer Atwood Belmont Blyth Bruce County Byron Cabot Head Chepstow Chesley Clinton Exeter

Goderich

Hanover Ingersoll Kimberley Kincardine

Kippen

Fishing Motorcycling Bicycling Ice hockey Soccer Boating Canoeing Bicycling, mountain-biking Fishing ATV riding Play, tree climbing Ice hockey Play, indoors Baseball Dirt-biking Ice hockey Snowmobiling Baseball Golf Ice hockey Tobogganing Badminton Golf Skiing Dirt-biking Horseback riding Ice hockey Swimming Horseback riding

Dec

May

July May Apr Feb Sept Oct Sept (2) Oct Oct June Mar Dec Apr Apr Aug Jan Jan Aug Aug Feb, Apr Dec Jan June (3) Mar Sept Feb Dec Aug Oct

104 Introduction and Overview Table 4.1 (continued ) Location b

Activity c

Month d

Komoka Lions Head London

Swimming Snowmobiling ATV riding Baseball Baseball, slow pitch Bicycling

July Mar July May, July Aug Apr, May, June, July, Aug (2), Sept July Jan, Oct Oct July Jan (3), Feb (2), Apr (2), Nov (2), Dec (2) June Oct July Aug Sept Sept Jan May, Aug, Nov Jan Jan Nov July June July Feb (3) June, Aug June Oct Mar May July Sept July, Aug July Aug May Jan, Dec May May June (2) July

Diving Floor hockey Football Golf Ice hockey

Londsborough Markdale

Meaford

Mitchell Muncey Owen Sound

Paisley Port Albert Port Burwell Port Burwell Park

In-line skating Martial arts Missile, darts Play, near river Play, swing Play, tree climbing Racquetball Soccer Tobogganing Winter, ringette Wrestling Diving Air sports, hang-gliding ATV riding Snowmobiling Bicycling Hunting Play, barn Skiing Play, indoors Bicycling Baseball Bicycling Boating Diving Motorbiking Snowmobiling In-line skating Sailing Fishing Swimming

Geographical Locations Where Injuries Were Sustained 105 Table 4.1 (continued ) Location b

Activity c

Month d

Port Elgin Port Stanley Sauble Beach

Bicycling Swimming ATV riding Snowmobiling ATV riding Snowmobiling Waterskiing Diving Ice hockey Missile, target practice Baseball Badminton Diving Horseback riding Golf Ice hockey Rugby ATV riding Bicycling Camping Fishing ATV riding Air sports, gliding Bicycling Skiing, cross-country Scuba-diving Baseball Boating Canoeing Fishing Ice hockey Play, swing Snowmobiling Soccer Swimming ATV riding Hunting, rabbit Snowmobiling Snowmobiling Horseback riding Swimming Camping Bicycling

May Aug July, Oct Jan Feb Jan July Aug Jan Mar June Feb July Sept Aug Jan Oct Oct May July (2) Mar (2) July (2) Apr Mar, Aug Jan July (2) Apr June (2) Nov May, Aug, Sept May Jan Mar Sept Aug (2) Apr Feb Jan Dec Aug Aug July May

Sebringville Southampton St Mary's St Thomas

Stratford

Thamesford Thornbury Thorndale Tillsonburg

Tobermory Trenton

Walkerton

Wiarton Wingham Woodstock

106 Introduction and Overview Table 4.1 (continued ) Location b Toronto Central LHIN Don Mills Downsview East York Toronto

Activity c

Month d

Bicycling Bicycling Bicycling Air sports, gliding Ball hockey Baseball

May Aug Aug May Aug Apr (2), June (5), July (3), Aug (3), Sept Jan, Feb (2), Apr Mar (4), Apr (4), May (7), June (14), July (16), Aug (7), Sept (7), Oct (4), Nov May, July, Aug Mar, June, July (6), Aug July, Aug Jan May May, July Feb, Sept (2), Oct (2) Jan Apr Jan (6), Feb (4), Mar (4), Apr (3), May, Nov, Dec (5), NA Jan, Feb (2), July, Nov July May Jan Jan Jan Sept Sept June May, NA July June Mar July, Oct June, July June, Sept (3) Mar Mar (2), Apr, June (2), Aug, Sept, Dec (2) May, July, Oct

Basketball Bicycling

Boating Diving Horseback riding Floor, gym Floor, weight lifting Floor hockey Football Gymnastics Gymnastics, trampoline Ice hockey

Ice skating In-line skating Jogging Martial arts Miscellaneous, lacrosse Miscellaneous, road hockey Miscellaneous, stickball Missile, darts Motorbiking Pellet gun use Play Play, Frisbee Play, jungle gym Play, monkey bars Play, skipping Play, slide Play, tag Racquetball Rugby

Geographical Locations Where Injuries Were Sustained 107 Table 4.1 (continued ) Location b

Activity c

Month d

Toronto Weston

Sailing Skateboarding Skiing Soccer Soccer, indoor Squash Summer, fairgrounds Swimming Tennis Tobogganing Unidentified War games Water, play Water, water polo Wrestling Ice hockey

June, Sept (2) Mar, Sept Jan, Feb Apr, July (2), Sept Feb Jan, Apr, May, Oct (2) Aug May, July (6), Aug (2) July (3) Jan (6), Feb (3), Dec Apr Apr, May, July, Nov July Apr Oct Jan

Motor, trail-biking Air sports, parachuting Badminton Baseball Bicycling Diving Horseback riding Gymnastics Ice hockey Ice skating Swimming Ice hockey Ice hockey Hunting, deer Wrestling Bicycling Camping Diving Bicycling Boating, power Canoeing Fishing Hunting, duck Baseball Bicycling Diving

June July May June Feb, May (3), Sept May, Aug Sept, Nov May Feb, Apr, Dec Feb July Oct Nov Nov Jan Aug July Aug Nov July Apr Apr Sept June June, Aug (3) June

Waterloo Wellington LHIN Alma Arthur Cambridge

Dundalk Elmira

Elora

Erin Fergus Grand River

Guelph

108 Introduction and Overview Table 4.1 (continued ) Location b

Harriston Heidelberg Kitchener

Kitchener-Waterloo Mount Forest

New Hamburg Rockwood Waterloo

Unknown LIHN Lake Erie Lake Huron Lake Simcoe Lake Superior Unknown

Activity c

Month d

Horseback riding Football Ice hockey Martial arts, karate Motor, go-carting Personal watercraft Play, slide Tobogganing Diving Badminton Baseball Bicycling Diving Horseback riding Ice hockey Missile, darts Swimming Tennis Horseback riding Baseball Hunting Play, barn Snowmobiling Winter, broomball Air sports, skydiving Horseback riding Bicycling Football Squash

Sept May Mar Aug June Aug Feb Jan June Nov June, July, Aug May, June, Sept July Aug Nov NA July Aug Apr July Sept Nov Jan, Feb (2) Mar July (3) Sept July, Sept Oct Oct

Fishing Swimming Snowmobiling Scuba-diving ATV riding, 3 wheel Badminton Ball hockey Baseball Pellet gun use, BB gun Bicycling Billiards Boating Camping

July Aug Jan (2), Feb Aug Feb Apr NA (7) Jan Apr, Dec Feb Aug, Sept May

Geographical Locations Where Injuries Were Sustained 109 Table 4.1 (continued ) Location b

Other Provinces Quebec Aylmer Blue Sea Lake Buckingham

Gatineau

Hull

Activity c

Month d

Diving Horseback riding Fishing Floor, kick boxing Football Golf Hunting Ice hockey Ice skating Personal watercraft Racquet sports Racquetball Skiing Snowmobiling Soccer Squash Summer, tree climbing, deer spotting Tennis Tobogganing War games Waterskiing Water, water-tubing

July June May, Aug, Sept, Oct, NA July NA NA (4) July Mar, Sept, Nov, NA (12) Feb NA NA (4) NA Jan, Feb Dec Sept, NA (3) Jan, NA

Bicycling Snowmobiling ATV riding Motorbiking Snowmobiling ATV riding Bicycling Diving Horseback riding Skiing Snowmobiling Baseball Bicycling Bicycling, tricycle Dirt-biking Ice skating Motorbiking Snowmobiling

Sept Jan July, Sept July Feb Apr Apr July Sept Feb, Dec (2) Dec Apr July Apr July Aug Aug Jan

Mar NA (2) Dec NA (2) NA June

110 Introduction and Overview Table 4.1 (continued ) Location b

Maniwaki Mont Cascades Mont Laurier Mont Ste Anne Shawville St Regis Temiscaming

Wakefield Alberta Banff Lake Louise British Columbia Kamloops Whistler Northwest Territories Thor Lake Unknown First Nations

United States Arizona: Phoenix Florida Hawaii: Honolulu Illinois Maine: Lewiston Michigan: Detroit Louisiana: New Orleans New York State Buffalo Jamestown Lake Placid Rochester Watertown Wilmington Pennsylvania: Philadelphia South Carolina

Activity c

Month d

Tobogganing ATV riding Snowmobiling Skiing Snowmobiling Skiing Snowmobiling Swimming ATV riding Ball hockey Play, slide Snowmobiling Snowboarding Skiing

Feb Oct Feb, Dec Feb Feb Feb Mar July July Oct Aug Mar Mar Jan, Mar

Skiing Skiing

Apr Mar

Swimming Skiing

June Apr, Dec (2)

Fishing

July

Boating

Sept

ATV riding, 3 wheel Tennis Hiking Boating Skiing Boating Rugby Ice hockey Snowmobiling Skiing Diving Skiing Skiing Diving Fishing Skiing Ice hockey Walking

Mar Apr Sept Jan Mar Oct Feb Jan Mar, Nov Mar July July Feb June Oct Feb Apr Oct

Geographical Locations Where Injuries Were Sustained 111 Table 4.1 (continued ) Location b

Activity c

Month d

State Unknown Vermont

Skiing Skiing Skiing, cross-country

Jan Dec Jan

Skiing Water, sailboarding Water, waterslide Diving Diving Swimming Skiing Diving Motor, moped Diving Swimming Water, surfing Tobogganing

Feb Jan NA Dec Feb Dec Feb Aug (2) Mar, NA May Feb, Mar May Dec

Other Countries / Regions Austria Caribbean Caribbean, San Andres Colombia Dominican Republic Europe Greece Jamaica Mexico Switzerland

NA = not available. a Survivors and fatalities; 4 survey years (1986, 1989, 1992, 1995). b Towns or cities listed alphabetically within each Local Health Integration Network (LHIN); LHINs listed alphabetically. c Sports and recreational activities are named in the same way as in the various chapters of this book, e.g., In-line skating = Rollerblading, Roller skating; activities with less than 5 catastrophic injuries recorded were combined, with the name (shortened) for the combined activities given first, e.g., Play, monkey bars. d Where there was more than one case in a given activity in a specified month, the number of cases is given in parentheses.

other provinces are shown with the province designated after the name of the town or city, and injuries to Ontario residents while in other countries are designated by listing the name of the state in the United States or the other country where such injuries occurred. All the Ontario sites have only the name of the city or town. In approximately 70 of the 2,154 injury cases, the location where the injury occurred was not recorded by the respondent or was not known, and these are listed as ‘Unknown’ in Table 4.1. In Ontario, the Ministry of Health and Long-Term Care has recently changed its method for designating regions. In the past the province was divided geographically into six or seven districts for

112 Introduction and Overview Table 4.2 Catastrophic Sports and Recreation Injury Cases in Each Ontario Local Health Integration Network (LHIN) and No. of Ontarians Injured Elsewherea Location

No. of Cases

Local Health Integration Network Central Central East Central West Champlain Erie St Clair Hamilton Niagara Haldimand Brant Mississauga Halton North East North Simcoe Muskoka North West South East South West Toronto Central Waterloo Wellington Central/Hamilton Niagara Haldimand Brant Champlain/South East South East/Central East Unknown Other Locations Other Provinces United States Other Countries Unknown Location Total aSurvivors

73 172 22 212 106 158 61 329 164 134 99 155 229 75 3 2 1 6 45 22 16 70 2,154

and fatalities; 4 survey years (1986, 1989, 1992, 1995).

delivery of health care and for collecting data on the incidence and prevalence of diseases and injuries. Recently, the method was changed, and the ministry has replaced the geographical districts with fourteen Local Health Integration Networks (LHINs). Thus, to make the present study as useful as possible to local and provincewide administrators and ‘preventionists,’ the LHIN responsible for each injury location is presented in Table 4.1. Table 4.2 shows the total injuries for each of the LHINs and for the other locations. In six cases, the injuries occurred close to the boundary between LHINs, and therefore, both are listed.

Geographical Locations Where Injuries Were Sustained 113

Designation of the Terrain We created broad categories of terrain at the geographical locations where the catastrophic injuries occurred, such as open terrain or lakes and rivers, and assigned each injury to one of these groups to help target injury prevention efforts. The terrain on which the catastrophic injuries occurred in each sport and recreational activity is shown in Chapter 2, Table 2.9. Large Cities Many injuries occurred in large cities, including Toronto, Hamilton, Ottawa, and London. Indeed, it is noteworthy that Toronto, including its boroughs and districts of Etobicoke, Downsview, Scarborough, East York, and North York (these are listed separately in Table 4.1), accounted for only 244 or 11% of the catastrophic injuries, although this region contains approximately 20% of the population of Ontario. However, one cannot conclude that Torontonians sustained fewer injuries proportionally; it is highly likely that many Torontonians were injured while in other locations to which they had travelled for recreational activities such as skiing, boating, fishing, and snowmobiling. In the large and medium-sized cities, there was a broad spectrum of activities leading to catastrophic injury. In Barrie, for example, catastrophic injuries were sustained in bicycling, baseball, motor sports such as ATV riding and especially snowmobiling, winter sports such as hockey and skiing, and summer activities such as diving, boating, and canoeing. There were also playground injuries and injuries in baseball and rugby, but, surprisingly, no tobogganing injuries. In the city of North Bay, however, the variety of activities leading to catastrophic injury was more limited, and winter activities caused a disproportionately large number of injuries in comparison with summer activities. This breadth of activities leading to catastrophic injury in the larger cities places a major burden on municipal governments and their recreation and parks facilities and staff in terms of safety promotion and injury prevention. Many municipalities have coped with this problem by enlisting the help of voluntary, non-profit agencies such as the Red Cross and the Lifesaving Society to teach injury prevention measures, as well as school-based injury prevention programs, such as

114 Introduction and Overview

ThinkFirst and Safe Kids. Ideally, however, even small and mediumsized cities and towns should employ safety administrators to organize and utilize these safety resources. Small Cities and Towns In small cities and towns, such as Huntsville and Bracebridge, which are hosts to large numbers of visitors, there was an inordinate number of catastrophic injuries in winter sports, especially snowmobiling (nine cases of injuries in each of these locations), but also large numbers of summer injuries in connection with boating and ATV riding. Approximately half of the catastrophic injuries in Bracebridge and Huntsville were in connection with snowmobiling, and it is highly likely that many of the injured people resided elsewhere. The responsibility for providing injury prevention programs must be shared between the recreational facilities in these locations, specific associations of participants such as snowmobile clubs (e.g., the Ontario Federation of Snowmobile Clubs), the home locations of the injured individuals, and the province at large (e.g., the Ministry of Transportation). Each partner in injury prevention has a unique role to play. Remote Geographical Locations In remote locations such as Atikokan, Kenora, Hearst, Cochrane, and Espanola, the number of catastrophic snowmobiling injuries was almost at epidemic levels. These communities attract participants who reside in other areas, and they must bear some of the responsibility for making their environments as safe as possible. Local clubs, facilities operators, and the province must all play a role in injury prevention, while the safety personnel in the communities and local schools and the media where the participants live must also be involved. Resort Locations In resort towns such as Grand Bend, where there are very active waterrelated activities in the summer months, almost all of the catastrophic injuries were water related and included ones resulting from fishing, boating, swimming, and canoeing. In places such as Huntsville, which attract vacationers who participate in water activities in summer and snow activities in winter, there were very large numbers of cata-

Geographical Locations Where Injuries Were Sustained 115

strophic injuries in relation to the population. Huntsville had many boating, diving, and canoeing injuries, as well as three ATV-riding injuries and nine snowmobile injuries, as noted above. This is a good example of the need for a coordinated approach between local and provincial organizations to prevent catastrophic injury. Northern versus South-Central Ontario The majority of the catastrophic injuries in hunting occurred in northern Ontario in locations such as Rainy River and Parry Sound, while catastrophic injuries in fishing were much more evenly dispersed between northern and south-central regions. With hunting, duck hunting was the exception, in that many of the injuries occurred in southern locations such as Orangeville, Picton, Barrie, and Wallaceburg. Fishing and hunting associations with memberships involved in these activities are already playing a major role in injury prevention, and they will benefit from having these data. Racquetball and squash were primarily southern activities. Thus, specific activities will require special attention at specific locations with respect to the opportunities for injury prevention. Geographical Considerations for Activities with a High Incidence of Catastrophic Injury Bicycling and Other Wheeled Activities Bicycling injuries were common ‘big city’ problems with large numbers of catastrophic injuries in bicycling in Toronto (64 cases), Hamilton (12), Ottawa (21), and London (7). Toronto and Ottawa seem to have a particular predilection for bicycle injuries, and thus it is especially appropriate that the City of Toronto has an injury prevention program directed specifically towards reducing the incidence of bicycle-related injuries. Young males are most prone to these injuries. However, bicycling was not only a big city issue because large numbers of catastrophic bicycling injuries also occured in smaller venues such as Acton, Alliston, Kleinburg, Kitchener, and Perth. Indeed, five of the 17 catastrophic injuries in Cambridge were due to bicycling. In 1995 helmets became mandatory in Ontario for bicyclists under 18 years of age. Therefore, our data were collected primarily in the era before mandatory helmets, and it would be instructive to

116 Introduction and Overview

repeat the present study for comparison. In addition to bicycling, there is an array of other non-motorized wheeled activities that require injury prevention efforts, and these include skateboarding, in-line skating, roller skating and scooter riding. More comprehensive bicycle helmet legislation to cover all of these activities for participants of all ages is being urged by ThinkFirst in all provinces. So far Nova Scotia is the only jurisdiction with a law requiring helmets for participants of all ages in all of these street activities on wheels. Water Activities Although catastrophic water-related injuries were concentrated in resort locations, they also occurred across Ontario in both large cities and small towns. Thus, prevention efforts in these activities must involve the entire province. For example, there were many catastrophic diving injuries in Toronto (10 cases) and Hamilton (7) and other large cities. In Algonquin Park four individuals suffered catastrophic injuries, two in connection with camping, one in canoeing, and one in fishing – all four died. The two campers died after being attacked by a bear, and the fishing and canoeing deaths were drownings. Swimmers died in other provincial parks, including Rondeau and Sandbanks. In only one of the four Algonquin deaths was alcohol known to be a factor, and neither of the two drownings there occurred in July or August, and therefore hypothermia may have been a factor. Tobogganing and Sledding Catastrophic tobogganing and sledding injuries were dispersed across the province including in large cities like Toronto (10 cases) and small communities such as Uxbridge (one), Pembroke (2), Peterborough (1), and Kingston (2). It was surprising to see so many in the cities. Thus, widespread injury prevention efforts in tobogganing and sledding must be implemented in every community, and this is probably an excellent example of an activity for which the TD-ThinkFirst for Kids prevention program is eminently suitable. This program is available free of charge to every elementary school in Ontario and other provinces. Snowmobiling and Other Snow Activities Some communities seem especially prone to injuried involving certain types of snow activities. For example, six of the 10 catastrophic

Geographical Locations Where Injuries Were Sustained 117

injuries in Minden were the result of snowmobiling, as were all four catastrophic injuries in Apsley. As mentioned above, injury prevention efforts for snowmobiling must involve many groups, including snowmobile associations, communities, and the Ministry of Transportation. To reduce alpine skiing and snowboarding injuries will require efforts on the part of resort and ski-hill operators, ski and boarding instructors, and many voluntary associations, including the Canadian Ski Patrol. Schools that sponsor ‘ski days’ must enlist classroom teachers to participate in ski safety instruction. ThinkFirst’s program A Little Respect: ThinkFirst is especially suited for schools that have ski days. Baseball and Football Most of the catastrophic baseball and football injuries were concentrated in southern and central Ontario, although there were some exceptions. Injury prevention programs for these activities should be the responsibility of schools and community centres that offer these activities. Equestrian Sports Surprisingly, equestrian injuries occurred mainly in southern and central locations, although there were exceptions. For example, there were two catastrophic equestrian injuries in Sudbury. Equestrian safety is the responsibility of many, including equestrian associations, riding schools and facilities, and camps. ThinkFirst’s program The Smart Equestrian contains numerous strategies for preventing catastrophic horseback-riding injuries. Catastrophic Injuries to Ontarians While in Other Provinces Almost all the Ontarians injured in Quebec were participating in snow activities, especially skiing and snowmobiling, and these occurred in a variety of ski resort locations including the Gatineau area, Mount Ste Anne, Lakefield, and others. Similarly, several Ontarians sustained catastrophic skiing injuries at Whistler, British Columbia, and Banff, Alberta. However, there were also catastrophic injuries in other activities in other provinces including two bicycling catastrophies, one dirt-biking, and one motorbike injury sustained in Hull, Quebec.

118 Introduction and Overview

Catastrophic Injuries to Ontarians While in Other Countries Many of the catastrophic injuries sustained by Ontarians while in other countries were traffic related, especially involving bicycles, motorized scooters, motorcycles, or mopeds. Water-related sports were the other major group of activities in which Ontarians suffered catastrophic injuries while abroad. Diving into shallow, unfamiliar water was a common cause of out-of-country injuries. For example, there were four catastrophic injuries in Greece, two due to diving and two due to mopeds. The Caribbean was a frequent destination of those who returned with broken necks incurred while diving. Targeted strategies should be developed to educate Ontarians going abroad about the specific hazards of participating in these sports and recreational activities while in unfamiliar locations and environments. Airlines, travel agents, and insurers should all play a role. Fatalities and Location The incidence of fatal catastrophic injuries is higher for certain activities than for others. For example, snowmobiling had one of the highest risks of death. Thus, communities with high snowmobile injury rates would necessarily have higher fatality rates for the catastrophic injuries in their locality. For example, in Cochrane, four of the eight catastrophic injuries were the result of snowmobiling, three of them fatal. Indeed, six of the eight catastrophic injuries in Cochrane resulted in death, and these included one canoeist, two fishermen, and the three snowmobilers. Distance from a tertiary care facility may have influenced the mortality rate, but the severity of the injuries is the prime factor with respect to survival. For example, of the 64 catastrophically injured bicyclists in Toronto, 13 died, even though emergency retrieval and transfer to a well-staffed and well-equipped hospital would have been rapid.

Recto Running Head 119

5 Anatomical Locations and Types of Ontarians’ Catastrophic Injuries alun ackery and charles h. tator

In this study, the following classification of anatomical location of catastrophic injuries was used: sudden death, drowning, head, spine, eye, abdomen, chest, face, limb, and miscellaneous. It should be noted that often numerous injuries result from one traumatic event, and these are called multiple trauma cases. Our study documented all the catastrophic injuries in every event, and these ae summarized in Table 5.1 (fatalities) and Table 5.2 (survivors). Below are descriptions of each type of catastrophic injury, starting with outright deaths and then injuries that may have been fatal or not, presented in rank order according to total mentions for that injury. Sudden Death Sudden death in sports is uncommon. It tends to occur in sports in which there is a need for maximum exertion, and it is often related to an underlying abnormality in the heart or brain. Further information is given in the specific chapters in which this condition occurred most frequently, including basketball, squash, badminton, running, and track and field. Drowning Drowning is a common catastrophic injury in sports and recreation, and it is usually fatal because of the profound effects on the cardiovascular and respiratory systems. Drowning accounted for more than half of the fatalities examined in this study. The human body requires the respiratory system to take in oxygen and expel carbon dioxide

120

Introduction and Overview

Table 5.1 Anatomical Location of Injuries Sustained in Fatal Cases in 55 Sports and Recreational Activities in Ontario between 1986 and 1995a Anatomical Location of Catastrophic Injury

Activity

Head

Snowmobiling 51 Fishing 1 Bicycling 50 Swimming 1 Boating, other 6 Boating, canoeing 3 ATV riding 6 Hunting 3 Scuba-diving 1 Aircraft flying 2 Playground / play 2 Horseback riding 6 Boat, sailing Air sports 1 Camping/hiking 4 Dirt-biking 2 Parachuting Diving Water play 1 Waterskiing 1 Skiing, alpine 3 Tobogganing/ sledding 3 Summer sports, other 2 Motorbiking 2 Motor sports, other 1 Mountain climbing 1 Personal watercraft Floor sports, other 1 Ice hockey 1 Running / jogging 1 Skateboarding 1 Field sports, other Football In-line skating 1 Missile sports 1 Ice skating 1 Soccer 1 Winter sports, other 1 Air gun use

Spine 19 1 13 3 3

Drowning Eye

Abdomen Chest Face Misc. Limb

38 110 2 86 65 24 2 2 9

13 1 14

2

33 4 24

5

7 3 2 2

2 1

2 2

1

4 6 3 3 1 1

3 2

1

1

3

1

2 4

1 1

1

1

3 1

2

2

3 1 3 4 1

7 2

2

3 4 1

1

1 1

1 1 1 1 1 1

1

1 1 1 1 1

1 1 1 1

Total 165 121 112 89 76 29 18 16 14 11 10 9 7 6 6 6 6 5 5 5 4 4 3 3 3 3 3 2 2 2 2 1 1 1 1 1 1 1 0

Anatomical Locations and Types of Injuries 121 Table 5.1 (continued ) Anatomical Location of Catastrophic Injury

Activity

Head

Badminton Ball hockey Baseball Basketball Floor hockey Golf Gymnastics Martial arts Racquetball Racquet sports, other Rugby Skiing, cross-country Snowboarding Squash Tennis War games Wrestling Total 162 a

Spine

46

Drowning Eye

357

2

Abdomen Chest Face Misc. Limb

Total

48

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 754

93

7

35

4

Survivors and fatalities; 4 survey years (1986, 1989, 1992, 1995).

with the lungs acting as an interface for the body to gather oxygen from the outside environment. The act of breathing changes the air pressure inside the lungs because of contraction of the intercostal muscles and the diaphragm, and allows new air filled with oxygen to enter the lungs and carbon dioxide to be expelled from the lungs. Once the interchange has occurred, the cardiovascular system, including the heart and blood vessels, transports oxygen throughout the body. In drowning, air flow is impeded because air is replaced by water in the lungs, or in some cases, due to the sensitivity of the upper airway passages, spasm occurs in the laryngeal muscles surrounding the airways, that seals off the airways. Water entering the bloodstream often changes the blood chemistry which can cause heart failure. The shutdown of the respiratory system creates an oxygendeprived environment, and it only takes 3 to 5 minutes of oxygen deprivation for brain damage to occur, and if severe damage, fatality may occur.

122 Introduction and Overview Table 5.2 Anatomical Location of Non-fatal Catastrophic Injuries Sustained in 55 Sports and Recreational Activities in Ontario between 1986 and 1995a Anatomical Location of Injury Activity

Head

Spine

Eye

Bicycling Snowmobiling Ice hockey Diving ATV riding Baseball Skiing, alpine Tobogganning/ sledding Playground / play Boating, other Horseback riding Football Soccer Dirt-biking Golf Badminton Squash Water play Rugby Motorbiking Skating Motor sports, other Ball hockey Swimming Hunting Racquetball In-line skating Tennis Basketball Missile sports Mountain climbing Air sports Fishing Air gun use Camping/hiking Floor hockey Personal watercraft Skateboarding War games

136 46 22 8 30 23 22

37 55 46 94 15 2 18

10 8 69

28 25 9 13 6 5 8 11

14 8 12 10 9

2 6 4 6 12 6 3 1 3 7

6 1

4 7 6 2 4 1 7 1 1 1 1

5 3 1 1 1 3 6

2 3

5 40 7 3 5 1 2 13 4 20 17 3

Chest

Face

44 48 23 1 19 7 17

36 54 2 2 16 1 9

13 9 8 6 11 5 3

2 3 7 5

1 1 3

1 2

1

2

2

1

1

1

3 1

Misc.

Limb Total

36 26 37 1 7 25 6

9 14 4

7 11 1

7

3 1 1

5 6 4 5 1 6 1 2

1 2 10 1 1

1 1 6

4

1 4 2

1 3

2

2

1

1

1

9 3 11

2 9 3 10 1 4 8

1 1

Abdomen

8

1

1 1

1

1

2 3 2

1 1

1 7 2

5 1

1 1

1 1 1

1 1

1 4

1 1 1

315 262 204 106 102 99 84 67 58 55 40 32 32 22 21 20 20 19 18 17 16 15 13 13 12 12 11 11 10 10 10 9 9 9 8 8 8 8 8

Anatomical Locations and Types of Injuries 123 Table 5.2 (continued ) Anatomical Location of Injury Activity

Head

Floor sports, other 2 Snowboarding 3 Waterskiing 1 Field sports, other 3 Gymnastics 1 Martial arts 1 Running / jogging 2 Summer sports, other 2 Skiing, cross-country Racquet sports, other Wrestling 1 Boating, sailing Parachuting Winter sports, other Boating, canoeing Aircraft flying Scuba-diving Total 478 a

Spine 1 2 2 3 1 1 1 2

Eye

1 1 4 2 1 2

1 5

3 2

387

Abdomen

Chest 2 1

Face

Misc.

Limb Total

1

1 1 1

1 1

1 1

1 1 1

1 1

299

1 1

1

2

243

158

191

3

1

73

40

7 7 7 6 6 6 5 5 5 5 5 4 4 4 0 0 0 1869

Survivors and fatalities; 4 survey years (1986, 1989, 1992, 1995).

Table 5.1 shows drowning as the most frequently reported type of fatal catastrophic injury associated with sports and recreational activities and as the cause of 357 (56.5%) of the 631 fatalities examined here. The three most frequent activities where drowning occurred were fishing (110 cases), boating (89), and swimming (86). Head (Brain Injuries) The brain is the control centre for the entire body, and injuries to it can be debilitating if not fatal. Head injuries were sustained in a full quarter of the cases of fatalities. Along with controlling conscious thoughts, emotions, and actions, the brain is responsible for controlling all movements of the limbs, organs, and vital actions, such as breathing, heart rate, and blood pressure. There are many types of brain injury, and concussion is one of the most common due to a blow to the head, although violent impacts to other parts of the body can also cause a concussion. Concussions vary in severity depending on

124 Introduction and Overview

the force inflicted upon the brain. Minor concussions can cause a person to be momentarily dazed, while higher-impact concussions can cause prolonged loss of consciousness. After concussion individuals can remain alert, but they may have amnesia for events preceding and following the injury. Other symptoms include confusion, vomiting, and headaches. Simple concussions usually cause only transient effects, and therefore they were specifically excluded from the present study, except when recorded in patients with catastrophic injuries in another anatomical location. Although repeated concussions can cause permanent brain damage, which would constitute a catastrophic injury, our data-gathering methodology did not allow the capture of such cases. A skull fracture is a break in one of the bones of the skull. The broken bone can penetrate the brain and tear the surrounding arteries, veins, and meninges (protective tissue layers that surround the brain). Skull fractures are more common in certain areas of the head where the bone is thinner (e.g., around the sinuses at the front and at the back of the skull). Skull fractures can be ‘open’ (to the environment) where they are more susceptible to being exposed to infection or ‘closed,’ where the meningeal layers are not penetrated. Skull fractures can be minor, without neurological repercussions, or severe, where surgeons must operate to remove imbedded bone and/or dead tissue from the brain. These injuries may have permanent debilitating repercussions with impairment of such functions as walking, communicating, thinking, or feeling. A brain contusion is a bruise of the brain, and a brain laceration is the tearing of brain tissue. These injuries usually damage the cerebral cortex (the outermost brain layer that controls motor and sensory information) and are more severe than concussions. These injuries are the result of acceleration or deceleration impacts where the brain twists or moves within the skull and hits the skull walls. Symptoms can include loss of consciousness, confusion, dizziness, vomiting, restlessness, irritability, loss of movement and sensation in the arms and legs on one or both sides, and in extreme cases, coma. These neurological deficits are often permanent. Subdural or extradural hematomas are accumulations of blood within the skull, either external or internal to the dura, the outer membrane surrounding the brain. Hematomas can arise from contusions or lacerations of the brain and can develop within minutes or hours following injury. Hematomas create swelling and herniation of the brain,

Anatomical Locations and Types of Injuries 125

which will lead to tissue death and damage. Symptoms include paralysis on one or both sides of the body, drowsiness, memory loss, confusion, coma, and death. Many require urgent surgical removal. Table 5.1 shows head injury as the second most frequent type of fatal catastrophic injury and present in 162 (26%) of the 631 fatalities. There were 51 fatal head injuries in snowmobiling and 50 in bicycling. Head injury was the most common type of non-fatal catastrophic injury and occurred in 478 (31%) of the 1,523 participants who survived their catastrophic injuries (Table 5.2). The activities with a high incidence of head injury were bicycling (136 cases), snowmobiling (46), ATV riding (30), and tobogganing and sledding (28). Spine Spinal injuries can occur with or without damage to the spinal cord, and both types were considered catastrophic in this study. They occurred in about 20% of all cases (433 of 2,154) examined (Tables 5.1 and 5.2). The spinal cord transports information between the brain and the rest of the body. Communication involves motor and sensory information, and also the relay of information to control organs and vital functions, such as breathing. Spinal injuries vary in severity, from pain, weakness, and numbness to total paralysis, such as paraplegia (paralysis of both legs) or quadriplegia (paralysis of both arms and both legs). Spinal trauma can affect all levels of the spine, with the highest being the neck or cervical level, followed by the thoracic, lumbar, and sacral levels. Each level of the spinal cord communicates with different levels of the body, and injuries closer to the head are usually more debilitating because more areas of the body lose communication with the brain. Spinal trauma can occur in various forms. A fracture or fracturedislocation of the spinal column surrounding the spinal cord can contuse, lacerate, or compress the cord, and a herniation of an intervertebral disc can also compress the spinal cord. The severity of injury to the spine can vary from no neurological deficit to a variety of neurological deficits, including nerve root damage, transient concussion, and spinal cord injury, whether complete or incomplete. In complete spinal cord injury there is no normal neurological function below the level of injury, whereas an incomplete spinal cord injury implies partial preservation of neurological function below the level of injury,

126 Introduction and Overview

so that there would be varying degrees of retained movement or sensation below the level of injury. Table 5.1 shows that there were 46 spinal injuries among the fatalities (or in 7% of the fatal cases), and Table 5.2 shows that there were 387 among the survivors (or in 25% of the non-fatal cases). Spinal injuries were the second most common type of catastrophic injury among the survivors, and the highest incidences were associated with diving (94 cases), snowmobiling (55), hockey (46), and bicycling (37). Abdomen The abdomen contains many organs that are frequently injured such as the liver, spleen, and kidneys, and also many large blood vessels, including the aorta and inferior vena cava. There were 48 cases with abdominal injuries among the fatalities, and 243 cases among the survivors (Tables 5.1 and 5.2). In total, 291 (13.5%) of the 2,154 cases had abdominal injuries. They were especially common in cases with multiple trauma such as snowmobiling and ATV riding. Bleeding can occur from the damaged organs or blood vessels in the abdomen and can be fatal. Emergency surgery is often required to stop the bleeding. Chest The chest contains the heart and the lungs, and trauma can cause fractures of the rib cage which then compress and penetrate into the chest cavity. Chest injuries were involved in just over 10% of the cases of catastrophic injury (251 of 2,154) examined in this study, and more than one-third of chest injuries involved fatalities. A catastrophic injury can produce a crushed or flail rib cage which then damages the heart and/or lungs. A pneumothorax causes a collapsed lung, and occurs when a puncture in the lung or its outer membrane allows air to escape into a space around the lungs. As the air builds up, it collapses the lung, impairing respiratory function. A pneumothorax can be lifethreatening, and often it requires surgery. A lung contusion results from blunt trauma that bruises the lung and causes bleeding. The symptoms are shortness of breath and coughing up blood. There are varying severities of lung contusion, and they often heal quickly. Trauma that compresses the chest can cause catastrophic injury to the heart and its connecting great vessels (i.e., aorta, venae cava, pul-

Anatomical Locations and Types of Injuries 127

monary veins, and arteries). Laceration of the heart or great vessels can be fatal. Table 5.1 shows that chest injuries were the third most frequent contributing cause to death, after drowning and head injuries, and occurred in 93 (15%) of the 631 fatality cases, with the highest case numbers in snowmobiling (33) and bicycling (24). Chest injuries in these activities were also frequent (158 or 10.4%) among the survivors (Table 5.2). Eyes Traumatic injury to one or both eyes is debilitating and can lead to blindness. Impairment of one eye can diminish depth perception and visual acuity, while impairment of both eyes will change totally how individuals will function in their everyday lives. Our study classified traumatic eye injuries into the following four categories: conjunctiva, hyphema, intraocular, and other. The conjunctiva is the thin outer layer of the eye, and begins at the cornea and covers the sclera (the white part of your eye) all the way to the eyelids. In addition to protection, its role is to moisten and lubricate the eye with fluid. A hyphema is bleeding in the anterior portion of the eye. Intraocular injuries are contusions, lacerations, or punctures of the eye itself, ranging from the cornea, through the lens and all the way back to the retina. Eye injuries were frequent among the survivors, and presented in almost one-fifth of all of the cases of non-fatal catastrophic injuries. The highest incidences were in hockey (69 cases), baseball (40), and all the racquet sports, including tennis, badminton, and squash. Eye injuries were reported in two of the 631 fatal cases. Face All catastrophic facial injuries in this study involved fractures of the facial bones, except that nasal fractures alone were not considered catastrophic and were excluded. The maxillary bone involves the upper jaw and the surrounding area around the nose, and the mandibular bone is the lower jaw. An orbital fracture involves an injury to the bones that surround the eye. Catastrophic facial injuries (Table 5.2) were very common among survivors, especially injuries in hockey (37 cases), bicycling (36), and snowmobiling (26).

128 Introduction and Overview

Limbs Catastrophic limb injuries were classified into three categories: loss of a limb, whether an arm or leg; arterial injury; and major peripheral nerve or brachial plexus injury, which is a plexus of peripheral nerves innervating the arms. Simple fractures of the limbs usually heal quickly, are seldom catastrophic, and therefore, were excluded from the present study. Tables 5.1 and 5.2 indicate that catastrophic limb injuries were the least common anatomical location of the injuries recorded in this study. Miscellaneous Injuries Injuries categorized as ‘miscellaneous’ were other catastrophic injuries such as burns, near drowning, and injuries to the throat which are not individually enumerated in this study. In contrast, persons who had sustained multiple trauma, often had many other non-catastrophic injuries such as concussions, and limb injuries, which were listed in the tables but not considered catastrophic in themselves. The presence of multiple injuries adds to the seriousness of certain activities such as snowmobiling, ATV riding and the use of power boats.

Canoeing 129

SECTION 2 Water Sports

This page intentionally left blank

Recto Running Head

131

6 Canoeing yusra ahmad and charles h. tator

Canoeing traces its origins to the dawn of human culture with the earliest canoes dating from 6000 B.C. North America was a fertile ground for the development of canoes, with indigenous peoples building them from a frame of wooden ribs covered with the lightweight bark of birch trees, and sometimes elm or cedar. Canoes were meant to be light, streamlined, and easy to manoeuvre through the rapids in the rivers of the North American wilderness. European settlers and voyageurs adapted indigenous peoples’ canoes for their needs. With the building of transcontinental railways, however, the commercial role of the canoe eroded, although canoeing as a sport continued to develop. Today, canoeing remains popular, in Ontario and many other provinces. We found that 100% of the catastrophic injuries associated with canoeing were fatal, 27 over the 4 survey years in this study (Table 6.1). This troubling statistic will be explored further in the following pages. Indeed, canoeing accounted for almost one in 20 (4.3%) of all the fatalities in sports and recreation during the study period (Chapter 2, Table 2.6). The McLaren Report indicates that the participation rate in canoeing in Ontario was 1.7% or 174,603 participants in 1995, and this figure was used for each of the 4 survey years (1986, 1989, 1992, and 1995). We estimated that there were 101,460 Ontario males and 77,967 Ontario females who participated in canoeing each year (Table 6.2). Incidence of Injuries Although more males participated in canoeing and kayaking than females, the overall injury rate was slightly higher for females (1.22%

132 Water Sports Table 6.1 Catastrophic Canoeing Injuries: No Survivors and 27 Fatalities, by Age and Gendera (% in parentheses)

Females Males Total

Ageb (years) 11–20 21–30 31–40 41–50 51–60 Total a b

Males 5 9 4 4 3 25

(18.5) (33.3) (14.8) (14.8) (11.1) (92.6)

Fatalities

Total

2 (7.4) 25 (92.6) 27 (100.0)

2 (7.4) 25 (92.6) 27 (100.0)

Females 2

(7.4)

2

(7.4)

Total 7 (25.9) 9 (33.3) 4 (14.8) 4 (14.8) 3 (11.1) 27 (100.0)

Data are from the surveys conducted in 1986, 1989, 1992, and 1995. Age (years) of injury victims: mean, 30.6; median, 27.0; minimum, 15; maximum, 56.

vs 1.59%), according to the McLaren Report. Our study showed a striking difference between the genders, in that 25 of 27 of the canoeing victims were males (Table 6.1). The overall annual number of catastrophic canoeing injuries was 6.75, with 6.25 involving males and 0.5 involving females (Table 6.2). The overall annual catastrophic injury rate, indicating the proportion of canoeists who sustained a catastrophic injury in any given year, was 0.004% (0.006% males, 0.001% females). The demographical details of the 27 catastrophic injury victims are as follows (Table 6.1): none under the age of 11 years (0%), seven in the 11–20 age group (25.9%), nine in the 21–30 group (33.3%), four in the 31–40 group (14.8%), four in the 41–50 group (14.8%), and three in the 51–60 group (11.1%). There were no injuries reported for canoeists above the age of 60. Thus, the incidence of catastrophic injuries in canoeing was higher among younger to middle-aged participants. The two fatally injured females were both between the ages of 11 and 20, while the age of the injured males ranged between 11 and 60. In general individuals who sustained catastrophic injury in canoeing were young, with a median age of 27 years (Table 6.1). There were 9 deaths due to fishing from a canoe, and these were classified as deaths due to fishing rather than canoeing (see Chapter 10).

Canoeing 133 Table 6.2 Canoeing in Ontario: Participation, Injuries, and Fatalities, 1986–1995 Participants – Estimated Annual

Number

Rate (%)

Overall Males Females

177,684 102,982 75,367

1.73 2.03 1.45

Injury Cases, All Types – Estimated Annual

Number

Rate (%)

2,408 1,237 1,238 1.0

1.38 1.22 1.59

4 Surveys

Annual

27 25 2 12.5 0.28%

6.75 6.25 0.5

4 Surveys

Annual

27 25 2

6.75 6.25 0.5

Overall Males Females Ratio of Males to Females Catastrophic Injury Cases (Number of Fatal and Non-Fatal) Overall Males Females Ratio of Males to Females As Proportion of Cases of All Injury Types (Cat and Non-Cat) Fatalities Only (Number) Overall Males Females Risk Analysis of Catastrophic Injuries 1 Personal Risk as % of Participants Overall Males Females 2 Personal Risk per 100,000 Participants Of Catastrophic Injury, Fatal or Non-Fatal Of Fatality 3 Population Risk per 100,000 Population Of Catastrophic Injury, Fatal or Non-Fatal Of Fatality

Source: See Chapter 1 for Method and Explanation of Calculations.

Annual % 0.004 0.006 0.001 /100,000 3.87 3.87 /100,000 0.066 0.066

134 Water Sports Table 6.3 Catastrophic Canoeing Injuries – Anatomical Location and Type, 27 Cases (All Fatal) Anatomical Location

Fatalities

Head Drowning Miscellaneous Total

3 24 2 29

Head – Injury Type Concussion Skull fracture Brain contusion / laceration Other Total

1 2 2 1 6

Note: Each entry indicates the number of cases in which this type of injury occurred. Persons may have had more than one injury.

Nature and Acquisition of Injuries Several types of injuries may arise from canoeing, ranging from mechanical injuries (that arise from biomechanical stress on muscles and joints from the action of paddling), environment-related injuries, workshop-induced injuries, and catastrophic submersion injuries (like drowning which are often correlated with alcohol consumption). All of these will be discussed briefly with a focus on catastrophic injuries (Tables 6.3 and 6.4). Mechanical Injuries Canoeing differs from rowing in that the lower part of the body is often held in an immobile position. The paddler often sits with legs held apart, in order to maximize stability. Such a position can create added strain on the lower back, and the back and pelvis are two of the most commonly injured body parts in canoeists.1 When paddling, the canoeist utilizes the paddle blade to catch the water’s surface and turn it into a fulcrum. A propulsive force is generated along the stretcher board, causing the boat to be impelled forward. A succession of joints contributes to the generation and transmission of the propulsive force. Electromyographical kinesiology studies have demonstrated that, in canoeing, this force is created by shoulder extension and a twist of the

Canoeing 135 Table 6.4 Catastrophic Canoeing Injuries – Whether Preventable, Alcohol-Related, or Incurred in a Supervised Setting (% in parentheses) Yes Was injury preventable? Was injury alcohol related? Was activity supervised?

19 7 2

No (95) (39) (12)

1 11 15

(5) (61) (88)

Note: As reported by the primary physician involved in the case. Data given are for cases with information provided, and therefore may not encompass all catastrophic injury cases in this sport or recreational activity.

trunk. Consequently, the bulk of the stress created by the paddling motion is put on the shoulder, elbow, and back.2 The shoulder is particularly subjected to a repetitive and powerful force, especially when paddling unilaterally and with a single-bladed paddle. Anterior glenohumeral subluxation often occurs, with attendant rotator cuff tendonitis and ultimately, even, subacromial impingement. On radiographical examination in one study,3 spondylolysis was evident in 17.5% of the canoeists examined, and ballooning discs in the 3rd to 5th lumbar vertebrae were visible in 85.7%. Of 417 respondents to a sports injury questionnaire administered by the Japan Canoe Association,3 94 canoeists (22.5%) reported that they had experienced lumbago and 20.9% complained of shoulder pain, while another 14.6% suffered from elbow and wrist pain. Excessive and repetitive wrist motions are commonplace in canoeing. The resulting injury often involves the wrist flexors or extensors of both hands, and is associated with a flexed or extended wrist during the pull phase of the stroke. Of 510 canoeists, 117 (23%) complained of tenosynovitis.4 Water and wind conditions have a significant impact on the risk of tendon injury. Blowing winds and choppy waters with high swells have been correlated with an increased incidence of tenosynovitis; however, the level of conditioning and skill at balancing the canoe with decreased hyperextension of the wrist were found to significantly reduce such injuries.4 Submersion Injuries In our study, 24 of the 27 cases of catastrophic canoeing injuries involved drowning. Data from the United States for 1981–85 indicated that about half of the people involved in boating-associated drowning

136 Water Sports

fatalities had a blood alcohol content level (BAC) of 40 mg% and about 30% a BAC of over 100 mg%.5,6 According to one study,7 alcohol use is particularly deadly while canoeing because it increases the probability of submersion, and it also lessens the odds of survival should submersion occur. Once an impaired person enters the water, the ability to stay above water is reduced and the risk for hypothermia is increased. Alcohol impairs judgment, slows reflexes, and decreases balance – all of which exacerbate the severity of the situation. Even a simple capsizing of the canoe in still waters can be fatal. This ‘double jeopardy’ suggests that alcohol use on board a watercraft is even more perilous than it is on land and that ‘even low BACs greatly increase relative risk.’7 Others have described the features of a prototypical canoe fatality.8,9 Usually, the victim is a young male (below the age of 30 years), who is intoxicated and dies of drowning on calm and still waters in the afternoon or evening. Inexperience in boating is often a factor.8 In our study, the 24 canoeing injuries that involved drowning were all fatal. The other fatalities resulted from head injuries including skull fractures, and brain contusions or lacerations incurred when the boat capsized or the paddler fell overboard. Environment-Related Injuries Some of the worst injuries occur when inexperienced canoeists attempt to paddle in waters beyond their skill where both water and weather conditions are unfavourable. White water rapids and whirlpools have been especially deadly sites. One study7 reported 20 fatalities that resulted from the submersion of a vessel that had entered a whirlpool; typically, the canoeist failed to extricate himself or herself from the danger zone before becoming exhausted or drowned. Six other cases were classified as ‘hydrocution,’ a cardiac arrest or ventricular fibrillation resulting from the mechanical impact of the capsized canoe and the shock of immersion in cold water.7 Workshop Injuries Finally, the materials used by canoeing enthusiasts to repair vessels may cause injury. Polystyrene and fibreglass resins can cause headaches, corneal irritation, and eczematous skin rashes. Frequent use of these kinds of materials has manifested as renal or hepatic damage, leucopenia, and even carcinogenesis.

Canoeing 137

Severity of Injuries All 27 of the reported catastrophic injuries in canoeing were fatal. This striking statistic may be attributable to limitations in our data collection. It is highly likely that some non-fatal catastrophic injuries went unreported because the type of craft may not have been noted in the hospital or coroner’s record. Regardless of the probable under-reporting of non-fatal catastrophic injuries, the numbers still reveal that canoeing can be a very dangerous sport. Increased focus on the nature of the injuries and the manner of their acquisition is warranted so that we can better elucidate how these injuries might be prevented. Injury Risk Factors A multiplicity of factors can increase the risk of catastrophic canoeing injury, including the canoeist’s gender. As mentioned earlier, the likelihood of males sustaining a catastrophic injury greatly exceeds that of females. In many sports and recreational activities, males engage in more risk-taking behaviour than females do. Age also poses a risk, with young to middle-aged adults being more likely to suffer injury. This probably reflects the increased prevalence of alcohol consumption by people in this age group. It might also be attributable to increased recklessness commonly associated with the younger age bracket. Other risk factors include the absence of safety equipment on board canoes, paddling alone, weather and water conditions, inexperience, lack of conditioning, and poor paddling technique. Canoeists should always wear a personal flotation device (PFD).9 There should be legislation against alcohol consumption during canoeing. Developing and using a standardized sobriety test for aquatic activities such as canoeing should be encouraged.10 Injury Prevention Tips • • • • • •

Do not canoe alone. Ropes should be carried in order to pull up someone in the water. Always wear a PFD while canoeing. Canoe only under fair weather conditions. Practise muscle-strengthening exercises. Obtain training in proper canoe handling.

138 Water Sports • Know how to swim well. • Support public education aimed at changing acceptance of drink-

ing alcohol while canoeing. • Alcohol and safe canoeing do not mix. • Ensure a safe workshop environment with proper ventilation

during canoe repair. References 1. MSN Encyclopedia Encarta. Canoeing. 2007. http://encarta.msn.com/encyclopedia_761580512/Canoeing.html. 2. Kumamoto M, Okamoto T. Kinesiological and electromyographical studies on the Canadian canoe pair paddling. Res Rep Sports Med Sci 1988;99–110. 3. Kameyama O, Shibano K, Kawakita H, Ogawa R, Kumamoto M. Medical check of competitive canoeists. J Orthop Sci 1999;4(4):243–9. 4. du Toit P, Sole G, Bowerbank P, Noakes TD. Incidence and causes of tenosynovitis of the wrist extensors in long distance paddle canoeists. Br J Sports Med 1999;33(2):105–9. 5. Mengert P, DiSario R. A Study of the Relationship between the Risk of Fatality and Blood Alcohol Concentration of Recreation Boat Operators. Washington, DC: U.S. Deptartment of Transportation, U.S. Coast Guard, 1992. 6. Hoxie P, Cardosi K, Stearns M, Mengert P. Alcohol in Recreational Boating Accidents. Washington, DC: U.S. Coast Guard, 1988. 7. Smith GS, Keyl PM, Hadley JA, Bartley CL, Foss RD, Tolbert WG, et al. Drinking and recreational boating fatalities: A population-based casecontrol study. JAMA 2001;286(23):2974–80. 8. Copeland AR. Non-commercial, accidental water transport (boating) fatalities. Z Rechtsmedizin 1986;96(4):291–6. 9. Plueckhahn VD. Death by drowning? Geelong 1959 to 1974. Med J Aust 1975;2(24):904–6. 10. Shephard RJ. Science and medicine of canoeing and kayaking. Sports Med 1987;4(1):19–33.

Recto Running Head

139

7 Sailing pemma muzumdar

Sailing continues to increase in popularity as both a sport and recreational activity. Regions such as the Caribbean, Australia, the Mediterranean basin of Europe, and the North American coasts attract millions of sailors, especially during the summer months.1 In Canada marine activities on the east and west coasts have shown steady growth. There is also a great deal of sailing activity in the country’s numerous inland lakes and rivers. In 2000 Canada was reported to have 3.5 million recreational boats, with almost 20% of them in British Columbia.2 Sailing injuries result from a lack of proper safety equipment, alcohol consumption, inexperience, carelessness, and bad weather conditions. Of course, drowning is the most disastrous catastrophic consequence of a sailing mishap. Other examples of sailing injuries include finger fractures, rope burns and abrasions, contusions, and head injury.1,3–5 Boom strikes are the main cause of head injuries, and involve the beam or boom that rotates the sail. During an uncontrolled jibe (rotation), the boom moves unexpectedly, and the sail is shifted to the other side of the boat. This usually occurs when the boat changes direction while sailing down wind. Ideally, a jibe should be performed with greater control, with the crew leader calling ‘jibing or tacking’ to ensure that the individuals on board lower their heads to avoid a potentially catastrophic injury.1,3,6,7 Recreational sailing can be highly pleasurable and relaxing. However, during any water-related activity, precautions must be taken to avoid preventable injuries. Safety measures can decrease the risk of fatality due to hypothermia and drowning. This chapter discusses the eight catastrophic injuries in sailing identified in the present study (Table 7.1), and offers prevention strategies for safer sailing.

140 Water Sports Table 7.1 Catastrophic Sailing Injuries: 1 Survivor and 7 Fatalities, by Age and Gendera (% in parentheses) Survivors Females Males Total

1

(12.5)

1

(12.5)

Ageb (years) < 11 11–20 21–30 41–50 51–60 Total a b

Males

1 2 1 1 5

(12.5) (25.0) (12.5) (12.5) (62.5)

Fatalities 2 5 7

(25.0) (62.5) (87.5)

Total 3 5 8

Females 1 1 1

(12.5) (12.5) (12.5)

3

(37.5)

(37.5) (62.5) (100.0) Total

1 2 3 1 1 8

(12.5) (25.0) (37.5) (12.5) (12.5) (100.0)

Data are from the surveys conducted in 1986, 1989, 1992, and 1995. Age (years) of injury victims: mean, 29.0; median, 26.0; minimum, 6; maximum, 58.

Incidence of Injuries Participation rates for sailing in Ontario were presented in the McLaren Report, and are as follows: 41,083 out of 10,270,754 Ontarians, for an overall participation rate of 0.40%; of these, 20,292 were males and 20,791 were females (Table 7.1). However, the overall, male and female injury rates in sailing were not available from the McLaren data, and neither were other estimates of the incidence of sailing injury in Canada available in the literature. In Ontario, during the 4 survey years (1986, 1989, 1992, and 1995) used in our study, there were a total of eight catastrophic injuries reported, yielding an annual catastrophic injury incidence of 2, and resulting in an overall annual catastrophic injury rate of 0.005% of participants (Table 7.2). Seven of the eight catastrophic injuries were deaths due to drowning, and the eighth involved the loss of a limb (Table 7.3). There were 4.868 catastrophic injuries per 100,000 participants each year. Five of the eight catastrophic injury victims were males, and three were females; the resulting annual incidence for male catastrophic injury was calculated as 1.25, compared with 0.75 for females. According to the Canadian Red Cross,8 recreational boating accounts for 76% of all boating injuries, while occupational boating is responsible for 11% of all boating injuries. The age group of 30–50

Sailing 141 Table 7.2 Sailing in Ontario: Participation, Injuries, and Fatalities, 1986–1995 Participants – Estimated Annual

Number

Rate (%)

Overall Males Females

43,137 22,828 20,271

0.42 0.45 0.39

Injury Cases, All Types – Estimated Annual

Number

Rate (%)

0 0 0 NA

0.00 0.00 0.00

Catastrophic Injury Cases (Number of Fatal and Non-Fatal)

4 Surveys

Annual

Overall Males Females Ratio of Males to Females As Proportion of Cases of All Injury Types (Cat and Non-Cat)

8 5 3 1.67 100%

2 1.25 0.75

4 Surveys

Annual

7 5 2

1.75 1.25 0.5

Overall Males Females Ratio of Males to Females

Fatalities Only (Number) Overall Males Females Risk Analysis of Catastrophic Injuries 1 Personal Risk as % of Participants Overall Males Females 2 Personal Risk per 100,000 Participants Of Catastrophic Injury, Fatal or Non-Fatal Of Fatality 3 Population Risk per 100,000 Population Of Catastrophic Injury, Fatal or Non-Fatal Of Fatality

Annual % 0.005 0.006 0.004 /100,000 4.87 4.26 /100,000 0.019 0.017

Source: See Chapter 1 for Method and Explanation of Calculations.

years has been identified as the one most likely to sustain injuries due to recreational boating.7,9 In our study 62.5% of the catastrophic injuries due to sailing were sustained by individuals aged 11–30. In the

142 Water Sports Table 7.3 Catastrophic Sailing Injuries – Anatomical Location and Type, 8 Cases Anatomical Location

Survivors

Drowning Miscellaneous Limb Total

3 1 4

Limb – Injury Type Loss of limb Total

1 1

Fatalities

Total

7

7 3 1 11

7

1 1

Note: Each entry indicates the number of cases in which this type of injury occurred. Persons may have had more than one injury.

11–20 age group, males and females each sustained 12.5% of the injuries, for a total of 25%. In comparison, males aged 21–30 sustained 25% of the injuries, whereas females in the same age group sustained only 12.5% of the injuries (Table 7.1). As previously noted, seven of the eight catastrophic sailing injuries were due to drowning. Research conducted by the Canadian Red Cross,8 partly during the same years as our survey, found that the rate of drowning associated with boating in general had decreased, but that associated specifically with sailing had actually increased. With respect to sailing, there were 0.01 drownings per 100,000 population per year between 1991 and 1995. During the following study period of 1996–2000, this number increased to 0.02 drownings per 100,000 population per year. The Red Cross also found that 4% of all drownings in recreational boating were associated with a sailboat or sailboard, compared with 37% associated with a small open powerboat. Overall, drowning was found to be the leading cause of death for recreational and sporting activities, and the fourth most common cause of death due to unintentional injury in Canada. Nature and Acquisition of Injuries The U.S. Coast Guard9 reported that sailboats, along with motorboats and personal watercraft, are responsible for the highest number of hospital admissions among all recreational boaters. The most frequently reported injuries included lacerations, contusions, broken

Sailing 143

bones, head injury, and back injury; the month of December poses the highest risk for sailing injuries in the United States, due in large part to the increased risk of developing hypothermia during the winter months.7,9 Common injuries related to recreational sailing include fractures, lacerations, contusions, abrasions, and strains due to falls, rope burn, or collisions, and lumbar strain.1,3–5,7,10 As noted above, head injury from boom strikes has the potential to be catastrophic. Indeed, a blow to the head by the boom is considered to be the most dangerous type of sailing injury.3 The prevention of hypothermic injury is also important. Hypothermia occurs when a person is sailing under wet, windy, and cold conditions. Immersive hypothermia can result from falling into cold water.11,12 In our study, drowning was the dominant injury, responsible for seven of eight catastrophic injuries; four were in May, one in June, none occurred in July, one in August, and two in September. Thus, May and June, when in Ontario the water is much colder than during the summer months of July and August, saw the majority of the catastrophic injuries, most of which were due to drowning. In an Australian youth sports survey, head injuries were the most common type of non-immersion injury in sailing.13 A German study3 found hand injuries to be most common, accounting for more than a quarter of 86 sailing-related injuries; head injuries accounted for 22%, and fractures 15%. Although in the German study injuries to the hand were more common than injuries to the head, boom strikes were identified as the most common cause of sailing injury overall.3 In contrast, in competitive sailing, knee and back injuries are more prevalent than hand or head injuries.4,5,10 In a study by Shephard,5 45% of sailing injuries were to the lower back, and 22% to the knee. Allen4,7,10 studied competitive female sailors and found that 24% of their injuries were lower back strains, while 16% were rotator cuff tendonitis (inflammation of the tendons in the shoulder). Allen4,10 also observed that injuries in competitive sailors are most often due to overuse; in contrast, recreational sailing injuries are most often due to inexperience and improper safety conditions.3,7,12 Injury Risk Factors Failing to wear a personal floatation device (PFD) while sailing poses a high risk of drowning. According to the Canadian Red Cross,8 most boaters who drowned did not wear a PFD properly, if at all: Between

144 Water Sports Table 7.4 Catastrophic Sailing Injuries – Whether Preventable, Alcohol-Related, or Incurred in a Supervised Setting (% in parentheses) Yes Was injury preventable? Was injury alcohol-related? Was activity supervised?

5 4 0

(100) (67) (0)

No 0 2 6

(0) (33) (100)

Note: As reported by the primary physician involved in the case. Data given are for cases with information provided, and therefore may not encompass all catastrophic injury cases in this sport or recreational activity.

1991 and 2000 only 11% to 12% of recreational boaters who drowned were wearing a PFD properly; it was also noted that drowning victims from boating who were non-swimmers were no more likely to wear a PFD than those capable of swimming. A 1998 study by the U.S. Coast Guard7,9 found that 508 of 815 drownings could have been prevented with the proper use of a PFD; it also found that in eight out of 10 boating fatalities the victims had not been wearing a PFD. Additional risk factors for recreational sailing injury include alcohol consumption, inexperience, overconfidence, inadequate physical condition, and not having a proper operator or boat lookout (Table 7.4). The U.S. Coast Guard study7,9 found that 88% of boating fatalities occurred on boats where the operator was not qualified (defined as not having taken a complete boating safety course). In an article Nikolic1 commented that recreational sailors are sometimes referred to as ‘weekend sailors’ because they often lack the strength and physical training necessary to operate heavy sailing equipment. Thus, inadequate physical condition can predispose recreational sailors to injury.1,4,5 Also, sailors, and indeed, boaters in general, are at risk for unattended or delayed attendance by medical personnel for medical emergencies such as heart attacks. Alcohol consumption has been found to be among the most common causes of sailing injuries, although precise numbers are not available. In Canada it is illegal to have a blood alcohol content level (BAC) of more than 80 mg% while boating.2,8 Canadian research8 has found that, between 1996 and 2000, in 23% of all cases of boating drownings BACs were above the legal limit, and alcohol involvement was suspected in another 7% A study by the U.S. National Transporta-

Sailing 145

tion Board7 found alcohol consumption to be involved in 32%–64% of recreational boating fatalities; boating safety guides caution that three drinks on shore are equivalent to one drink on a boat because of fatigue, the effects of sun and wind, and the motion of the boat. Alcohol impairs judgment and decreases reaction time. Alcoholrelated boating injuries are often sustained while boarding or leaving the boat. Alcohol can also cause falls into the water and, by extension, hypothermia and drowning. A person who has consumed alcohol develops hypothermia more easily than one who has not, and can become unconscious. Without a PFD, the risk of drowning due to alcohol consumption is higher.8,11,12 In our study, information relating to alcohol consumption was reported in six of the eight cases of catastrophic injuries in sailing (Table 7.4) – alcohol was involved in four of them, and all four were drownings. Injury Prevention Tips Sailing will always have inherent risks because of potentially unfavourable interactions with the water, weather conditions, and other boats. However, the risk of drowning, hypothermia, and other injury can be greatly decreased by employing the following prevention strategies. What to Wear • A properly fitted personal flotation device (PFD) should be worn

at all times, rather than simply being kept on board the boat. Once someone falls into the water, it is very difficult to put on a PFD properly. This is especially true if the water is cold or if darkness has decreased visibility. • Shoes must be worn to protect the feet from falling objects and other possible injury. Special sailing boots can be purchased. • Sunglasses, a hat, and sun block should be worn to ensure protection from the sun and to maintain optimum visibility. • If sailing in cold and wet conditions, warm dry layers of clothing and a windproof jacket help to prevent heat loss and hypothermia. If sailing in the spring, autumn, or in otherwise difficult conditions, consider wearing a hypothermia-protective flotation garment.

146 Water Sports

Before Sailing • The boat should be checked to ensure that it is in good working

order. • Check the weather forecast and the wind strength. If the wind

exceeds 30 km/hour, only experienced sailors should be on the water. • Check the people you are sailing with about their ability to swim, and about their level of strength and physical fitness. Ask if they have any special medical conditions or allergies. • Assign someone to be the lookout for possible obstructions and environmental problems. • Discuss the possibility of boom strikes with the crew. Decide who will call ‘jibing’ and ‘tacking’ and practise ducking your heads to avoid the boom. In the literature, helmets have been suggested to protect sailors during boom strikes. General Safety • Avoid alcohol consumption to maintain proper judgment, reaction

•

• • • • •

• • •

time, and body temperature. Alcohol interferes with an individual’s ability to properly operate a sailboat and increases the risk of hypothermia. The legal BAC limit in boating is 80 mg%. The boat operator should have taken a boating safety course and should have experience operating a sailboat, especially if the others on board are inexperienced sailors. Be sure to sail with other passengers, as there is safety in numbers. A rope should be towed behind the boat, so that someone who has fallen overboard can pull themselves back up if necessary. Practice ‘man overboard’ procedures to maximize recovery strategies. Think ahead about the management of acute medical conditions on board such as heart attacks. Stay hydrated by drinking enough water before and after sailing. Dehydration can produce disorientation and increase the risk of injury. Try to sail within sight of others. Keep a working radio and a first aid kit on board the boat. Check for changing weather conditions regularly.

Sailing 147

References 1. Nikolic N. Sailing safely. J Travel Med 2001;8(6):309–18. 2. Fisheries and Oceans Canada. Recreational Boating. http://www.pac .dfo-mpo.gc.ca/oceans/Policy/boatfact_e.htm. Retrieved 16 July 2004. 3. Chalmers D, Morrison L. Epidemiology of non-submersion injuries in aquatic sporting and recreational activities. Sports Med 2003;33(10): 745–70. 4. Allen JB. Sports medicine and sailing. Phys Med Rehabil Clin N Am 1999;10(1):49–65. 5. Shephard RJ. Biology and medicine of sailing: An update. Sports Med 1997;23(6):350–6. 6. Parts of a Sailboat. http://www.sailfree.com/. Retrieved 20 July 2004. 7. Shipshape for Sailing. http://physicaltherapy.about.com/library/ weekly/aa043001g.htm. Retrieved 15 July 2004. 8. Canadian Red Cross. What We Have Learned: 10 Years of Pertinent Facts about Drownings and Other Water-Related Injuries in Canada. 2003. http://www.redcross.ca/cmslib/general/10drwn_english.pdf 9. U.S. Coast Guard. Boating Safety. http://www.uscgboating.org/. Retrieved 14 July 2004. 10. Allen JB. SailSportMed: Injuries in Sailing. http://www.sailsportmed .org/html/95_a3_study.htm. Retrieved 13 July 2004. 11. Around the World of Sailing: Boating First Aid Primer. 2003. http://www.torresen.com/sailing/content_archives/000443.php. Retrieved 20 July 2004. 12. Canadian Coast Guard. Canada’s Safe Boating Guide. http://www .ccg-gcc.gc.ca/obs-bsn/sbg-gsn/main_e.htm. Retrieved 16 July 2004. 13. Sporting Injuries in NSW: New South Wales Youth Sports Injury Report 1997. http://www.youthsafe.org/injury/sport.htm. Retrieved 15 July 2004.

Recto Running Head 148

8 Personal Watercraft douglas j. cook and charles h. tator

The personal watercraft (PWC) industry began in the late 1960s with the first commercially available Seadoo® from Bombardier. This initial offering was not popular, and it was not until the 1970s when the Kawasaki Jet-Ski® was introduced that the PWC became a common public pastime. The Bombardier model required the passenger to sit while driving, whereas Kawasaki incorporated sitting and standing positions. The current PWC industry has several manufacturers with different models available, including sitting or standing models and single or multiple user models for up to four people. PWC are powered by a jet of water generated by the inflow of water through a vent in the front of the vessel. The water is pressurized by an impeller mounted in a conical cylinder and then expelled from the rear of the vessel as a jet. Many privately owned PWC have top speeds approaching 100 km/hour. Directional control of the PWC is achieved by rotating the water jet using handlebars. Hence, at low speeds, when the water jet is at low pressure, the vehicle is difficult to manoeuvre. This situation puts PWC operators at high risk for collision, as quick deceleration and/or braking is not possible, and as the PWC decelerates it becomes harder to steer away from the direction of motion. There are an estimated 1.4 million PWC in private ownership in the United States today. In 2003, in the United States 80,600 units were sold with a total retail value of U.S. $716,501,760. It appears that the popularity of PWC operation is peaking, with a large proportion of North Americans using privately owned and/or rental PWC each year. A national review of PWC injuries in the United States by Branche et al. estimated that there were 32,954 PWC injuries between 1990 and

Personal Watercraft 149 Table 8.1 Catastrophic Personal Watercraft Injuries: 5 Survivors and 2 Fatalities, All Males, by Agea (% in parentheses) Survivors Males Total

5 5

Ageb (years) < 11 11–20 21–30 31–40 Total a b

(71.4) (71.4)

Fatalities 2 2

Males 1 4 1 1 7

(14.3) (57.1) (14.3) (14.3) (100.0)

(28.6) (28.6)

Total 7 7

(100.0) (100.0)

Total 1 4 1 1 7

(14.3) (57.1) (14.3) (14.3) (100.0)

Data are from the surveys conducted in 1986, 1989, 1992, and 1995. Age (years) of injury victims: mean, 28.9; median, 27.0; minimum, 18; maximum, 47.

1995, representing a fourfold increase in the number of injuries in this period. Participants sustained a majority of lower limb injuries (34.4%), with head injuries the second most common (29.1%). Individuals aged 15 to 44 (median age, 25) years represented 86% of the injured, and males accounted for 75% of the victims. Incidence of Injuries In our study of the years 1986, 1989, 1992, and 1995, there were seven catastrophic injuries due to PWC, all males, including two fatalities (Table 8.1). The highest number of injuries were in the 21–30 age group, with four injuries, and there was one each in the age groups 11–20, 31–40, and 41–50 years. Table 8.2 indicates that the McLaren Report did not include the participation and overall injury rates in Ontario for PWC use in 1995, and thus we cannot calculate the relative risk factors from participation data. However, the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP)2 reported a cumulative incidence of 10 PWC injuries per 100,000 population per year between 1990 and 1997, and 7% of them met the criteria of catastrophic injury. The CHIRPP found that 35% of those with PWC injuries required minor treatment, 35% required medical follow-up after discharge from the hospital emergency department, and 29% required hospital admission.

150 Water Sports Table 8.2 Personal Watercraft Use in Ontario: Participation, Injuries, and Fatalities, 1986–1995 Participants – Estimated Annual

Number

Rate (%)

NA NA NA

NA NA NA

Number

Rate (%)

NA NA NA NA

NA NA

Catastrophic Injury Cases (Number of Fatal and Non-Fatal)

4 Surveys

Annual

Overall Males Females Ratio of Males to Females As Proportion of Cases of All Injury Types (Cat and Non-Cat) (%)

7 7 0 All Males NA

1.75 1.75 0

Fatalities Only (Number)

4 Surveys

Annual

2 2 0

0.5 0.5 0

Overall Males Females Injury Cases, All Types – Estimated Annual Overall Males Females Ratio of Males to Females

Overall Males Females Risk Analysis of Catastrophic Injuries 1 Personal Risk as % of Participants Overall Males Females 2 Personal Risk per 100,000 Participants Of Catastrophic Injury, Fatal or Non-Fatal Of Fatality 3 Population Risk per 100,000 Population Of Catastrophic Injury, Fatal or Non-Fatal Of Fatality

Source: See Chapter 1 for Method and Explanation of Calculations.

Annual % NA NA NA /100,000 NA NA /100,000 0.017 0.005

Personal Watercraft 151

Nature and Acquisition of Injuries Table 8.3 shows the type of injury sustained in the seven cases examined in this study. Due to multiple injuries in some victims, there were 11 types of injuries: three to the head; two each to the eyes and abdomen; one each to the spine, chest, and face; and one drowning. Head and Face Garri et al.3 reviewed all admissions for watercraft injuries to two Miami hospitals over a 5-year period; there were 74 injuries in 41 patients. The injuries included three varieties of watercraft: 50.6% PWC, 48.1% powerboats, and 1.2% airboats. The injuries sustained by PWC riders were not isolated in the data. From the entire cohort, there were 24 facial fractures, 18 facial lacerations, 14 closed-head injuries, 8 skull fractures, 4 scalp lacerations, 4 cervical spine fractures, one ear laceration, and one death. Swinburn4 reported six major injuries in Australia between 1990 and 1995, including two major head injuries, resulting in death and in the other case the patient remained in a persistent vegetative state. Gieron et al.5 reported a case in which a 16-year-old female passenger of a PWC made contact with pylons which resulted in bilateral leg fractures and a head injury involving diffuse axonal injury that required 3 months for recovery to baseline cognitive function. Haan et al.6 described the pattern of injury in 24 Maryland patients between 1996 and 2001, 54% of whom had brain injury, and found that collision and fall was the predominant mechanism of injury. Spine and Spinal Cord In the Maryland study,6 30% of the patients had spinal injury – two cervical, two thoracic, one thoraco-lumbar, and two lumbar – and all occurred following wave jumping causing axial loading. The Australian study4 included two spinal injuries, one fatal, and another fatality from a high cervical injury was reported by Carson and Martin7 in a 9-year-old passenger thrown from a PWC. Collision with outstretched ropes has also caused major cervical spinal injuries.8,9 Other Injuries Kim et al.8 reviewed 62 PWC-related injuries in San Diego area hospitals, including 17 chest injuries, eight with unilateral and two with

152 Water Sports Table 8.3 Catastrophic Personal Watercraft Injuries – Anatomical Location and Type, 7 Cases Anatomical Location

Survivors

Head Spine Drowning Eye Abdomen Chest Face Total

3 1

Fatalities

1 2 1 1 8

1 1 3

Total 3 1 1 2 2 1 1 11

Head – Injury Type Skull fracture Subdural / extradural hematoma Other Total

2 1 1 4

2 1 1 4

Spine/Cord – Injury Level Cervical Total

1 1

1 1

Spine/Cord – Injury Type Fracture only Total

1 1

1 1

Spine/Cord – Injury Severity No neurological deficit Total

1 1

1 1

Face – Injury Type Maxillary fracture Mandibular fracture Total

1 1 2

1 1 2

Eye – Injury Type Other Total

2 2

2 2

Abdomen – Injury Type Liver Intestine Pelvic fracture Total Chest – Injury Type Pneumothorax Lung contusion Total

1 1

1

1

1

1 2

1 1 2

1 1 2

Note: Each entry indicates the number of cases in which this type of injury occurred. Persons may have had more than one injury.

Personal Watercraft 153

bilateral pneumothoraces; abdominal injuries included two liver lacerations, four kidney injuries, three splenic ruptures, and one rectal wall laceration. One patient died of a bowel injury related to the jet being projected towards the rectum.10 In the San Diego study,8 50% of the fractures involved the lower extremities; there were nine femur fractures, three hip fractures, three tibia-fibula fractures, and one patellar fracture. Fatalities In the present study, there were seven catastrophic injuries involving personal watercraft recorded in the 4 survey years, and two of these there were fatalities. Both events involved collisions of PWC at high speeds. The first fatally injured participant, who was not wearing a personal flotation device (PFD), collided with a submerged log, was thrown from the machine, and died of hypothermia and drowning. The second involved two PWC operators riding in close proximity to each other who collided, and one rider died of unspecified cause. Four deaths were reported in the other studies cited above, including two involving high cervical spine dislocation: one in a patient with an unstable cervical fracture and severe head injury (autopsy suggested that the high cervical dislocation was the ultimate cause of death) and one from sepsis as a result of a rectal wall rupture. Severity of Injuries Only one of the studies11 reviewed reported the Injury Severity Score (ISS) for PWC-related injury. The majority of the injuries were low in severity, as suggested by White and Cheatham,11 who reported that 78% of the injured were released from the emergency department and 22% required hospitalization. The mean ISS for discharged patients was 3 versus 13 for hospitalized patients. White and Cheatham also reported an ISS of 8 versus 5 for tourists versus local residents and 9 versus 4 for children versus adults. These results suggest that inexperienced and young PWC operators have more severe injuries. Branche et al.1 calculated that there were 8.5 times more injuries seen in emergency departments from PWC compared with traditional motorboats; however, 15% of motorboat injuries required hospitalization with only 3% for PWC injuries. This suggests that PWC use results

154 Water Sports

in more frequent injury but of lesser severity when compared with conventional motorboat use. However, with the overwhelming popularity of PWC the absolute number of patients with serious PWCrelated injury is greater than the number with motorboat-related injury. Injury Risk Factors Age and experience have been identified as risk factors for PWC injury severity, although there are no definite data linking these factors to an increased incidence of injury. Mandatory educational programs, licensing, and age limitations are all legislative actions that may be important components of an injury prevention initiative for PWC users. In our study, comments about preventability accompanied three of the seven cases and all three were deemed to be preventable (Table 8.4). Of the four with information about supervision, only one occurred in a supervised setting. Alcohol and drug use among PWC operators has the potential to increase the likelihood of an injury occurring. Table 8.4 shows that in our study we did not have evidence of alcohol consumption as a factor in any of the three cases in which this information was available. However, alcohol is reported to be a contributing factor in only one of the reports reviewed in this chapter, which also described the protective effects of personal flotation devices.12 Injury Prevention Tips The American Academy of Pediatrics, Committee on Injury and Poison Prevention has very good recommendations for the prevention of PWC injury,13 and the following are adapted from their report. • No one younger than 16 years of age should operate a PWC. • The operator and every passenger must wear an approved per-

sonal flotation device. • Alcohol or other drug use should be avoided before and while

operating PWC. • Participation in a safe boater course with specific information

about PWC should be required before operating a PWC. • Safe operating practices, such as no operation between sunset and

Personal Watercraft 155 Table 8.4 Catastrophic Personal Watercraft Injuries – Whether Preventable, AlcoholRelated, or Incurred in a Supervised Setting (% in parentheses) Yes Was injury preventable? Was injury alcohol-related? Was activity supervised?

3 0 1

(100) (0) (25)

No 0 5 3

(0) (100) (75)

Note: As reported by the primary physician involved in the case. Data given are for cases with information provided, and therefore may not encompass all catastrophic injury cases in this sport or recreational activity.

• •

• • •

•

sunrise, no wake jumping, and observing posted speed limits or no-wake zones, should be followed. (No-wake zone means the craft speed is slow enough that no wake is formed behind the craft as it crosses a specific area.) PWC should never be operated where swimmers are in the water. If a PWC is being used to tow another person on skis, knee boards, tubes, or other devices, a second person must face the rear to monitor the person being towed. All persons who rent PWC should be required to comply with these recommendations. Protective equipment such as wetsuits, gloves, boots, eyewear, and helmets may be appropriate. Communities should pass legislation that supports the previously mentioned recommendations. Included in such legislation should be funding to support adequate enforcement of regulations such as alcohol consumption, speed limits, and the use of personal flotation devices. There should be additional research into appropriate protective equipment and modification of PWC to improve safety.

The Canadian Coast Guard requires the following minimum safety equipment for PWC operation:14 • One Canadian-approved personal flotation device or lifejacket of

appropriate size for each person on board. • One buoyant heaving line of not less than 15 m in length. • A watertight flashlight or three Canadian-approved flares of Types

A, B, or C.

156 Water Sports • A sound-signalling device or a sound-signalling appliance. • Navigation lights that meet the applicable standards set out in the

Collision Regulations if the pleasure craft is operated after sunset and before sunrise or in periods of restricted visibility. The Canadian Coast Guard and PWC manufactures strongly advise against operating at night. • One manual propelling device or an anchor with not less than 15 m of cable, rope, or chain in any combination. • One bailer or one manual water pump fitted with or accompanied by sufficient hose to enable a person using the pump to pump water from the bilge of the vessel over the side of the vessel. • One Class 5BC fire extinguisher. This equipment is not mandatory if all people on the PWC are wearing a Canadian-approved personal flotation device of appropriate size. References 1. Branche CM, Conn JM, Annest JL. Personal watercraft-related injuries: A growing public health concern. JAMA 1997;278(8):663–5. 2. CHIRPP. Injuries Associated with Personal Powered Watercraft. 1999. http://www.phac-aspc.gc.ca/injury-bles/chirpp/injrep-rapbles/jetski_e .html. Retrieved 10 August 2005. 3. Garri JI, Perlyn CA, Johnson MJ, Mobley SR, Shatz DV, Kirton OC, et al. Patterns of maxillofacial injuries in powered watercraft collisions. Plast Reconstr Surg 1999;104(4):922–7. 4. Swinburn EE. Serious injuries in jet skiers. Med J Aust 1996;165(11–12): 606–9. 5. Gieron MA, Korthals JK, Riggs CD. Diffuse axonal injury without direct head trauma and with delayed onset of coma. Ped Neurol 1998;19(5): 382–4. 6. Haan JM, Kramer ME, Scalea TM. Pattern of injury from personal watercraft. Am Surg 2002;68(7):624–7. 7. Carson HJ, Martin JJ. Death from atlanto-occipital dislocation in a boy due to personal water craft collision. J Clin Forensic Med 2002;2:189–91. 8. Kim CW, Smith JM, Lee A, Hoyt DB, Kennedy F, Newton PO, et al. Personal watercraft injuries: 62 patients admitted to the San Diego County trauma services. J Orthop Trauma 2003;17(8):571–3. 9. Davies G, Leighton S, Hayward R, Spitz L. Jet-ski injury: Severe blunt neck trauma with survival. J R Soc Med 2001;94(8):402–3. 10. Descottes B, Lachachi F, Moumouni I, Durand-Fontanier S, Geballa R.

Personal Watercraft 157

11. 12.

13.

14.

Rectal injury caused by personal watercraft accident: Report of a case. Dis Colon Rectum 2003;46(7):971–3. White MW, Cheatham ML. The underestimated impact of personal watercraft injuries. Am Surgeon 1999;65(9):865–9. Jones CS. Drowning among personal watercraft passengers: The ability of personal flotation devices to preserve life on Arkansas waterways, 1994–1997. J Ark Med Soc 1999;96(3):97–8. American Academy of Pediatrics, Committee on Injury and Poison Prevention. Personal watercraft use by children and adolescents. Pediatrics 2000;105(2):452–3. Canadian Coast Guard, Office of Boating Safety. Minimum required safety equipment: Personal watercraft. In: Safe Boating Guide. Ottawa: Transport Canada, 2005, 34–5. http://www.tc.gc.ca/marinesafety/ TP/TP511/menu.htm.

Recto Running Head 158

9 Other Boating Activities pemma muzumdar and charles h. tator

This chapter includes boating activities other than canoeing, sailing, and the use of personal watercraft. Recreational boating is often enjoyed as a relaxing activity, but boating also entails considerable risk of injury. To ensure that boating remains pleasurable, precautions must be taken to avoid injury. Safety measures such as abstaining from alcohol use and wearing a personal floatation device (PFD) decrease the risk of fatality from drowning and hypothermia. Non-fatal catastrophic injuries, such as the loss of a limb because of a propeller strike, can also be prevented. This chapter discusses injuries associated with recreational boating, and offers prevention strategies. Incidence of Injuries Participation rates and injury rates for boating were not available from the McLaren data. In Ontario, during the survey years used for our study (1986, 1989, 1992, and 1995), there were a total of 112 reported catastrophic injuries in boating (Table 9.1), yielding a total annual incidence of 28 injuries. There were 0.273 catastrophic injuries per 100,000 population. A total of 93 of the 112 catastrophic injuries in our study involved males, while 19 involved females (Table 9.1). The resulting annual incidence for male catastrophic injury is 23.25, compared with 4.75 for females (Table 9.2). Recreational boating is responsible for 76% of all boating injuries in Canada, with occupational boating accounting for 11%.1,2 The age group of 30–50 years has been identified as most likely to sustain injuries while recreational boating. In our study, 35.5% of the boating (other) injuries were sustained by individuals aged 31–50 years. Indi-

Other Boating Activities 159 Table 9.1 Other Catastrophic Boating Injuries: 40 Survivors and 72 Fatalities, by Age and Gendera (% in parentheses) Survivors Females Males Total

12 28 40

Ageb (years) < 11 11–20 21–30 31–40 41–50 51–60 61–70 71–80 Total

(10.7) (25.0) (35.7) Males

2 15 14 19 16 14 9 2 91

(1.8) (13.6) (12.7) (17.3) (14.5) (12.7) (8.2) (1.8) (82.7)

Fatalities 7 65 72

(6.3) (58.0) (64.3)

Total 19 93 112

Females 3 4 6 3 1 1 1

(2.7) (3.6) (5.5) (2.7) (0.9) (0.9) (0.9)

19

(17.3)

(17.0) (83.0) (100.0) Total

5 19 20 22 17 15 10 2 110

(4.5) (17.3) (18.2) (20.0) (15.5) (13.6) (9.1) (1.8) (100.0)

a

Data are from the surveys conducted in 1986, 1989, 1992, and 1995. Age (years) of injury victims: mean, 36.7; median, 36.5; minimum, 5; maximum, 74. Missing information for two participants. b

viduals under the age of 11 sustained 4.5% of the injuries; ages 11–20, 17.3%; ages 31–40, 20%; ages 41–50, 15.5%; ages 51–60, 13.6%; ages 61–70, 9.1%; and ages 71–80, 1.8% (Table 9.1). The average age of the victims was 36.7 years, and the age range was 5–74 years. Individuals with catastrophic boating injuries tended to be older than those with catastrophic injuries in canoeing and sailing and, indeed, older than in most other sports and recreational activities (see Chapter 2). During our 4 survey years, 72 of the 112 catastrophic injuries were fatal (65 males, 7 females; Table 9.1). Thus, the annual number of fatalities in males and females was 16.25 and 1.75, respectively; the fatality rate per 100,000 population was 0.175 (Table 9.2). Of the 72 fatalities, 65 (90%) were due to drowning (Table 9.3). According to the Red Cross,2 37% of all recreational boating drownings in Canada are associated with small open power boats, 6% with large powerboats, and 12% with powerboats of unspecified size. Injuries associated with other types of boats account for a smaller proportion of drownings, with 4% associated with a rowboat and 3% associated with a kayak. One study5 found that in drowning, boating

160 Water Sports Table 9.2 Other Boating Activities in Ontario: Participation, Injuries, and Fatalities, 1986–1995 Participants – Estimated Annual

Number

Rate (%)

NA NA NA

NA NA NA

Number

Rate (%)

NA NA NA NA

NA NA NA

4 Surveys

Annual

Overall Males Females Injury Cases, All Types – Estimated Annual Overall Males Females Ratio of Males to Females Catastrophic Injury Cases (Number of Fatal and Non-Fatal)

Overall Males Females Ratio of Males to Females As Proportion of Cases of All Injury Types (Cat and Non-Cat) (%) Fatalities Only (Number) Overall Males Females

112 93 19 4.9 NA

28 23.25 4.75

4 Surveys

Annual

72 65 7

18 16.25 1.75

Risk Analysis of Catastrophic Injuries 1 Personal Risk as % of Participants Overall Males Females 2 Personal Risk per 100,000 Participants Of Catastrophic Injury, Fatal or Non-Fatal Of Fatality 3 Population Risk per 100,000 Population Of Catastrophic Injury, Fatal or Non-Fatal Of Fatality

Source: See Chapter 1 for Method and Explanation of Calculations.

Annual % NA NA NA /100,000 NA NA /100,000 0.273 0.175

Other Boating Activities 161

was the most common prior activity; it was also reported that boating was associated with 20% of all drownings of individuals who were between the ages of 15 and 64 years. Boating is the main water-related activity to be complicated by hypothermia, which was a contributing factor in 19% of all drownings in boating incidents between 1991 and 2000. Hypothermia was also the primary cause of death in 34% of nondrowning boating deaths. When recreational boaters die of hypothermia, the condition is difficult to diagnose after death, and therefore, it is likely that current figures underestimate the actual incidence of hypothermia-related drownings. Overall, in Canada, drowning is the leading cause of death in recreational and sporting activities, and the fourth most common cause of death due to unintentional injury.2 In our study, drowning was the third most common cause of catastrophic injury, after head and spine injury (see Chapter 2). Propeller strikes also play a part in boating injuries. A U.S. Coast Guard study4,6 of 4,442 boating injuries, 171 involved propellers. In another series, propeller injury caused traumatic amputations in four out of 235 children.7 Head injury often occurs following a propeller injury, and is responsible for 40% of fatalities after a propeller strike.8 Nature and Acquisition of Injuries The most frequent injuries in recreational boaters include lacerations, contusions, broken bones, head injury, and back injury,4 and these are due to a variety of mechanisms in different forms of recreational boating, generally because of one or more of the following factors: falls, hypothermia, collisions with other boats, propeller strikes, and the overuse of body parts.8 In our study, in addition to drowning, many types of boating injuries were present, including injuries to the head, spinal cord, face, abdomen, chest, and limbs. The 15 cases of head injuries sustained consisted of concussions, skull fractures, brain contusions, and lacerations, and subdural and extradural hematomas. The 15 cases with injuries to the spine included fractures and dislocations, and among the nine chest injury cases were pneumothorax and lung contusions. Further information on injury types and sub-types can be found in Table 9.3. Propellers can cause multiple injuries such as deep lacerations, traumatic or surgical amputation (loss of a limb), or death. Three catastrophic boating injuries in our study involved the loss of a limb in

162 Water Sports Table 9.3 Catastrophic Injuries in Other Boating Activities – Anatomical Location and Type, 112 Cases Anatomical Location

Survivors

Fatalities

Total

Head Spine Drowning Eye Abdomen Chest Face Miscellaneous Limb Total

9 12 0 1 8 7 4 10 4 55

6 3 65

15 15 65 1 8 9 4 10 4 131

Head – Injury Type Concussion Skull fracture Brain contusion / laceration Subdural / extradural hematoma Other Total

2 4 2 3 1 12

2 3 1 2

Spine/Cord – Injury Level Cervical Thoracic Thoraco-lumbar Sacral Total

4 1 3 2 10

2

Spine/Cord – Injury Type No bony injury Fracture only Fracture / dislocation Total

2 5 1 8

Spine/Cord – Injury Severity No neurological deficit Concussion, transient Total

6 2 8

Face – Injury Type Maxillary fracture Mandibular fracture Orbital fracture Total

2 1 3 6

2

76

8

4 7 3 5 1 20

3

6 1 4 2 13

1 1 2

2 6 2 10

1

1 1

7 2 9

2 1 3 6

Other Boating Activities 163 Table 9.3 (continued ) Anatomical Location

Survivors

Fatalities

Total

Eye – Injury Type Conjuctiva Other Total

1 1 2

1 1 2

Abdomen – Injury Type Kidney Pelvic fracture Other Total

2 4 1 7

2 4 1 7

Chest – Injury Type Pneumothorax Hemothorax Lung contusion Heart / great vessel Crushed / flail Other Total Limb – Injury Type Loss of limb Brachial plexus / peripheral nerve Total

4 1 2 1 4 12

3 1 4

1 1 1 1 4

5 1 3 1 2 4 16

3 1 4

Note: Each entry indicates the number of cases in which this type of injury occurred. Persons may have had more than one injury.

three individuals. The continuous rotation of the propeller coupled with the forward movement of the boat can cause injuries of high severity. Deep lacerations and traumatic amputations are examples. A study in Texas9 investigated 13 cases of propeller interaction, consisting of three fatal and 10 non-fatal injuries. All of the fatalities occurred in individuals who were not wearing a PFD; after falling into the water, each suffered a propeller strike and drowned. In this series, the average age of the victims was 26 years, and nine of the 13 individuals were males. The authors concluded that propeller injuries occur most often after falls from a boat, or when one is climbing on or off the boat.

164 Water Sports

Finally, injury due to hypothermia is a particular concern for Canadian boaters, as water temperatures can remain below 10o Celsius in both the spring and autumn. There were 51 injuries in the warm water months in Ontario (July and August), and thus, more than half of the 112 injuries occurred in the cold water months as follows: February, two; April, one; May, 11; June, 20; September, eight; October, 11; and November, eight. Thus, hypothermia is a significant factor in boating deaths in Ontario. Injury Risk Factors The two most important modifiable risk factors for boating injury are the non-use or misuse of a PFD, and the consumption of alcohol (Table 9.4). Other risk factors include the failure to follow basic boating safety rules and recommendations, and hypothermia. The U.S. Coast Guard study3,4 found that 88% of boating fatalities occurred on boats where the operator was not qualified with a complete boating safety course. In Ontario, new regulations have been introduced concerning the use of powerboats and the upgrading of the skills and education of boaters. The Canadian Red Cross identified standing up in boats and overloading as risk factors for recreational boating injury. In Canada, most boaters do not wear a PFD properly, if at all. Between 1991 and 2000, of recreational boaters who drowned only 11%–12% were wearing a PFD properly; it was also noted that drowning victims in boating who were non-swimmers were no more likely to wear a PFD than were those who were experienced swimmers.2 The U.S. Coast Guard found3,4 that 508 of 815 (62%) drownings could have been prevented with the proper use of a PFD and that eight out of 10 boaters who drowned were not wearing a PFD at all. In our study, information relating to alcohol consumption was reported for 75 of the 112 catastrophic injuries cases (Table 9.4), and alcohol was involved in 31 (41%) of them. Among these 31, there were five survivors and 26 fatalities. In Canada, it is illegal to have a blood alcohol (BAC) level of more than 80 mg% while boating.1,2 Canadian research has found that between 1996 and 2000, 23% of all boaters who drowned had BACs above the legal limit, and alcohol involvement was suspected in another 7%.2 A Washington-based study5 found that adults, rather than adolescents, had the highest proportion of drownings associated with alcohol use; the authors reported that in the age group 20–34 years, 33% of drownings were associated with alcohol

Other Boating Activities 165 Table 9.4 Catastrophic Boating Injuries – Whether Preventable, Alcohol-Related, or Incurred in a Supervised Setting (% in parentheses) Yes Was injury preventable? Was injury alcohol-related? Was activity supervised?

62 31 3

(85) (41) (4)

No 11 44 64

(15) (59) (96)

Note: As reported by the primary physician involved in the case. Data given are for cases with information provided, and therefore may not encompass all catastrophic injury cases in this sport or recreational activity.

consumption compared with 13% in the 15–19 age group. A study by the U.S. National Transportation Board3 found alcohol to be involved in 32%–64% of recreational boating deaths.3 Boating safety guides caution that three alcohol-containing drinks on shore is equivalent to one drink while on a boat because of fatigue, sun, wind, and the motion of the boat.3,10 Alcohol impairs judgment, reaction time, and coordination.2,10–12 Smith et al.13 found that alcohol increases the risks of collision, falling overboard, and developing hypothermia and that these risks were the same for both passengers and operators, regardless of whether the boat was in motion. Several studies mention that Aboriginal populations are at a higher risk of incurring injuries in recreational boating.2,12 In fact, in some Aboriginal communities the number of boating fatalities due to drowning exceeds the number of motor vehicle fatalities. Aboriginal populations are thought to be at risk of sustaining boating injuries because of their high rates of alcohol consumption and their extremely low rates of PFD use.12 Injury Prevention In 1999, the Canadian Coast Guard (CCG) introduced new legislation concerning recreational boating. If a pleasure craft is equipped with a motor, the operator must carry proof of competency on board at all times. According to this legislation, a boat operator of a motorized pleasure craft must take a CCG-accredited test to obtain a Pleasure Craft Operator Card. For more information visit http://www.tc.gc.ca/ BoatingSafety, Transport Canada’s website for boating safety. This is an important step in reducing catastrophic injury in boating.

166 Water Sports

The risk of catastrophic injury in recreational boating can be decreased by employing the following prevention strategies. Injury Prevention Tips • Take a course on boating competence and safety, accredited by the

CCG. What to Wear • A properly fitted PFD should be worn at all times, rather than

simply being kept on board the boat. Once someone falls into the water, it is very difficult to put on a PFD properly. This is especially true if the water is cold or if darkness has decreased visibility. • Parents should be informed that they are important role models for their children. If parents wear PFDs, rather than just keep them on board without wearing them, children will be more likely to wear a PFD. • Sunglasses, a hat, and sun block should be worn to ensure protection from the sun, and to maintain optimum visibility. • When boating in cold and wet conditions, warm dry layers of clothing and a windproof jacket help to prevent heat loss and hypothermia. Before Boating • The boat should be checked to ensure that it is in good working

order. • Check the weather forecast and the wind strength. • Check the people you are boating with about their ability to swim.

Ask if they have any special medical conditions or allergies. • Assign someone to be the lookout for possible obstructions and

environmental problems. • Have your boating licence and qualifications up to date.

Prevent Propeller Injuries • Keep the boat away from swimming and diving areas. • Ensure that passengers are seated before taking off in the boat.

Other Boating Activities 167 • Do not start a boat with the engine already in gear. • Do not allow passengers to ride on the seat back or bow.

General Safety • Avoid alcohol consumption to maintain proper judgment, reaction

• • • • •

• •

time, and proper body temperature. Alcohol interferes with an individual’s ability to properly operate a boat, and increases the risk of hypothermia. The legal BAC limit in boating is 80 mg%. The boat operator should have taken a current boating safety course. Do not stand up in the boat, especially while it is moving at high speeds. Do not overload the boat with more people than it was designed for. Check for changing weather conditions regularly. Stay hydrated by drinking enough water before and after boating. Dehydration can cause disorientation and put a boater at a higher risk of injury. Try to keep your boat within sight of the water police or other local boating authorities. Keep a working radio and a first aid kit on board the boat.

References 1. Fisheries and Oceans Canada. Recreational Boating. http://www.pac .dfo-mpo.gc.ca/oceans/Policy/boatfact_e.htm. Retrieved 16 July 2004. 2. Canadian Red Cross. What We Have Learned: 10 Years of Pertinent Facts About Drownings and Other Water-Related Injuries in Canada. Canadian Red Cross 2003. http://www.redcross.ca/cmslib/general/10drwn _english.pdf 3. Shipshape for Sailing. http://physicaltherapy.about.com/library/weekly /aa043001g.htm. Retrieved 15 July 2004. 4. U.S. Coast Guard. Boating Safety. http://www.uscgboating.org/. Retrieved 14 July 2004. 5. Quan L, Cummings P. Characteristics of drowning by different age groups. Inj Prev 2003;9(2):163–8. 6. U.S. Centers for Disease Control and Prevention. Boat-propeller-related injuries – Texas, 1997. JAMA 1998;279(23):1858.

168 Water Sports 7. Loder RT. Demographics of traumatic amputations in children: Implications for prevention strategies. J Bone J Surg [Am] 2004;86-A(5):923–8. 8. Chalmers D, Morrison L. Epidemiology of non-submersion injuries in aquatic sporting and recreational activities. Sports Med 2003;33(10): 745–70. 9. U.S. Centers for Disease Control. Boat-propeller-related injuries – Texas, 1997. MMWR 1998;47(17):354–6. 10. Canadian Coast Guard. Canada’s Safe Boating Guide. http://www .ccg-gcc.gc.ca/obs-bsn/sbg-gsn/main_e.htm. Retrieved 16 July 2004. 11. Around the World of Sailing: Boating First Aid Primer. 2003. http://www.torresen.com/sailing/content_archives/000443.php. Retrieved 20 July 2004. 12. Chochinov A. Alcohol ‘on board,’ man overboard – boating fatalities in Canada. CMAJ 1998;159(3):259–60. 13. Smith GS, Keyl PM, Hadley JA, Bartley CL, Foss RD, Tolbert WG, et al. Drinking and recreational boating fatalities: A population-based casecontrol study. JAMA 2001;286(23):2974–80.

Recto Running Head 169

10 Fishing yusra ahmad and charles h. tator

If people concentrated on the really important things in life, there’d be a shortage of fishing poles. Doug Larson

In both Canada and the United States, fishing ranks as the second most popular water sport, surpassed only by recreational swimming.1 Ontario, in particular, has the distinction of having the largest freshwater fishery in Canada, and indeed, one of the largest in the world. What distinguishes fishing from other sports is its appeal and accessibility to all ages, ethnoracial groups, and socioeconomic backgrounds.1,2 School-aged youngsters who can swim can partake in the pleasures of fishing on an almost equal footing with seniors. Basic fishing does not require extravagant equipment, specialized training, or extra physical conditioning. In spite of factors that seemingly render fishing a more accessible and egalitarian sport than some other leisure activities, fishing remains a male-dominated sport. Unfortunately, the passive and relaxed picture that fishing evokes is deceptive because in our study fishing resulted in the second greatest number of fatalities (117 cases or 18.5% of all fatalities; Table 10.1), second only to snowmobiling (Chapter 2). The McLaren Report reveals that the fishing participation rate in Ontario was 2.8% or 287,581 participants in 1995, a figure that in this study was used for all four survey years (1986, 1989, 1992 and 1995); 233,357 of the participants were males while 57,175 were females, for a male-to-female ratio of 4 (Table 10.2).

170 Water Sports Table 10.1 Catastrophic Fishing Injuries: 9 Survivors and 117 Fatalities, by Age and Gendera (% in parentheses) Survivors Females Males Total

2 7 9

Ageb (years) < 11 11–20 21–30 31–40 41–50 51–60 61–70 71–80 > 80 Total

(1.6) (5.6) (7.1) Males

2 14 20 25 22 11 15 6 1 116

(1.6) (11.4) (16.3) (20.3) (17.9) (8.9) (12.2) (4.9) (0.8) (94.3)

Fatalities 5 112 117

(4.0) (88.9) (92.9)

Total 7 119 126

Females 1

(0.8)

2 2 2

(1.6) (1.6) (1.6)

7

(5.7)

(5.6) (94.4) (100.0) Total

3 14 22 27 24 11 15 6 1 123

(2.4) (11.4) (17.9) (22.0) (19.5) (8.9) (12.2) (4.9) (0.8) (100.0)

a

Data are from the surveys conducted in 1986, 1989, 1992, and 1995. Age (years) of injury victims: mean, 40.3; median, 38.0; minimum, 5; maximum, 84. Missing information for three participants.

b

Incidence of Injuries The rate of all types of injuries in fishing in males was 0.54% of participants, and in females the rate was much lower (0.43%; Table 10.2). We found the same trend with respect to catastrophic injuries. Over the 4 survey years, 119 of the 126 catastrophic injuries involved males while only seven involved females (Table 10.1). The total annual catastrophic injury incidence was 31.5 (29.75 for males and 1.75 for females), and the total annual catastrophic injury rate was 0.011% (0.013% for males and 0.003% for females). Among all of the fishing injuries, 2.54% were catastrophic, and this was one of the highest levels for all activities. There were 10.95 catastrophic injuries per 100,000 participants per year (Table 10.2). The 126 catastrophic injuries occurred among all age groups (Table 10.1): three in the under 11 years age group (2.4%), 14 in the 11–20 group (11.4%), 22 in the 21–30 group (17.9%), 27 in the 31–40 group (21.9%), 24 in the 41–50 group (19.5%), 11 in the 51–60 group (8.9%), 15

Fishing 171 Table 10.2 Fishing in Ontario: Participation, Injuries, and Fatalities, 1986–1995 Participants – Estimated Annual

Number

Rate (%)

Overall Males Females

284,450 236,401 55,096

2.77 4.62 1.06

Injury Cases, All Types – Estimated Annual

Number

Rate (%)

Overall Males Females Ratio of Males to Females

1,240 1,255 0 All Males

0.43 0.54 0.00

Catastrophic Injury Cases (Number of Fatal and Non-Fatal)

4 Surveys

Annual

Overall Males Females Ratio of Males to Females As Proportion of Cases of All Injury Types (Cat and Non-Cat)

126 119 7 17.0 2.54%

31.5 29.75 1.75

4 Surveys

Annual

117 112 5

29.25 28 1.25

Fatalities Only (Number) Overall Males Females Risk Analysis of Catastrophic Injuries 1 Personal Risk as % of Participants Overall Males Females 2 Personal Risk per 100,000 Participants Of Catastrophic Injury, Fatal or Non-Fatal Of Fatality 3 Population Risk per 100,000 Population Of Catastrophic Injury, Fatal or Non-Fatal Of Fatality

Source: See Chapter 1 for Method and Explanation of Calculations.

Annual % 0.011 0.013 0.003 /100,000 10.95 10.17 /100,000 0.307 0.280

172 Water Sports Table 10.3 Catastrophic Fishing Injuries – Anatomical Location and Type, 126 Cases Anatomical Location

Survivors

Fatalities

Total

Head Spine Drowning Eye Abdomen Chest Face Miscellaneous Limb Total

1

1 1 110

3 1 121

2 1 110 4 3 4 1 4 1 130

1 1

1 1 2

Spine/Cord – Injury Level Thoracic Total

1 1

1 1

Spine/Cord – Injury Type Fracture / dislocation Total

1 1

1 1

Head – Injury Type Subdural / extradural hematoma Other Total

4 2 1 1 9

1 4

1 1

Face – Injury Type Mandibular fracture Total

1 1

1 1

Eye – Injury Type Hyphema Other Total

2 3 5

2 3 5

Abdomen – Injury Type Spleen Liver Total Chest – Injury Type Pneumothorax Hemothorax Heart / great vessel Other Total

2 2

1 1

2 1 3

1 1 3 1 6

1 1 3 1 6

Note: Each entry indicates the number of cases in which this type of injury occurred. Persons may have had more than one injury.

Fishing 173

in the 61–70 group (12.2%), six in the 71–80 group (4.9%), and one in the above 80 category (0.8%). For both males and females, the largest numbers of injuries (59) were to individuals between the ages of 21 and 50 years. However, it is noteworthy that approximately onequarter of the injuries occurred in anglers over the age of 50. This is in sharp contrast to most other sports, where it is rare to encounter this high a proportion of injured middle-aged and elderly participants, and indicates that fishing is a unique sport in terms of its accessibility to all demographical groups. Nature and Acquisition of Injuries Table 10.3 shows the anatomical location of catastrophic fishing injuries examined in the present study. There were a total of 130 such injuries sustained by 126 individuals, including 110 drownings. There were four reported cases of eye injuries, four chest injuries, three abdominal injuries, two head injuries, and one spinal injury. The nature of fishing injuries and the manner in which they are acquired differ dramatically from other sports. For example, interactions with the environment and other living creatures (i.e., bait and fish) are two features that distinguish fishing injuries, in general. The causes of fishing injuries are therefore quite broad and multifactorial. For the purposes of this chapter, they have been organized into four categories: equipment-related, fish-related, alcohol-related, and environment-related. Equipment-related injuries can be subdivided into ingestion, electrocution, and penetration injuries, all of which result from the equipment used: bait, lures and sinkers, rods, and hooks or harpoons. Penetration injuries are one of the commonest in fishing. They can be further classified according to the site or type of penetration: tissue trauma, craniocerebral, testicular, and ocular injuries. The fish themselves pose a hazard to the welfare of the angler through fish-handling injuries and poisons, infections, and contaminant exposure from fish consumption. Finally, there are multiple environmental causes for fishing injuries such as overexposure to solar radiation, viruses propagated by mosquito bites, snakebites, hyperbaric conditions encountered in deep sea fishing, hypothermic conditions in ice fishing, and electrocution by lightning. We will briefly explore all of these possibilities, emphasizing catastrophic injuries.

174 Water Sports

Equipment-Related Injuries Several cases of children ingesting fishing lures and sinkers were reported. Lures are typically colourful and may bear a striking resemblance to candy for a young child; swallowing a lure can lead to lead poisoning. One patient exhibited symptoms of early-onset acute lead encephalopathy with vertigo, ataxia, confusion, and convulsions.3 Electrical burns sustained while fishing with carbon fibre and graphite fishing rods are often severe and fatal. The use of carbon and graphite renders the rod a superconductor.4,5 In most cases, electrocution occurred when the angler’s rod came into contact with overhead high-voltage electrical cables.6 Penetrating trauma due to fishing hooks is frequent among anglers. When an angler casts a fishing line, there is a significant danger of accidentally hitting a bystander with the hook, bait, and sinkers, and this is how most hook penetrations of the ocular region occur.7 Of more serious concern is a growing number of catastrophic penetration injuries caused by underwater fishing harpoons. Since harpoons are designed to expand upon contact to ensure maximal destruction, lesions to the head, for example, can be catastrophic.8 Harpoons used in submarine fishing have also resulted in unusual penetration injuries to the perineal region in men.9 Fish-Related Injuries Hooks and harpoons are not the only objects that can penetrate the unsuspecting angler. Fish themselves have sharp scales, prickles, stinging needles, and razor-sharp teeth that can endanger anglers. These injuries, frequently non-catastrophic, are often contracted when unhooking fish.10 Alcohol-Related Injuries Fishing from boats is a popular way to engage in the sport of angling. Unfortunately, the rate of boating fatalities in Ontario is the third highest in North America, after Texas and Florida, which have boating year-round. Most of the fishing fatalities occur in males between 18 and 54 years of age, usually on weekend evenings, while boating on calm waters, and most often they are due to alcohol impairment. In one Canadian study,11 blood alcohol content (BAC) levels above the

Fishing 175 Table 10.4 Catastrophic Fishing Injuries – Whether Preventable, Alcohol-Related, or Incurred in a Supervised Setting (% in parentheses) Yes Was injury preventable? Was injury alcohol-related? Was activity supervised?

90 41 0

(95) (42) (0)

No 5 56 85

(5) (58) (100)

Note: As reported by the primary physician involved in the case. Data given are for cases with information provided, and therefore may not encompass all catastrophic injury cases in this sport or recreational activity.

legal limit were detected in approximately two-thirds of boatingrelated drowning victims.11 In the present study, there was information about alcohol intake in 97 of the 126 catastrophic injuries cases, and in 41 (42%) alcohol was known to have been a factor (Table 10.4). In North Carolina,12 off-boat fishing was implicated as the leading cause of drowning deaths other than swimming. Analysis of deaths resulting from leisure activities in Great Britain13 between 1982 and 1988 similarly revealed that fishing was the second commonest cause of drowning in England and Wales. Although operating a boat while intoxicated is illegal in Canada, compliance is marginal, and the regulations are often not enforced. Environment-Related Injuries Participation in aquatic sports like sailing and fishing often entails exposure to hazardous levels of ultraviolet radiation. In a casecontrolled study with 507 participants,14 the increased incidence of superficially spreading melanoma was correlated with frequent participation in boating and fishing. The recent outbreak of West Nile virus underscores the importance of being wary of mosquito-infested waterways. Worldwide, fishing in still waters like marshes and ponds poses a high risk of contracting other mosquito-borne illnesses like dengue, viral encephalitis, and malaria. One-third of snakebites in one study15 were the result of unintentional exposure to snakes while the victims were walking in wooded areas or fishing by streams; the authors discovered that many of these snakebite victims had consumed alcohol and, consequently, exhibited a slow reaction time upon encountering the snake.

176 Water Sports

Underwater fishing divers are exposed to exceptionally high alveolar gas pressures, which can adversely impact body physiology.16 An in-depth discussion of the resulting injuries can be found in the chapter on diving injuries. In our study, four people drowned while ice fishing when the ice gave way. Immersion in freezing water and overexposure to cold, wet, and windy conditions can lead to shivering, flushed skin, slurred speech, mental confusion, poor coordination, and stiff muscles. Ultimately, severe hypothermia may result in unconsciousness and heart failure. In our study, many of the catastrophic injuries in fishing occurred in the warm weather months of June to September, and only a small number occurred in the very cold weather months of November to April (Chapter 2). However, a surprisingly large number of individuals drowned in the months of May and October, when many Ontarians would not have expected the water temperature to be near freezing. May was the peak month, with 26 (21%) catastrophic injuries in fishing, and October was the second highest with 24 (19%) of the 124 cases in which the month was identified. Electrocution by lightning is a possibility for those who enjoy fishing from boats. In one incident, an angler suffered a fatal intracerebral hemorrage, while in another, the person experienced hemorrage of his basal ganglia after being struck by lightning.17 Other Injury Risk Factors As noted above, fishing injuries can be attributed to many factors. As was previously mentioned, young to middle-aged adults are most likely to be injured while fishing. This may reflect the increased participation rates of these age groups. It might also be attributable to increased alcohol consumption by those in the 21–50 age group. However, injuries can occur to anglers of all ages. For instance, children who are momentarily left unsupervised during fishing expeditions are especially susceptible to ingestion injuries. Gender is another risk factor. Four times as many Ontario men engage in fishing as Ontario women, and males are at a greater risk of injury than females. Experienced anglers are less likely to suffer from certain injuries (e.g., erratic casting that causes the hook to penetrate the eye of a companion) or electrocution, and yet, even they are not immune from

Fishing 177

catastrophic injuries. At least nine of our cases occurred when fishing alone, and many occurred in non-swimmers. Choppy, rough, or quickly running water was frequently mentioned in the reports. Nine people drowned while fishing from a canoe. Of major importance was the finding that in 22 (20%) of the 110 drowning cases, the respondent (usually the coroner) noted the absence of a personal flotation device (PFD). Awareness of the risk factors involved and adopting suitable preventive measures will reduce fishing injuries for all segments of the population (Table 10.4). Injury Prevention Tips General Measures Avoid fishing alone. Inform others about the destination and duration of the trip. Always wear a personal flotation device while boating. Children must be supervised at all times. Don’t drink and boat. Drinking and driving a boat should incur penalties similar to those for drinking and driving an automobile. • Fish from a canoe only if you are a good canoeist and a good swimmer. • Legislation is an important aspect of prevention of catastrophic injuries in fishing. • • • • •

Equipment-Related Injury Prevention • Lock the tackle box when not in use, especially when children are

present. • Use non-lead alternatives to lead sinkers. Environment Canada

• • • •

recommends non-toxic sinkers made of bismuth, clay, steel, tin, glass, tungsten, or putty. Use insulated fishing rods only. Prominent warning signs should be displayed at fishing spots with overhead high tension cables. Be wary of nearby individuals when casting a fishing rod. Be wary of nearby individuals when releasing a harpoon. Utilize safety locks on power-head harpoons. Wear durable rubber gloves when handling large fish to avoid laceration.

178 Water Sports

Environment-Related Injury Prevention • Avoid injury from excessive exposure to the sun: utilize sunscreen,

wear a hat, long sleeves, and pants. • Apply insect repellant containing DEET. • For ice fishing, wear thick, warm clothing in layers. Assess ice

thickness and weather conditions. Bring a small bag of sand to sprinkle around the ice hole for better traction. • Be aware that the water temperature can be much colder than the air temperature, and that fatal hypothermia can occur from nearfreezing waters, especially in May and October. References 1. National Sporting Goods Association. Sports Participation in 1998. http://www.wildernesspros.com/outdoorfacts/fishing001.html. 2. U.S. Department of the Interior, Fish and Wildlife Service and U.S. Department of Commerce. 1996 National Survey of Fishing, Hunting and Wildlife-associated Recreation. Washington: Bureau of the Census, 1996. 3. Laszloffy M, Keszei N, Kakosy T, Soos G, Hudak A, Naray M. [Severe lead poisoning caused by an ingested fishing weight]. Orvosi Hetilap 1998;139(16):963–5. 4. Chi L, Ning YD, Jun QF, Zhong C, Hua SY. Electrical injuries from graphite fishing rods. Burns 1996;22(8):638–40. 5. Clarke AM, Moss AL. Severe electrical injury from a graphite fishing rod. Injury 1990;21(2):120–1. 6. Logan MA. Electrical burns caused by fishing rod contact with overhead electric cables: A potential hazard to fishermen. Burns 1993;19(6):535–7. 7. Malhotra R, Tappin M, Olver JM. Angler’s fishing line sinker causing rupture of globe and medial wall fracture. Eye 1999;13(Pt 2):260–2. 8. Bell CA, Stout NA, Bender TR, Conroy CS, Crouse WE, Myers JR. Fatal occupational injuries in the United States, 1980 through 1985. [Comment]. JAMA. 1990;263(22):3047–50. 9. Diallo AB, Ndoye A, Fall PA, Ba M, Sylla C, Diagne BA. [Harpoon scrotal injury: Unusual accident in submarine fishing]. Progres en Urologie 2001;11(2):334–5. 10. Barss PG. Penetrating wounds caused by needle-fish in Oceania. Med J Aust. 1985;143(12–13):617–18, 21–2. 11. Canadian Red Cross Society. Drowning among recreational boaters in

Fishing 179

12. 13.

14.

15. 16.

17.

Canada: A problem of male adults in small powerboats and canoes. Ottawa: author;1994. Patetta MJ, Biddinger PW. Characteristics of drowning deaths in North Carolina. Public Health Rep 1988;103(4):406–11. Avery JG, Harper P, Ackroyd S. Do we pay too dearly for our sport and leisure activities? An investigation into fatalities as a result of sporting and leisure activities in England and Wales, 1982–1988. Public Health Rep 1990;104(6):417–23. Holman CD, Armstrong BK, Heenan PJ. Relationship of cutaneous malignant melanoma to individual sunlight-exposure habits. J Nat Cancer Inst 1986;76(3):403–14. Risher WH, Arensman R, Falterman KW. Louisiana the sportsman’s paradise: Fishing lure of the esophagus. J La State Med Soc 1990;142(2):31–3. Boussuges A, Abdellaoui S, Gardette B, Sainty JM. Circulating bubbles and breath-hold underwater fishing divers: A two-dimensional echocardiography and continuous wave Doppler study. Undersea Hyperb Med 1997;24(4):309–14. Dudkiewicz I, Salai M, Blankstein A, Chechik A. Fishing penetration injuries. Br J Sports Med. 2000;34(6):459–61.

Recto Running Head 180

11 Diving sheila heinicke and charles h. tator

Whether from a diving board, the side of a swimming pool, or a rock on the edge of a lake, diving involves head-first entry into the water and subsequent risk of impact. Given the warm summers and the abundance of swimming pools, lakes, and rivers across Canada, many Canadians have attempted to dive at some time in their lives. According to the McLaren Report (see Appendix), only a small proportion, approximately 0.04%, of the Ontario population regularly engages in diving activities. However, the rate of catastrophic injuries among this population, and the severity of the injuries sustained from diving mishaps, warrant a serious examination of the risks involved in diving activities. Indeed, in Canada and many other countries, diving has always been recognized as one of the leading causes of spinal cord injury among all sports and recreational activities.1–4 Each year, many Canadians become seriously injured as a result of diving mishaps, and research has suggested that many of these incidents are avoidable and that many of the injuries are preventable.5 This chapter reviews the circumstances and mechanisms of injury in diving mishaps, the severity of the injuries, the risk factors, and injury prevention strategies. Incidence of Injuries Reports from many countries including Australia, the United States, and Canada, indicate that diving-related injuries represent a significant number of admissions annually to hospitals that have spinal cord injury units. For example, diving injuries account for 10% of all admissions to spinal injury units in Australia,6 and approximately 9% of all spinal cord injuries sustained in the United States.7 Similarly, Ontario

Diving 181 Table 11.1 Catastrophic Diving Injuries: 100 Survivors and 5 Fatalities, by Age and Gendera (% in parentheses) Survivors Females Males Total

12 88 100

Ageb (years) < 11 11–20 21–30 31–40 41–50 51–60 Total a b

(11.4) (83.8) (95.2) Males

3 35 35 13 5 2 93

(2.9) (33.3) (33.3) (12.4) (4.8) (1.9) (88.6)

Fatalities 0 5 5

(4.8) (4.8)

Total 12 93 105

Females 0 7 4 0 1 0 12

(6.7) (3.8) (1.0) (11.4)

(11.4) (88.6) (100.0) Total

3 42 39 13 6 2 105

(3) (40) (37) (12) (6) (2) (100.0)

Data are from the surveys conducted in 1986, 1989, 1992, and 1995. Age (years) of injury victims: mean, 24.1; median, 21.0; minimum, 7; maximum, 60.

researchers have found that approximately 10% of spinal cord injuries treated at Toronto-area hospitals were the result of diving injuries.1,3 Furthermore, diving-related injuries can be very severe. In one study,4 90.6% of the spinal injuries in Ontario from diving resulted in a spinal cord injury, while in Australia diving-related injuries account for approximately 20% of all cases of quadriplegia.6 During the 4 survey years (1986, 1989, 1992, and 1995) used in the present study, there were a total of 105 catastrophic injuries resulting from diving mishaps in Ontario, including five fatalities (Tables 11.1 and 11.2). These 105 individuals sustained a total of 111 injuries, 96 spinal injuries, eight head injuries, two chest injuries, one facial injury, one abdominal injury, and three drowned (Table 11.3). Three of the head injuries were skull fractures, and the diver with facial fractures had multiple fractures of the facial bones. The spinal injuries were very severe, with 92 in the cervical region. There was a neurological deficit in more than half (53%) of the divers with spinal injuries, including 30 complete cord injuries (total paralysis and total sensory loss below the level of the injury) and 21 incomplete cord injuries. There was a fracture-dislocation of the spine in 66 divers. Although the number of fatalities was low, these injuries frequently produce long-term disability from major neurological deficits.5,6 In 1979, diving was the most

182 Water Sports Table 11.2 Diving in Ontario: Participation, Injuries, and Fatalities, 1986–1995 Participants – Estimated Annual

Number

Rate (%)

5,135 3,551 1,040

0.05 0.07 0.02

Number

Rate (%)

0 0 0 NA

0.00 0.00 0.00

Catastrophic Injury Cases (Number of Fatal and Non-Fatal)

4 Surveys

Annual

Overall Males Females Ratio of Males to Females As Proportion of Cases of All Injury Types (Cat and Non-Cat)

105 93 12 7.75 100%

26.25 23.25 3

4 Surveys

Annual

5 5 0

1.25 1.25 0

Overall Males Females Injury Cases, All Types – Estimated Annual Overall Males Females Ratio of Males to Females

Fatalities Only (Number) Overall Males Females Risk Analysis of Catastrophic Injuries 1 Personal Risk as % of Participants Overall Males Females 2 Personal Risk per 100,000 Participants Of Catastrophic Injury, Fatal or Non-Fatal Of Fatality 3 Population Risk per 100,000 Population Of Catastrophic Injury, Fatal or Non-Fatal Of Fatality

Source: See Chapter 1 for Method and Explanation of Calculations.

Annual % 0.57 0.65 0.29 /100,000 570.0 30.43 /100,000 0.256 0.012

Diving 183 Table 11.3 Catastrophic Diving Injuries – Anatomical Location and Type, 105 Cases Anatomical Location Head Spine Drowning Abdomen Chest Face Total

Head – Injury Type Concussion Skull fracture Total

Survivors 8 94 1 2 1 106

Fatalities

2 3

5

6 3 9

Spine/Cord – Injury Level Cervical Thoracic Thoraco-lumbar Total

90 2 1 93

Spine/Cord – Injury Type Fracture only Fracture/dislocation Disc herniation Total

24 64 2 90

Spine/Cord – Injury Severity No neurological deficit Nerve root only Concussion, transient Incomplete cord Complete cord Total

29 3 5 20 29 86

Total 8 96 3 1 2 1 111

6 3 9

2

2

92 2 1 95

2

24 66 2 92

1 1 2

29 3 5 21 30 88

2

Face – Injury Type Mandibular fracture Orbital fracture Other Total

1 1 1 3

1 1 1 3

Abdomen – Injury Type Spleen Total

1 1

1 1

184 Water Sports Table 11.3 (continued ) Anatomical Location

Survivors

Chest – Injury Type Lung contusion Other Total

1 2 3

Fatalities

Total

1 2 3

Note: Each entry indicates the number of cases in which this type of injury occurred. Persons may have had more than one injury.

common cause of spinal cord injury among sports and recreational activities in Ontario,2 and more recent research confirms the prevalence of diving-related spinal cord injuries among those injured while engaging in sports and recreation.4,5,8 In the present study, diving was the most common cause of spinal injury among all the sports and recreational activities in Ontario, and snowmobiling was the second (Chapter 16, Tables 16.1 and 16.2). Up to about 1975, the majority of diving injuries occurred in natural environments such as lakes, while relatively few occurred in swimming pools.2,3 However, since then the site of injury has become more evenly distributed, with approximately 45% of diving injuries occurring in pools, and approximately 55% in natural aquatic environments.1,2 Researchers using retrospective data suggest that this shift in location corresponds with an increase in the popularity of backyard swimming pools in the mid-1970s.2,3 Of the injuries in swimming pools, approximately 86% occur in private residential pools.7 In the present study, the site of injury was recorded in 104 cases of which 56 (54%) occurred in pools, and 43 (41%) in either a lake or river. As has been the case with other reports of diving injuries, very few occurred in the presence of supervision. In our study, information about supervision was submitted for 84 cases, and in 81 (96%) of these there was no supervision at the time of the injury (Table 11.4). In Canada the majority of diving injuries are sustained during the summer months, particularly July.3 Of the 105 diving injuries in our study, 65 (62%) occurred during the summer months of July and August, and an additional 30 (29%) in the spring months of May and June. Only seven injuries (6.7%) were sustained during the remainder of the year. This suggests that the majority of diving injuries occur

Diving 185 Table 11.4 Catastrophic Diving Injuries – Whether Preventable, Alcohol-Related, or Incurred in a Supervised Setting (% in parentheses) Yes Was injury preventable? Was injury alcohol-related? Was activity supervised?

89 40 3

(98) (56) (4)

No 2 31 81

(2) (44) (96)

Note: As reported by the primary physician involved in the case. Data given are for cases with information provided, and therefore may not encompass all catastrophic injury cases in this sport or recreational activity.

during recreational, private, and unsupervised sessions rather than at supervised facilities, such as a school pool or summer camp. DeVivo and Sekar7 found that 46% of diving injuries were sustained during parties, and 51% of injuries on Saturdays or Sundays, with an additional 14% on Fridays, which is further substantiated by Tator’s finding that the majority of diving injuries were sustained in the late afternoon and evening hours.1,3 Furthermore, of the 1,106 cases of diving injuries studied by DeVivo and Sekar, almost half (49%) selfreported alcohol use at the time of injury, and 2% indicated forms of illegal drug use.7 We found that the incidence of alcohol use was higher than in all previously published studies. Of our 105 cases of diving injuries, information about alcohol use was provided for 71, and alcohol was found to be a factor in 40 (56%) (Table 11.4). The high rate of alcohol use further suggests that the majority of catastrophic diving injuries are sustained during recreational, private, and unsupervised activities – as alcohol use is forbidden at most public swimming pools. The majority of diving injuries were sustained by males. In our study, 93 (88.6%) of the 105 diving injury victims were males, and this represents a male:female ratio of 7.75 (Table 11.2). Our data compliment other reports, where approximately 85% of diving injury cases were males.7,8 At this time it is not well understood why so many more males are injured while diving than females. However, given that the majority of these injuries were deemed to be preventable (Table 11.4), a reluctance to follow safety guidelines may be a factor contributing the diving injuries. Serious diving injuries tend to be sustained by teenagers and young adults.7,8 Of our 105 catastrophic diving injuries, only three were sus-

186 Water Sports

tained by children under the age of 11 years (Table 11.1). This is perhaps because young children are more closely supervised by adults while playing in aquatic environments. We found that the age groups with the greatest number of diving-related injuries were the 11–20 group (42 cases) and the 21–30 group (39). In total, 84 of the 105 victims, or 80% of those seriously injured while diving were 30 years of age or younger. The remaining 20% of the injuries were sustained by adults over the age of 30: 13 were in the 31–40 age group, six in the 41–50 group, and only two in the 51–60 age group. In our study, there were no documented cases of diving injuries among individuals older than 60 years. The most common type of diving injury is damage to the spinal cord, and the majority of these injuries occur at the C4 to C6 levels.1,3,7 These injuries can be severe, as they are often neurologically complete. For example, DeVivo and Sekar reported that in half of the cases they studied the result was neurologically complete tetraplegia after the rehabilitation process, and complete recovery was very rare. Nature and Acquisition of Injuries As previously noted, the majority of diving-related injuries are sustained on impact with the bottom of the swimming area, although some occur when the diver strikes the edge of the swimming pool, diving board, another swimmer, or some other submerged object. Although uncommon, divers may sustain more than one type of injury, as occurred in our study, in which there were a small number with abdominal, chest, and other injuries (Table 11.3). Head and Face We found eight cases of head injuries among the 105 (8.6%), six with concussion and three involved skull fracture (one had both). There were no cases of diving-related fatalities resulting from head injury during our study. There was one case with multiple facial fractures. Spine and Spinal Cord As noted above, spinal injury is the most common type of catastrophic injury in diving, and diving-related injuries have been the most common cause of spinal cord injury incurred during sports and recreational activities.2 Most occur when the spine is fractured on impact

Diving 187

with the bottom of the pool or lake, although many injuries may also occur on impact with the water.7 Tator et al.2,3 reported that the majority of diving injuries studied by them occurred when divers’ heads struck bottom, and not on impact with the water. On striking the bottom of the swimming area, the cervical spinal cord is injured when it is compressed between the decelerated head and the weight of the body coming after, still in motion. The force of the impact is then transmitted along the length of the vertebral column, causing fracture-dislocation (either anterior or posterior) or burst fractures of the vertebrae.1 In our study, there were 96 individuals with spine or spinal cord injury during the 4 survey years, including two fatalities, representing 91% of the 105 catastrophic injuries in diving. These predominantly occurred at the cervical level: there were 92 cases of cervical injury, including the two fatalities, and two cases of injuries at the thoracic level, one at the thoraco-lumbar level and in the other the level was not documented (Table 11.3). The most common type of injury to the vertebral column was fracture with dislocation of the vertebral body (66 cases, including two fatalities); 24 victims (no fatalities) had vertebral body fracture alone, and two had disc herniation. These injuries resulted in a wide variety of neurological deficits, ranging from no neurological deficit to complete spinal cord injury: 29 individuals sustained injuries to the spinal cord without any neurological damage; in three there was damage only to the nerve roots, and in five transient spinal concussion. Most importantly, there were 21 cases (including one fatality) of incomplete spinal cord injury, and 30 (including one fatality) of complete spinal cord injury (Table 11.3). There were also seven spinal injuries recorded in Chapter 13 that may be diving related. Torso In diving, there is relatively little risk to the chest, abdomen, and pelvis. Of the 105 individuals in our study who sustained catastrophic injuries in diving, only two sustained chest injuries and these were not fatal. We found one case of catastrophic injury to the abdomen that involved a non-fatal injury to the spleen. Fatalities Relative to other forms of sports and recreation, diving has a fairly low level of associated fatality.2,3 The five (4.8%) deaths among the 105 cat-

188 Water Sports

astrophic injury cases represents a fatality rate of 30 per 100,000 participants (Table 11.2). Three died due to drowning, and the other two sustained cervical spinal cord injury due to fracture-dislocation. Furthermore, it has been suggested that the fatality rate associated with spinal cord injury may be higher than reported, as some cases of drowning may have also had an undetected spinal cord injury.1 Injury Risk Factors The overall risk of diving injuries is shown in Table 11.2. Due to the very low participation rates in Ontario as determined by the McLaren Report, coupled with the relatively high annual incidence of about 26 cases, the risk of a catastrophic injury is high, at 0.51% of participants per year. Indeed, due to the very low participation rate this injury risk is the highest for all sports and recreational activities (see Chapter 2). Table 11.4 shows that the vast majority of respondents in the present study concluded that the injuries were preventable. Most of the injuries occurred in unsupervised settings, and this suggests that increasing supervision might reduce the incidence of injury. Of major importance was the finding that alcohol was known to be a factor in 40 (56%) of the 71 cases in which information was available about alcohol intake (Table 11.4). Risk factors for diving-related catastrophic injuries can be divided into two categories; environmental factors that precede the dive and factors associated with the dive itself. Common environmental factors include the following:7 • Shallow water depth – 57% of catastrophic diving injuries occurred

• •

• • •

in water depths of less than 4 feet, while an additional 38% occurred in depths of between 4 and 8 feet. Lack of depth indicators – three-quarters of the catastrophic injuries occurred in pools that did not have posted depth indicators. Lack of warning signs – 87% of catastrophic injuries occurred in areas that did not have signs warning of the dangers of diving or depth of water. Lack of lifeguards – 94% of catastrophic injuries occurred in locations that did not have lifeguards on duty at the time of the incident. Use of alcohol – alcohol use has been found to be a factor in many diving-related injuries. Lack of diving knowledge – competitive divers are seldom injured, as

Diving 189

they have received adequate instruction regarding safe diving techniques.1 • Lack of supervision – diving injuries are more likely to occur in locations where there is poor supervision. Some studies have shown that 86% of pool-based incidents occur in private, residential pools. Common risk factors associated with the dive itself include the following:6 • Deep dives – dives from which swimmers do not attempt to surface

quickly tend to be deeper in nature and increase the likelihood of the diver striking the bottom of the swimming area. • Short flight distance – dives from which swimmers enter the water close to the edge of the pool or shore tend to result in deeper dives than dives that have a longer flight distance, and thus increase the likelihood of the diver striking the bottom. • Great angle of entry – dives with a higher entry angle increase the likelihood of the diver striking the bottom. Injury Prevention Tips Many of the injuries associated with diving are preventable. The diver, companions, lifeguards, swimming pool owners, and all others involved must take responsibility to minimize exposure to the significant risk factors. Many risk factors can be controlled.3,6,7 Education is key, especially through schools and youth activity groups. For example, the ThinkFirst Foundation of Canada developed an injury prevention program targeted towards unsafe diving, entitled Sudden Impact, and attempted to reach the target audience of youth through a variety of methods, including distribution of the program through the Lifesaving Society of Canada and Canadian Red Cross. Another strategy was the distribution of free copies of the program to every high school in Canada. Although this prevention strategy was important for those who saw the video, we found that the video was usually shown only in physical and health education classes. Unfortunately, these classes are not mandatory for all high school students, and thus large numbers of the population at risk did not have access to the program.5 Given the physical, emotional, and financial costs of diving injuries, such efforts need to be continued. A new edition of the program is

190 Water Sports

available from ThinkFirst through its website at www.thinkfirst.ca, and from the Canadian Red Cross. Tips for Divers • Safe diving techniques should be learned. • Avoid the use of alcohol and drugs in aquatic environments. • Dive only in water that is deep enough to support the skill level of

•

• •

• • • • • • • • • •

the diver. The depth of the water should be twice the height of the diver. Know water depth before diving. Dive only in well-marked and well-supervised environments and ones designated for diving. Never dive into unfamiliar bodies of water. Don’t dive or swim alone. The hazards of shallow water diving are extreme in unknown waters, and therefore, ‘Feet First, First Time’ is strongly recommended. Be sure there are no submerged objects. Never dive into an above-ground pool – they are not designed for diving. Never dive into the shallow end of a pool. Never run and dive. Never dive from retaining walls, ladders, slides, or other pool equipment. When diving from a diving board, always dive from the end and not the sides. Never dive through objects such as inner tubes. Swim with a buddy or have a qualified guard present. Never slide down slides head first. Dive only using shallow dive techniques that can reduce the risk of injury such as the following: – Surface quickly after diving to decrease the depth of the dive. – Aim to enter the water at least 3 metres from the edge of the pool or shore to decrease the depth of the dive. – Attempt to enter the water shallowly to decrease the depth of the dive. – Keep hands together and arms extended above the head throughout the dive to protect the head and neck against impact in the event that you strike bottom.

Diving 191

Tips for Other Individuals Pool owners, lifeguards, companions, and aquatic managers of both public and private pools and other swimming areas are responsible for increasing environmental safety and should pay attention to the following: • Safe diving techniques should be taught, especially how to do a

shallow dive. Water depths must be clearly marked. Post signs warning of water depth and risks of diving. Be knowledgeable about rescue techniques and lifesaving measures. Provide appropriate supervision to those using the pool or dock, etc. Prohibit the use of drugs and alcohol in the aquatic environment. Install and use adequate lighting, especially if the swimming area is to be used after daylight hours. • Be especially cautious in a party environment. Party hosts and companions have a responsibility. • • • • • •

References 1. Tator CH. Diving. In: Jordan BD, Tsairis T, Warren RF (eds.). Sports Neurology, 2nd ed. Philadelphia: Lippincott-Raven, pp. 375–80, 1998. 2. Tator CH, Palm J. Spinal injuries in diving: Incidence high and rising. Ont Med Rev 1981;48:628–31. 3. Tator CH, Edmonds VE, New ML. Diving: A frequent and potentially preventable cause of spinal cord injury. CMAJ 1981;124(10):1323–4. 4. Tator CH, Edmonds VE, Duncan EG, Tator IB. Danger upstream: Catastrophic sports and recreational injury in Ontario. Ont Med Rev 1988:1-3. 5. Bhide VM, Edmonds VE, Tator CH. Prevention of spinal cord injuries caused by diving: Evaluation of the distribution and usage of a diving safety video in high schools. In Prev 2000;6(2):154–6. 6. Blitvitch JD, McElroy GK, Blanksby BA, Douglas GA. Characteristics of ‘low risk’ and ‘high risk’ dives by young adults: Risk reduction in spinal cord injury. Spinal Cord 1999;37(8):553–9. 7. DeVivo MJ, Sekar P. Prevention of spinal cord injuries that occur in swimming pools. Spinal Cord 1997:35(8):509–15. 8. Schmitt H, Gerner H. Paralysis from sport and diving accidents. Clin J Sports Med 2001:11(1):17–22.

Recto Running Head 192

12 Scuba-Diving sheila heinicke

Recreational diving using a scuba, which is a self-contained underwater breathing apparatus, is defined as ‘pleasure diving without mandatory decompression to a maximum depth of 130 feet.’ 1 Scubadiving is a sport with growing popularity in North America. Between 1996 and 2001 the number of certified divers in the United States rose from a reported two million to an estimated nine million.1–5 Given the expanse of Canada’s coasts and vast inland waterways, it is reasonable to assume that scuba-diving has also gained in popularity in this country. In the present study, there were 10 catastrophic injuries over the 4 survey years examined (1986, 1989, 1992, and 1995; Table 12.1). According to the McLaren Report, some 18,500 Ontarians enjoy this sport, representing a scuba-diving participation rate of 0.2% of the Ontario population. While the male:female ratio is approximately 1, there are six times as many male scuba-divers (estimated at 18,500) as there are female divers (estimated at 2,599), indicating that approximately 0.3% of males and 0.05% of females participate in this form of recreational activity (Table 12.2). The morbidity and mortality rates associated with scuba-diving are relatively low when compared with other forms of sports and recreation. On a worldwide scale, each year there is an average of 90 scubadiving fatalities, and an annual average of fewer than 1,000 scubadivers require treatment for severe scuba-diving-related health concerns.1,2,5 Furthermore, these rates of scuba-diving injury and death have remained quite stable over the years, despite the increasing popularity of the sport.5 Inexperienced divers are at high risk for injury, however, and many of these injuries and related illnesses are avoidable.5 This chapter outlines the catastrophic injuries in scuba-

Scuba-Diving 193 Table 12.1 Catastrophic Scuba-Diving Injuries: No Survivors and 10 Fatalities, by Age and Gendera (% in parentheses) Survivors Female Male Total

1 9 10

Ageb (years) 11–20 21–30 31–40 41–50 51–60 Total a b

Fatalities

Males 1 1 3 3 1 9

(10) (10) (30) (30) (10) (90)

(10) (90) (100)

Total 1 9 10

Females

1

(10)

1

(10)

(10) (90) (100) Total

1 1 3 4 1 10

(10) (10) (30) (40) (10) (100)

Data are from the surveys conducted in 1986, 1989, 1992, and 1995. Age (years) of injury victims: mean, 37.1; median, 38.0; minimum, 17; maximum, 54.

diving identified in the present study, describes the common types of scuba-diving-related injuries and illnesses and their mechanisms, and reviews scuba-diving risk factors and injury prevention strategies. Incidence of Injuries As stated above, the rate of catastrophic injuries in scuba-diving is quite low, when compared with other forms of sports and recreation. While this is encouraging, it is important not to minimize the potential severity of the injuries that do occur. The Divers Alert Network (DAN) estimates that there are millions of scuba-dives each year in the United States. 1 The exact number in Canada is unknown. It has been reported that the overall scuba injury rate is approximately 0.53 to 3.4 injuries per 10,000 dives.5,6 As stated above, there are approximately 18,500 Ontarians who participate in scuba-diving annually, and during the 4 survey years used in our study, there were 10 catastrophic injuries, all fatal. Thus, in Ontario, the relative annual risk for a catastrophic injury was 12.2 per 100,000 participants (Table 2.17). The majority of scuba-diving-related injuries were sustained by males, and nine of our cases were male and one was a female, producing a male:female injury ratio of 9, which is significantly greater than the male:female participation ratio of approximately 6. At this time it

194 Water Sports Table 12.2 Scuba-Diving in Ontario: Participation, Injuries, and Fatalities, 1986–1995 Participants – Estimated Annual

Number

Rate (%)

Overall Males Females

18,500 16,234 2,599

0.18 0.32 0.05

Injury Cases, All Types – Estimated Annual

Number

Rate (%)

0 0 0 NA

0.00 0.00 0.00

Catastrophic Injury Cases (Number of Fatal and Non-Fatal)

4 Surveys

Annual

Overall Males Females Ratio of Males to Females As Proportion of Cases of All Injury Types (Cat and Non-Cat)

10 9 1 9.0 100%

2.50 2.25 0.25

4 Surveys

Annual

10 9 1

2.50 2.25 0.25

Overall Males Females Ratio of Males to Females

Fatalities Only (Number) Overall Males Females Risk Analysis of Catastrophic Injuries 1 Personal Risk as % of Participants Overall Males Females 2 Personal Risk per 100,000 Participants Of Catastrophic Injury, Fatal or Non-Fatal Of Fatality 3 Population Risk per 100,000 Population Of Catastrophic Injury, Fatal or Non-Fatal Of Fatality

Source: See Chapter 1 for Method and Explanation of Calculations.

Annual % 0.012 0.015 NA /100,000 12.17 12.17 /100,000 0.024 0.024

Scuba-Diving 195

is not well understood why the male injury rate is so much higher than the rate for females. Given that many of the injuries are preventable, the degree of risk-taking behaviour and reluctance to follow safety guidelines (such as diving within one’s known limits) may be factors. None of the articles reviewed for this chapter specifically discussed the ages of those injured during scuba-diving. In our study, none were under the age of 11 years. This is perhaps due to the scuba-divers’ certification process, which typically involves a financial investment and encompasses both theoretical and practical learning.7 In each of the age groups of 11–20 and 21–30 years there was one recorded catastrophic injury, while the largest number were in the 31–40 group (3 of the 10 injured) and the 41–50 range (4 of the 10), with one in the 51–60 age group. In total, 70% of those injured were middle-aged. Nature and Acquisition of Injuries There are three major mechanisms of injury in scuba-diving: drowning, barotrauma, and decompression sickness. Each of these is associated with changes in ambient (surrounding) pressure placed on the diver when depth increases, and the subsequent physiological consequences. Table 12.3 shows that nine of the 10 catastrophic injuries were due to drowning and the tenth was due to a head injury. Barotrauma Barotrauma is defined as ‘tissue damage resulting from a pressure differential between the environment and a non-compressible gas-filled body cavity. During a dive, this pressure differential must be equalized or the resulting expansion and contraction of trapped gas will cause tissue injury.’3 Barotrauma injuries associated with scuba-diving are largely related to the depth and duration of the dive. The deeper the dive, the greater the risk of such injury.3,4 The human body has many spaces that are filled with gas. As the diver changes depth, the gas in these spaces must be equalized to the ambient pressure. During the descent, as the pressure increases, the volume of these spaces must decrease. When the diver rises to the surface, the ambient pressure decreases, and the volume of these spaces must increase. However, if pockets of gas become trapped in a body part that cannot be compressed, the pressure cannot become equalized, and damage can occur to the surrounding tissues.1,3,4,7 Barotrauma can occur during the

196 Water Sports Table 12.3 Catastrophic Scuba-Diving Injuries – Anatomical Location and Type, 10 Cases (All Fatal) Anatomical Location

Fatalities

Head Drowning Chest Miscellaneous Total

1 9 3 1 14

Head – Injury Type Other Total

1 1

Chest – Injury Type Other Total

3 3

Note: Each entry indicates the number of cases in which this type of injury occurred. Persons may have had more than one injury.

descent or ascent phase of a dive.1 Furthermore, barotrauma can occur in many parts of the body, including the middle and inner ear and the lungs. Severe complications of barotrauma can include pneumothorax and the development of arterial gas emboli. Pulmonary barotrauma (barotrauma to the lungs causing pulmonary embolism) is the second leading cause of death among scuba-divers, following drowning.8 Decompression Sickness Decompressions sickness, also known as the ‘bends,’ is a serious complication of scuba-diving. As a diver descends, the ambient pressure surrounding him or her increases, and in order to breathe, air must be delivered to the diver at a higher pressure. When the diver ascends, the ambient pressure decreases, and the nitrogen that has gone into the tissues must be released from the solution. If the diver ascends too quickly, the nitrogen will form bubbles in the blood, interstitial fluid, and body organs.1,4 These bubbles can obstruct blood vessels and lymphatic drainage, or cause structural damage to surrounding tissues.3 These, in turn, may result in serious complications such as arterial emboli or neurological damage (such as strokes) resulting in paralysis.1,4

Scuba-Diving 197

Other Scuba-Related Injuries In addition to drowning, barotrauma, and decompression sickness, scuba-divers are at risk for many types of non-catastrophic injuries such as cuts and scrapes, contact with fish and other marine animals, or exposure to environmental hazards such as sharp metal on boat wrecks.2 It is important to note that an individual may sustain more than one type of injury in a single incident while scuba-diving. head and face All injuries to the head, eyes, or facial fracture were considered to be catastrophic in nature, with the exception of nasal fractures and simple, uncomplicated concussions. In our data, there was one case of head injury among the 10 documented cases of catastrophic scubadiving injuries in Ontario. This injury was classified as ‘other head injury.’ spine and spinal cord Although there were no documented cases of injury to the spine or spinal cord among those injured during our study period, there are reports1 that neurological decompression sickness can affect the brain (30%–40% of cases of Type II decompression sickness) and the spinal cord (50%–60% of cases of Type II decompression sickness), and may result in permanent paralysis. torso The most serious form of barotrauma, pulmonary barotrauma, occurs within the lungs. There are several forms of pulmonary barotrauma, the most dangerous of which is the development of arterial gas embolism. Once developed, the embolus can travel throughout the body. The type of life-threatening condition that can result will depend on where the bubbles travel.4 Damage can occur in many places throughout the body, including the brain and the kidneys.4 Almost 25% of all recreational scuba-related deaths are caused by the development of arterial gas embolism.1 Of the 10 individuals in our study who sustained catastrophic injuries while scuba-diving, three (30%) sustained chest injuries. All three were categorized as ‘other chest injuries,’ and all three resulted in a fatal outcome.

198 Water Sports

limbs On occasion, decompression sickness can manifest in the muscles, joints, and peripheral nervous system. This form of decompression sickness is quite responsive to treatment, however, and not typically catastrophic in nature.1 When decompression sickness is manifested in the joints, the elbow and shoulder are more commonly affected than the hip or knee.3 There were no documented cases of catastrophic limb injury in our study. fatalities Although the rate of catastrophic injury is lower in scuba-diving than in many other activities,1,2,5 the injuries that occur can be catastrophic. All 10 of our cases were fatalities. Thus, scuba-diving with a 100% fatality rate exceeded all other sports and recreational activities. In nine of the 10 cases (90%), the individuals were reported to have drowned. One individual had a catastrophic head injury, three also had catastrophic chest injuries that may have contributed to their deaths. Injury Risk Factors Table 12.4 shows that two of the three respondents reported that the scuba-diving injuries were preventable, and that none were known to be related to alcohol consumption. Many of the risks in scuba-diving are related to exposure to changes in ambient pressure, as well as the need for specialized equipment and training. In our study, cold water and hypothermia may have been a factor in five of the 10 incidents that occurred in the cold water months (one in January, two in April, and two in June). The following is an outline of some of the risk factors associated with scuba-diving.5 • While certification is required to participate in scuba-diving, and

training courses are available through very reputable agencies and programs, the application of such courses is highly dependent on the skill of the local instructor and diver operator. Concern has been raised that consumer pressure (e.g., to satisfy holiday plans) may compromise the quality of instruction and the certification process. • Once certified, ongoing evaluation is not required to continue to dive. Scuba-diving in different types of water (warm vs cold, etc.)

Scuba-Diving 199 Table 12.4 Catastrophic Scuba-Diving Injuries – Whether Preventable, AlcoholRelated, or Incurred in a Supervised Setting (% in parentheses) Yes Was injury preventable? Was injury alcohol-related? Was activity supervised?

3 0 0

(75) (0) (0)

No 1 7 3

(25) (100) (100)

Note: As reported by the primary physician involved in the case. Data given are for cases with information provided, and therefore may not encompass all catastrophic injury cases in this sport or recreational activity.

requires different types of skills. However, once certified, a diver is able to dive in various conditions without upgrading his or her skills. • Once certified, medical re-evaluation is not required upon changes in the health status of the diver. For example, if the diver is certified while healthy, but later develops a health condition (such as cardiovascular disease, diabetes, asthma, epilepsy, etc.) which may increase the risk of diving, medical re-evaluation is not required (although highly recommended). Injury Prevention Tips • Investigate your local certification instructors before taking their

•

•

• • • •

courses. Ensure that the instructors are affiliated with reputable instruction agencies and that they have maintained their own instructors’ certification. Maintain your skills. Before attempting dives in new types of environments (e.g., cold water dives), determine that your skill level is appropriate to meet the demands of the environment. If your health status has changed since becoming certified, check with your physician before diving again. Safe scuba-diving is contraindicated with certain disorders. Always stay within the limits of your experience, training, and skill level. Never attempt a dive with which you are not fully comfortable. Always dive with a partner. Never dive alone. Before a dive become familiar with the local underwater environment, including fish, coral, and other possible hazards.

200 Water Sports • During the descent, take the time to equalize your ears and your

mask. • Once at depth, do not attempt to extend your dive beyond the

parameters (depth or duration) of your dive table or computer dive. Recent advances in technology have resulted in computer programs that have assisted with the calculation of safe dive depths and duration. It is important to blend these new advances with common sense. • During the ascent, always ascend slowly and breathe normally. Allow yourself the time to ascend safely. • Do not panic under water. If you find yourself becoming anxious, stop and relax. Breathe regularly. Do not rush back to the surface. • Always dive responsibly. References 1. Newton HB. Neurologic complications of scuba diving. Am Fam Physician 2001;63(11):2211–18. 2. American Academy of Family Physicians. Medical problems of recreational scuba diving. Am Fam Physician 2001;63(11):2225–6. 3. Clenney TL, Lassen LF. Recreational scuba diving injuries. Am Fam Physician 1996;53(5):1761–7. 4. Pelletier JP. Recognizing sport diving injuries. Dimensions Crit Care Nursing 2002:21(1):26–7. 5. Strauss MB, Borer RC. Diving medicine: Contemporary topics and their controversies. Am J Emerg Med 2001;19(3):232–8. 6. Koehle M, Lloyd-Smith R, McKenzie D, Taunton J. Asthma and recreational scuba diving: A systematic review. Sports Med 2003;33(2):109–16. 7. Professional Association of Diving Instructors. www.padi.com. Retrieved 17 Nov. 2003. 8. Slade Jr. JB, Hattori T, Ray, CS, Bove AA, Cianci P. Pulmonary edema associated with scuba diving: Case reports and review. Chest 2001;120(5):1686–94.

Recto Running Head 201

13 Swimming alun ackery

Swimming is a sport enjoyed by many people in many regions of Ontario and elsewhere, and it can provide recreation and physical activity for the entire family. The high participation rates and popularity have been attributed to the leisure and cardiovascular benefits of this activity. Swimming is done in residential and community swimming pools, lakes, rivers, and oceans, and it is also a competitive Olympic sport. Competitive swimming involves people of all ages, from youths to seniors. In the 4 survey years there were 100 catastrophic swimming injuries (Table 13.1). The McLaren Report showed that 29% of the Ontario population participated in swimming in 1995, with male and female participation rates of 26% and 32%, respectively (Table 13.2). However, not everybody who swims does so at the same skill level. Whether it is swimming on the beach or in the backyard of homes, each swimming environment has life-threatening risks that participants must be aware of to avoid catastrophic injuries. Incidence of Injuries The 100 catastrophic injuries during the years covered by our study (1986, 1989, 1992, and 1995; Table 13.1) yield an annual catastrophic injury incidence of 25 cases and an annual catastrophic injury rate of 0.001% of participants (Table 13.2). These data give a rate of 0.831 catastrophic injury cases per 100,000 participants per year. There were 79 male and 21 female catastrophic injuries, giving annual catastrophic injury incidences of 19.75 and 5.25 in males and females, respectively (Table 13.2). Of all injuries associated with swimming 0.29% were con-

202 Water Sports Table 13.1 Catastrophic Swimming Injuries: 14 Survivors and 86 Fatalities, by Age and Gendera (% in parentheses) Survivors Females Males Total

2 12 14

Ageb (years) < 11 11–20 21–30 31–40 41–50 51–60 61–70 71–80 > 80 Total a b

(2) (12) (14) Males

14 18 23 9 5 5 3 1 1 79

(14) (18) (23) (9) (5) (5) (3) (1) (1) (79.0)

Fatalities 19 67 86

(19) (67) (86)

Total 21 79 100

Females 6 7

(6) (7)

4 1 1 1 1

(4) (1) (1) (1) (1)

21

(21.0)

(21) (79) (100) Total

20 25 23 13 6 6 4 2 1 100

(20.0) (25.0) (23.0) (13.0) (6.0) (6.0) (4.0) (2.0) (1.0) (100.0)

Data are from the surveys conducted in 1986, 1989, 1992, and 1995. Age (years) of injury victims: mean, 26.4; median, 21.0; minimum, 1; maximum, 87.

sidered catastrophic, and the catastrophic injury male-to-female ratio was 3.8. Of the 100 participants with catastrophic injuries, 20 were less than 11 years old (14 males, 6 females), 25 in the 11–20 age group (18 males, 7 females), 23 in the 21–30 group (all males), 13 in the 31–40 group (9 males, 4 females), 6 in the 41–50 group (5 males, 1 female), 6 in the 51–60 group (5 males, 1 female), 4 in the 61–70 group (3 males, 1 female), 2 in the 71–80 group (1 male, 1 female), and one male was over 80 years old (Table 13.1). Among the 100 catastrophic injuries in swimming, 86 were fatalities (67 males, 19 females; Table 13.2). World-wide, swimming has a relatively low incidence of injury when compared with other activities, even though it ranks, in absolute terms, among the top 10 to 15 contributors to sports and recreational injuries (see Relative Incidence Table, Chapter 2.18).1 Although there are injuries in competitive swimming, specifically to the eyes, ears, shoulders, legs, and feet, catastrophic injuries are very rare in this swimming environment. Almost all the catastrophic injuries occur in non-competitive and recreational swimming.

Swimming 203 Table 13.2 Swimming in Ontario: Participation, Injuries, and Fatalities, 1986–1995 Participants – Estimated Annual

Number

Rate (%)

3,012,412 1,323,034 1,681,479

29.33 26.08 32.35

Number

Rate (%)

8,584 3,779 4,787 0.79

0.29 0.29 0.29

Catastrophic Injury Cases (Number of Fatal and Non-Fatal)

4 Surveys

Annual

Overall Males Females Ratio of Males to Females As Proportion of Cases of All Injury Types (Cat and Non-Cat)

100 79 21 3.76 0.291%

25 19.75 5.25

4 Surveys

Annual

86 67 19

21.5 16.75 4.75

Overall Males Females Injury Cases, All Types – Estimated Annual Overall Males Females Ratio of Males to Females

Fatalities Only (Number) Overall Males Females Risk Analysis of Catastrophic Injuries 1 Personal Risk as % of Participants Overall Males Females 2 Personal Risk per 100,000 Participants Of Catastrophic Injury, Fatal or Non-Fatal Of Fatality 3 Population Risk per 100,000 Population Of Catastrophic Injury, Fatal or Non-Fatal Of Fatality

Source: See Chapter 1 for Method and Explanation of Calculations.

Annual % 0.001 0.001 0.0003 /100,000 0.831 0.714 /100,000 0.243 0.209

204 Water Sports

Statistics Canada and the Canadian Red Cross reported on 10 years of drownings:2 They found drowning to be the fourth most common cause of unintentional death in Canada and the leading cause of death in sports and recreation. There were 5,900 deaths and 3,289 hospitalizations from swimming in the 10 years ending in 2000. For Canada as a whole, death by drowning decreased by 21% between the 1991–95 and 1996–2000; swimming as an activity is one of the most prevalent causes of drowning, although improving from an annual 0.29 (1991–95) to 0.23 drownings per 100,000 population (1996–2000). Ontario had one of the lowest rates of drowning, improving 25% from an annual 1.44 to 1.08 drownings per 100,000 population. The highest drowning rates occurred in the territories, and in the eastern and western coastal provinces. The Red Cross also reported that swimming was the predominant activity (69%) in all of the recreational aquatic drownings, followed by playing/wading in the water (15%). A report from Canada’s National Trauma Registry3 on water-related trauma hospitalizations found that in 2000–01 near-drowning hospitalizations in Canada declined by 35% compared with 1996–97, and that the majority (90%) of these were classified under the International Classification of Disease (ICD) code E910, which includes drowning due to swimming, water-skiing, bathing, and swimming in a pool. Both our data and the above-mentioned reports indicate that drowning occurs predominantly in young adult males (15–40 years old).2,3 Additionally, toddlers (children under the age of 5) are at risk for drowning. The Lifesaving Society of Canada4 labelled these two highrisk groups as the ‘risk taker’ and the ‘unattended toddler.’ Nature and Acquisition of Injuries Although this chapter is specifically directed towards catastrophic injuries in swimming, there is some overlap with other activities in other chapters. Physicians and other personnel completing the questionnaires for the 4 surveys sometimes had varying interpretations of the activity at the time of injury. For example, some diving injuries could have been placed in either the swimming or diving chapter, or if a child was running in shallow water and then dove, it is likely that this activity would have been considered a swimming injury. Our data showed 102 separate catastrophic injuries in the 100 victims of swimming injuries because some individuals suffered multiple trauma. There were 86 drownings (Table 13.3), and as mentioned

Swimming 205 Table 13.3 Catastrophic Swimming Injuries – Anatomical Location and Type, 100 Cases Anatomical Location Head Spine Drowning Miscellaneous Total

Head – Injury Type Concussion Other Total

Survivors 1 7 5 13

Fatalities 1 86 2 89

2 7 86 7 102

1 1

1 1 2

1 1

Total

Spine/Cord – Injury Level Cervical Total

7 7

7 7

Spine/Cord – Injury Type Fracture only Fracture / dislocation Total

2 4 6

2 4 6

Spine/Cord – Injury Severity No neurological deficit Incomplete cord Complete cord Total

1 3 3 7

1 3 3 7

Note: Each entry indicates the number of cases in which this type of injury occurred. Persons may have had more than one injury.

above these predominantly involved young males and toddlers. Unattended toddlers near water are at considerable risk, because these young children can walk, but not necessarily swim. Adults must supervise children at all times when they are near open water. An Australian study5 reported that toddler drownings occur most often in a child’s home, in either the family pool or bathtub. The Lifesaving Society of Canada4 reported that 58% of drownings of children under the age of 5 years occurred when the child had been left alone to play near water (e.g., backyard pool, river, lake, or bathtub). In our study, of the 98 cases in which the site of injury was documented, 18 were

206 Water Sports

injured in pools, 64 in lakes or rivers, and the remaining 16 in other locations. The young adult male ‘risk taker’ had the highest rate of drowning in Canada, and this mirrors the similarly high rate of catastrophic injury in this group in several other activities (e.g., snowmobiling, boating, and fishing), often because of impaired judgment and careless decision-making, such as neglecting to use personal flotation devices (PFDs), combining drugs or alcohol with high-risk activities, and overestimating their level of skill. Our data include seven spinal cord injuries, all at the cervical level. One spinal injury reported no neurological deficit, three suffered incomplete spinal cord injuries, and three suffered complete and three incomplete spinal cord injuries. It is noteworthy that a majority of these spinal cord injuries occurred in Ontario residents who were outside the province at the time they were injured. Two were injured in Mexico when they were upended by large waves, and one was injured by the surf in the Dominican Republic. One Ontario resident was pushed backward into a swimming pool while vacationing in Quebec. The other four spinal cord injuries occurred while shallowdiving in Ontario, but were classified as swimming injuries. Also, there were two head injuries (1 concussion, 1 unknown), which could have occurred in a variety of ways, but most likely through contact with an underwater object (including the bottom) or contact with another person. Injury Risk Factors The Canadian Red Cross reported the incidence rate of drownings in different types of water: lakes, 40%; rivers, 34%; public swimming pools, 9%; residential pools, 7%; and in oceans, 4%; with 6% in an unknown site. Currents in rivers and rough waters create areas of high risk, with rapids, white water, and waterfalls having the greatest potential for danger. Our data suggest that Ontario residents on vacation outside the province are particularly at risk, as can be seen regarding spinal injuries. As noted above, almost four times as many swimming mishaps occurred in lakes and rivers compared with pools. Of the 41 cases in which information about the presence of supervision was known, in seven (17%), the injury occurred in a supervised setting, and in 34 (83%) there was no supervision. In the 64 cases for which information about preventability was recorded 54 (84%) were

Swimming 207 Table 13.4 Catastrophic Swimming Injuries – Whether Preventable, Alcohol-Related, or Incurred in a Supervised Setting (% in parentheses) Yes Was injury preventable? Was injury alcohol-related? Was activity supervised?

54 31 7

(84) (47) (17)

No 10 35 34

(16) (53) (83)

Note: As reported by the primary physician involved in the case. Data given are for cases with information provided, and therefore may not encompass all catastrophic injury cases in this sport or recreational activity.

deemed to have been preventable while 10 (16%) were considered non-preventable (Table 13.4). Drowning can occur to both swimmers and non-swimmers.4 The Canadian Red Cross2 reported that 32% of swimming victims between 5 and 14 years of age were non-swimmers or weak swimmers, with 42% of them not properly accompanied by an adult. Even strong swimmers take unwise risks and can be swept away into unfamiliar water, but in many circumstances participants impair their own abilities and judgment; for example, in testing blood alcohol content (BAC), the Red Cross found that 19% of drowning victims aged 15–24 years had known BAC levels above the legal limit, while 42% of drowning victims 25 years or older had BAC levels above the legal limit. Another review6 reported that alcohol was detected in the blood of 30% to 70% of persons who had drowned in recreational aquatic incidents. Even small amounts of alcohol and/or intoxicating drugs can adversely affect performance in swimming and must be used with caution. Our study showed that in the 66 cases for which data were available, 31 (including 50% of the fatalities) had alcohol involvement (Table 13.4). There have been many reports of toddler drownings (1–5 years old). These typically happen when a parent or other adult providing supervision has a momentary lapse in judgment, forgetting and taking their focus away from the toddler who is playing close to open water. The toddler falls into the water and within minutes can drown or suffer severe brain damage because of the lack of oxygen. 4 This age group would be better protected if backyard swimming pools had four-sided fencing. There is a movement towards legislation to make this mandatory.

208 Water Sports

Injury Prevention Tips • Never leave children unsupervised near water. • Learn to swim and tread water. • Never swim alone. Every swimmer should be supervised, and this

applies to pools, lakes, and rivers. • Weak swimmers should wear a certified PFD. • Learn lifesaving skills (first aid and lifesaving courses). • Put secure, four-sided fencing and barriers around residential

swimming pools and open water. • Avoid alcohol even in small amounts when swimming. • Avoid drugs even in small amounts when swimming. • Feet first, first time! Protect your neck and head – never dive into

shallow or unknown water. Learn to do shallow dives. Twice your height is the safe depth of water for diving. • Check the weather and water conditions, especially in rivers and lakes. • Identify water-related hazards (such as docks, rocks, and logs) in your community so that other participants will be aware. References 1. Chalmers D, Morrison L. Epidemiology of non-submersion injuries in aquatic sporting and recreational activities. Sports Med 2003;33(10): 745–70. 2. Barss P. What we have learned: 10 years of pertinent facts about drownings and other water-related injuries in Canada 1991–2000. Ottawa: Canadian Red Cross; 2003, pp. 1–24. 3. National Trauma Registry. Analytic Bulletin – Water-Related Trauma Hospitalizations in Canada, 2000–2001. Ottawa: Canadian Institute for Health Information, Toronto, 2003, pp. 1–17. 4. Lifesaving Society (Canada). National Drowning Trends Report 1991–2000. Ottawa, 2003, pp. 1–4. 5. Ross FI, Elliott EJ, Lam LT, Cass DT. Children under 5 years presenting to paediatricians with near-drowning. J Paediatr Child Health 2003;39(6): 446–50. 6. Driscoll TR, Harrison JA, Steenkamp M. Review of the role of alcohol in drowning associated with recreational aquatic activity. Inj Prev 2004;10(2): 107–13.

Recto Running Head

209

14 Waterskiing pemma muzumdar

Waterskiing was first attempted in 1922, and has since become an increasingly popular activity. Recent surveys estimate that there are 2.5 million waterskiers in Canada,1 and 11 million waterskiers in the United States.2 Waterskiing is recognized as both a competitive sport and a recreational activity. There are different kinds of traditional waterskiing, and several activities that are related or similar to waterskiing. Traditional waterskiing includes slalom, trick, and jump skiing.2 Slalom skiing involves a series of buoys that are typically set in a straight path and placed 8 feet apart. In slalom, the boat that tows the skier is challenged by having to travel in a straight line through the path of buoys. Ideally, the skier will tilt the body in order to successfully round the buoys at the maximum speed set for their age group.2,3 As an additional challenge, the tow rope can be shortened from its maximum length of 75 feet; the shortened length is referred to by the amount that it differs from the original 75 feet, for example, if you are skiing on a 60-foot rope you are described as skiing ‘15 feet off.’2,3 During trick skiing, an individual can either remove a ski while in motion or hold the tow rope by the foot and perform a flip or a step-over. The third type of traditional waterskiing includes jumping, and involves a ramp to become momentarily airborne.2 Recreational activities that are related to water skiing include wakeboarding, barefoot skiing, and tubing. Wakeboarding is a mixture of waterskiing and snowboarding. It employs the use of a single, small board on which the ‘boarder’ needs to balance and coordinate his or her movements. Barefoot skiing is done without skis. Water tubing involves a large donut-shaped inflatable device that carries a person and is pulled behind the boat.1–3

210 Water Sports

Waterskiing and its related activities are great fun. However, there is a significant danger of injury or death if safety is not taken into consideration. Safety precautions should be made known to the skier and followed in order to prevent possible injury. In this chapter, the incidence, nature, and severity of waterskiing injuries will be discussed. Risk factors for such injuries will be identified, and prevention strategies suggested. Incidence of Injuries The participation rate for waterskiing in Ontario was not included in the McLaren Report, but there are a number of estimates in the literature. Waterskiing is an extremely popular activity in Canada and the United States, as well as in other countries such as Australia. The sport has experienced increasing popularity as a recreational activity, and it is estimated that there are now over 30 million waterskiers worldwide,4 among them 11 million in the United States and 2.5 million in Canada.1,2 In Canada, the demographical details are as follows: 62% of waterskiers are males, and 38% females; 35% are under 18 years of age, another 35% are between 18 and 29, 20% are between 30 and 39, and 10% are above 40.1 In the United States, Roberts5 reported that approximately 61% of waterskiing participants are males, and that between 1980 and 1991 there was an annual average of 23,400 waterskiing injuries. Men sustained 76% of these injuries, and the injury rate ranged between 0.2 and 0.3 injuries per 1,000 skier-days. Roberts noted that injury rates for waterskiing were relatively low compared with snow skiing. Propeller injuries are a leading cause of catastrophic injury, and waterskiing (accounting for 48%) is the leading activity associated with propeller injuries.6 Over the 4 survey years (1986, 1989, 1992 and 1995), a total of nine catastrophic injuries due to waterskiing were recorded in Ontario, for an annual rate of 0.022 catastrophic injuries per 100,000 population (Tables 14.1 and 14.2). Of these, there were seven survivors and two fatalities, producing a fatality rate of 0.005 per 100,000 population. Men sustained 100% of the nine catastrophic injuries, with an annual catastrophic injury incidence of 2.25. In this series, 75% of catastrophic injuries occurred between the ages of 11 and 20 years, and 25% between the ages of 21 and 40. Our data are based on hospital admissions and coroners’ reports, but many waterskiing injuries are very

Waterskiing 211 Table 14.1 Catastrophic Waterskiing Injuries: 7 Survivors and 2 Fatalities, All Males, by Agea (% in parentheses) Survivors Males Total

7 7

Ageb (years) 11–20 21–30 31–40 Total

(77.8) (77.8)

Fatalities 2 2

Males 6 1 1 8

(75.0) (12.5) (12.5) (100.0)

(22.2) (22.2)

Total 9 9

(100.0) (100.0)

Total 6 1 1 8

(75.0) (12.5) (12.5) (100.0)

a

Data are from the surveys conducted in 1986, 1989, 1992, and 1995. Age (years) of injury victims: mean, 20.8; median, 19.0; minimum, 16; maximum, 35. Missing information for one participant. b

likely entered in hospital records as boating injuries. Therefore, our data probably underestimate the true incidence of waterskiing injuries in Ontario. Nature and Acquisition of Injuries In 1982, Hummel and Gainor7 examined 26 cases of waterskiingrelated injuries, and were the first to classify these into four distinct categories: injuries related to a fall, collision-related injuries, propellerrelated injuries, and tow rope-related injuries. Falls were the most frequent cause of waterskiing injury, accounting for 12 of the 26 cases. Injuries due to falls caused facial lacerations, torn medial meniscus, pubic diastasis, cervical sprain, dislocated shoulder, and fractured femur.5,7 Shoulder injuries secondary to falls were due in large part to the reflex of placing the arms in an outstretched position while falling.7 Lacerations to a waterskier’s face were also reported to be a common result of a fall.5 A skier who leans forward too much can fall forward and strike the face against a ski. Falls can also be dangerous for barefoot skiers, because they tend to travel at higher speeds. When they fall, their bodies often plane hydrodynamically. The limbs can then engage the water at high speeds, and there is a high risk of neck injuries.5 Hamstring injuries occur when novice skiers are improperly positioned for take-off, or try to get up on their

212 Water Sports Table 14.2 Waterskiing in Ontario: Participation, Injuries, and Fatalities, 1986–1995 Participants – Estimated Annual

Number

Rate (%)

NA NA NA

NA NA NA

Number

Rate (%)

NA NA NA NA

NA NA NA

Catastrophic Injury Cases (Number of Fatal and Non-Fatal)

4 Surveys

Annual

Overall Males Females Ratio of Males to Females As Proportion of Cases of All Injury Types (Cat and Non-Cat)

9 9 0 All Male 100%

2.25 2.25 0

4 Surveys

Annual

2 2 0

0.5 0.5 05

Overall Males Females Injury Cases, All Types – Estimated Annual Overall Males Females Ratio of Males to Females

Fatalities Only (Number) Overall Males Females Risk Analysis of Catastrophic Injuries 1 Personal Risk as % of Participants Overall Males Females 2 Personal Risk per 100,000 Participants Of Catastrophic Injury, Fatal or Non-Fatal Of Fatality 3 Population Risk per 100,000 Population Of Catastrophic Injury, Fatal or Non-Fatal Of Fatality

Source: See Chapter 1 for Method and Explanation of Calculations.

Annual % NA NA NA /100,000 NA NA /100,000 0.022 0.005

Waterskiing 213

skis from a submerged position. Hamstring injuries in more experienced skiers often occur after a fall.8 Collision injuries occur when a waterskier comes into contact with an obstacle, such as another boat, floating debris, a dock, or the shoreline. Five of Hummel and Gainor’s 26 injury cases sustained injuries from collisions, and these included facial lacerations, an open elbow fracture, and a closed head injury with fractured vertebrae.7 Amputations, severe lacerations, and infections due to bacterial flora in the water are all examples of propeller-related injuries. As noted above, 48% of all propeller injuries occur in waterskiing.6 Mann9 found that propeller injuries related to waterskiing were the most disabling and dangerous, and that the fatality rate among them was 17.4 per 100. Mann provided several examples of multiple trauma that can occur with injuries of this type, including a 16-year-old girl who was run over by her own tow boat, and then it backed over her again. She sustained multiple lacerations involving her lower extremities and extending into her pelvis, and required an above-the-knee amputation. Hummel and Gainor7 found that five of their 26 cases had propellerrelated injuries, and these tended to occur when a fallen skier was retrieved by his or her own boat, or when a tow boat made contact with another individual in the water. For example, one propeller injury occurred because a waterskier’s boat was too close to the shore and ran over an individual who was snorkelling. The five cases of propeller injuries included lacerations of the buttock and thigh, calf, and urethra; one case of foot amputation; and one open head injury. Head injury has been reported to account for 40% of the fatalities due to propeller strikes.6 The shearing action of the tow rope is unique to waterskiing injuries. If a waterskier has the misfortune of entangling a limb in the tow rope, he or she can be dragged through the water by the limb at a dangerous speed. The reported injuries include rope burns, fingertip avulsions, a near de-gloving of the thumb, and a fractured skull.5,7 Of the 26 cases studied by Hummel and Gainor,7 four sustained injuries due to interaction with the tow rope; these authors also reported four drownings, one of which was thought to occur when the skier was struck in the face by his own ski and knocked unconscious. Vulvovaginal and rectal tears also occur in waterskiing as a result of douche enemas, and rushes of water, although the available literature is limited.5,7,10

214 Water Sports Table 14.3 Catastrophic Waterskiing Injuries – Anatomical Location and Type, 9 Cases Anatomical Location

Survivors

Fatalities

Total

Head Spine Drowning Eye Abdomen Chest Limb Total

1 2

1

7

1 1 1 5

2 2 1 4 1 1 1 12

Head – Injury Type Skull fracture Total

1 1

1 1

2 2

Spine/Cord – Injury Level Cervical Thoracic Total

1 1 2

1 1 2

Spine/Cord – Injury Type Fracture only Fracture / dislocation Total

1 1 2

1 1 2

Spine/Cord – Injury Severity No neurological deficit Nerve root only Total

1 1 2

1 1 2

Eye – Injury Type Hyphema Other Total

3 2 5

3 2 5

Abdomen – Injury Type Kidney Spleen Liver Intestine Total

1 4

1 1 1 1 4

1 1 1 1 4

Waterskiing 215 Table 14.3 (continued ) Anatomical Location

Survivors

Fatalities

Total

Chest – Injury Type Pneumothorax Hemothorax Total

1 1 2

1 1 2

Limb – Injury Type Loss of limb Total

1 1

1 1

Note: Each entry indicates the number of cases in which this type of injury occurred. Persons may have had more than one injury.

Head and Face In waterskiing, catastrophic injuries of the head and face occur most often after falls, propeller injuries, and collisions.7 As previously stated, head injuries have been reported as the primary cause of death due to propeller strikes.6 Head injuries sustained in waterskiing include subdural hematoma, fractured skull, closed and open head injury, and scalp laceration.5,7,9 In Hummel and Gainor’s series,7 a fatal open head injury was due to a propeller strike, and a closed head injury was also reported as a result of a collision. There is one report11 of an unusual wake-boarding injury in a male, age 14 years, who sustained an intracranial subdural hemorrhage after a malfunction of the towing device. In our series, there were two skull fractures (Table 14.3). Spine and Spinal Cord In our study, there were two spinal cord injuries during the 4 survey years: one spinal fracture and one spinal fracture-dislocation. Hummel and Gainor7 also reported spinal cord injuries, with a C5–C6 dislocation that resulted from a collision. Although our study focuses on injuries associated with recreational waterskiing, it should be noted that there is a high incidence of lumbar spine injury associated with the high impact jump event in competitive waterskiing.12

216 Water Sports Table 14.4 Catastrophic Waterskiing Injuries – Whether Preventable, AlcoholRelated, or Incurred in a Supervised Setting (% in parentheses) Yes Was injury preventable? Was injury alcohol-related? Was activity supervised?

3 0 0

(75) (0) (0)

No 1 4 4

(25) (100) (100)

Note: As reported by the primary physician involved in the case. Data given are for cases with information provided, and therefore may not encompass all catastrophic injury cases in this sport or recreational activity.

Lower Limbs The lower limbs are most frequently involved in propeller-related waterskiing injuries, and in injuries due to collisions and falls.7 In general, the lower limbs are the most frequently affected part of the body in waterskiing injuries, and in one series accounted for 35.3% of all injuries; 17.3% were to the knee joint.13 Hamstring injuries have already been described, and other reported injuries to the lower limbs include lacerations of the thigh, calf, and foot, as well as a traumatic foot amputation; several were due to propeller strikes.7–9 Our study included one waterskier who lost a limb and subsequently died as a result of the injury. Fatalities Although national figures specific to waterskiing remain unavailable, it is known that 5,900 Canadians drowned between 1991 and 2000, and 68% of these drownings were due to recreational activities such as boating and other aquatic activities.14 As previously stated, head injuries account for 40% of deaths related to propeller injuries.6 In our study, there were 0.5 fatalities per year and 0.005 fatalities per 100,000 population (Table 14.2). The two fatalities involved one drowning, as well as the following multiple injuries: loss of limb; pneumothorax; hemothorax; abdominal injuries involving the spleen, kidney, liver and intestine; and skull fracture (Table 14.3). Severity of Injuries A review of the literature revealed that waterskiing injuries can be very severe, and further injury prevention research is necessary for a

Waterskiing 217

sport that continues to grow in popularity. Injuries secondary to falls were found to be associated with a high level of trauma, and comparable to the severity of injuries in major contact sports. Finally, tow rope-related injuries can be extremely severe and disabling from injuries such as avulsion of digits.5,7 Injury Risk Factors The following risk factors for waterskiing injuries were identified in the literature and in our study (Table 14.4): • The use of alcohol and drugs increases the risk of injury in water-

• • • • • • •

skiing. In our study, alcohol was definitely not involved in four of the nine catastrophic injury cases; however, information relating to alcohol involvement is not known for the remaining five. Waterskiing without a capable observer present, in addition to the boat driver. The absence of a personal flotation device (PFD). Waterskiing at high speeds, especially near the shoreline and around buoys. Absence of a proper warm-up program. Fatigue. Low level of experience. Male gender.

Gender has been suggested to be a risk factor for injury. More men than women participate in waterskiing. Many waterskiing accidents have been caused by prior alcohol consumption, or by inexperienced waterskiers who think themselves capable of performing advanced tricks. Some authors have theorized that men are predisposed to such behaviour, and are therefore more likely to sustain injuries in waterskiing than women.1,5,6,8 Tips for waterskiing safety often indicate that boat speeds should be better regulated, especially in areas that are close to the shoreline and around docks and buoys.5–7 Travelling at very high speeds can increase the risk of severe injuries due to falls or collisions. Injury Prevention Tips Some strategies for injury prevention with respect to equipment and preparation, boat operation, and general safety are detailed below.

218 Water Sports

Equipment and Preparation • Before each use, waterskis should be inspected to ensure that

• •

•

•

they are free of any wear and tear such as loose screws and cracks. Before each use, the tow rope should be inspected, and should only be used if it is free of frays or knots. Waterskiers, boat operators, and observers should all wear an approved PFD. If an individual is knocked unconscious, the PFD is designed to turn the wearer onto his or her back, greatly reducing the risk of drowning or further injury. To minimize errors in communication, standard hand signals should be discussed among the boat driver, observer, and skier before waterskiing. More advanced waterskiing requires special bindings that should be fitted by a professional. Make sure that the correct size ski and bindings are being used. The fit of the binding should be snug, but not tight.

Boat Operation • The boat operator, observer, and waterskier should all be sober and

alert. Fatigue, alcohol, and drugs can all seriously impair safety. It is also important to note that alcohol increases body heat loss, and can therefore reduce the survival time of a skier who has fallen into cold water. • Boat speeds should not exceed 32 km/hour for beginners and 58 km/hour for advanced skiers.2,15,16 • The observer should be responsible for giving the boat driver instructions about the skier in order to ensure the skier’s safety. The observer should also look out for debris or possible obstructions in the water. Hummel and Gainor7 addressed the importance of the ‘nuclear trio’ of participants. This idea has been referred to in more recent literature, which stresses the importance of a capable and careful boat driver, a constantly alert and attentive observer on board the boat, and a well-informed waterskier wearing a PFD. • Boat operators should turn the engine off before attending to any injuries. This will decrease the risk of propeller injuries.

Waterskiing 219

General Safety • Always check the weather prior to leaving, and make sure to

return to shore if the weather becomes unfavourable. • Familiarize yourself with the waterskiing area. • Avoid waterskiing near docks, pilings, shoreline, and shallow

water. Serious collision and propeller injuries can occur in these areas for both the waterskier and for other swimmers who are in the water. • Skis or tow ropes that are left trailing behind a boat must be removed from the water before returning to the take-off area. • Dropped skis should be promptly removed from the water in order to decrease the risk that other boats, skiers, or swimmers will sustain a collision injury. • In recreational waterskiing and unsupervised settings, jumps and ramps should not be used. References 1. Water Ski Canada Snapshot. http://www.utoronto.ca/ski/water/ca /geninfo.html. Retrieved 15 June, 2004. 2. WaterSki History. http://keneva.com/WaterskiHistory.htm. Retrieved 22 June, 2004. 3. Bellis M. History of Waterskiing: Ralph Samuelson Invented the Sport of Water Skiing in 1922. http://inventors.about.com/library/inventors/ blwaterskiing.htm. Retrieved 23 June, 2004. 4. Water Ski. http://www.worldgames-iwga.org/vsite/vcontent/page/ custom/0,8510,1044-127200-128507-18076-62427-custom-item,00.html. Retrieved 20 June, 2004. 5. Roberts C. A Review of Water-Skiing Safety in the USA. 1993. http://www .roberts.ezpublishing.com/wski/safety.htm. Retrieved 15 June, 2004. 6. Chalmers D, Morrison L. Epidemiology of non-submersion injuries in aquatic sporting and recreational activities. Sports Med 2003;33(10): 745–70. 7. Hummel G, Gainor BJ. Waterskiing-related injuries. Am J Sports Med 1982;10(4):215–18. 8. Sallay PI, Friedman RL, Coogan PG, Garrett WE. Hamstring muscle injuries among waterskiers. Functional outcome and prevention. Am J Sports Med 1996;24(2:130–6.

220 Water Sports 9. Mann RJ. Propeller injuries incurred in boating accidents. Am J Sports Med 1980;8(4):280–4. 10. Lee RY, Miller S, Thorpe C. Intrarectal tear from waterskiing. Am J Gastroenterol 1992;87(5):662–3. 11. Chia JK, Goh KY, Chan C. An unusual case of traumatic intracranial hemorrhage caused by wakeboarding. Pediatr Neurosurg 2000;32(6): 291–4. 12. Roberts SN, Roberts PM. Tournament waterskiing trauma. Br J Sports Med 1996;30(2):90–3. 13. Truong A, Ward J. Strength and Conditioning to Prevent Knee Injuries in Waterskiers. http://waterski.about.com/library/weekly/blknee _prevention.htm. Retrieved 10 June, 2004. 14. Barss, P. What We Have Learned: 10 Years of Pertinent Facts About Drownings and Other Water-Related Injuries in Canada 1991–2000. Ottawa: Canadian Red Cross, pp. 1–24. 15. Waterskiing Safety. http://www.waterski-az.co.uk/safety.htm. Retrieved 20 June, 2004. 16. Water Ski Safety. http://www.murrayriver.com.au/boating/skiing.htm. Retrieved 20 June, 2004.

Recto Running Head 221

15 Other Water Sports Parasailing, Parachute-Skiing, Sailboarding, Sea-Biscuit Riding, Surfing, Water-Tubing, Water Polo, Watersliding, Water Play, and Windsurfing michael detsky and mark o. baerlocher Water sports can be healthy, outdoor activities for fun and fitness. Indeed, many believe swimming to be one of the best forms of exercise, given its joint-protective, low-impact nature. Water sports are very popular activities for all age groups, especially in the summer, but with popularity comes a high incidence of injuries. Worldwide, there are many causes of injuries in this diverse group of water-play activities such as jellyfish stings and shark bites, although in Ontario the causes are more circumscribed.1 This chapter focuses on catastrophic injuries in the following water sports which we classify as other water sports: parasailing, parachute-skiing, sailboarding, seabiscuit riding, surfing, water-tubing, water polo, waterslide play, windsurfing, and other water play. These activities are quite popular among all members of society, and as such, people from all age ranges are susceptible to the associated injuries. The relatively high incidence of these injuries has raised concern about the safety of these activities, and specifically about whether additional efforts and funding should be targeted towards safety programs in this area.2 Specific water activities such as boating, swimming, and waterskiing are examined in separate chapters. Incidence of Injuries According to the McLaren Report,3 there is a 1.1% participation rate among all ages in sailboarding (1.7% for males, 0.6% for females) and a less than 0.1% participation rate in water polo (Appendix). There were no data on participation rates for parasailing, parachute-skiing, sea-biscuit riding, surfing, water-tubing, waterslide play, windsurfing,

222 Water Sports Table 15.1 Catastrophic Injuries Sustained in Other Water Sports: 15 Survivors and 6 Fatalities, by Activity, Gender, and Agea,b Activity

Total

Fatalities

Gender, and Age (years)

Parasailing Parachute Skiing Sailboard Sea-Biscuit Riding Surfing Water Tubing

1 1 1 1 1 3

1 Female

Water Polo Watersliding Windsurfing

1 2 3

2 Males

Play

7

2 Females, 1 Male

Female, 41–50 Male, 11–20 Male, age missing Female, 11–20 Male, 31–40 Female,