BG Trauma Center, Eberhard-Karls-University, Tübingen, Germany
BG Trauma Center, University of Tübingen
72076 Tübingen / Germany
Key words: in-line skating, wrist fracture, sports injury, prevention, epidemiology
In-line skating is getting more and more popular, and an increasing number of in-line related injuries have been reported in several studies. We registered prospectively the pattern of injuries in rollerbladers during one summer season. Injury severity has been assessed according to three groups. Group A: fractures requiring operative treatment, group B: fractures not requiring operative treatment, and group C: sprains, bruises and abrasions. Skating experience, mechanisms of accident and use of safety gear have been recorded with a questionnaire. 58 in-line skaters with 63 single injuries were included in the study. The predominant site of injury was the upper extremity with wrist fractures the most common single injury, but there were also three proximal femoral fractures in patients older than 36 years. Severe injuries according to group A were three times as high in patients older than 36 years, in skaters with less experience than 1 month and in skaters classifying themselves as beginner". Safety gear was not widely used in our study group. Besides its direct effects, protective equipment enables skaters to fall securely; thus, it may also help to prevent severe injuries.
In-line skating has gained increased popularity in recent years as recreational activity in children, youngsters and adults as well. Due to the characteristics of the sport device, acrobatic maneuvers and high speed skating can be performed. In the United States, the estimated number of skaters has increased from 12.5 millions in 1993 to 22.6 millions in 1995, and the number of in-line related injuries had been estimated as high as 31,000 and 99,500 respectively [10,12]. Although in-line skating still is a sport mainly popular in teenagers, the highest number of novice skaters can be found beyond the age of 30.
All in-line skaters who where referred to our trauma center within the summer season 1996 were included in this study. Patterns of injury and treatment were recorded. The injury severity was classified in three groups:
Group A: fractures, which had to be treated operatively,
Group B: fractures which could be treated non-operatively and
Group C: sprains, abrasions and bruises.
The cause of the accident according to self-assessment of the skaters, duration of and experience in skating and the use of safety gear was recorded by means of a questionnaire.
Fifty-eight patients aged 8 to 54 years were included in the study, mean age was 22.2 years and the age median was 16 years. 48 % of the patients were aged 16 or younger, but, on the other hand, 15 patients were older than 30 years, and 7 patients were older than 40 years (figure 1). There were 34 males (58.6 %) and 24 females (41.4 %). According to self-assessment, 57 % rated themselves as having some experience" or professional", but other 43 % regarded themselves as beginners". 28 % of patients had less than 1 month experience in in-line skating.
The most common mechanism of injury was simply falling (57 %); the secondmost mechanism (22 %) was an obstacle suddenly hidden by the skater. Collision with other skater, pedestrians or vehicles could be observed only occasionally. According to the self-assessment, insufficient ability to control one's skates (48 %) and difficulties in stopping (16 %) were the most common causes for the accident.
Safety gear was not widely used by skaters included in our study. Only two skaters (3.4 %) used a complete set of safety gear including wrist guard, elbow pads, knee pads and helmet, and 22 % used a complete set of joint guards but no helmet. The protective device most commonly used was a wrist guard, which had been worn by 52.1 % of injured skaters. On the other hand, 43.8 % did not use any protective gear at all.
Sixty-three single injuries could be found in our patients, i.e. 1.1 injury per patient; 8.6 % of the patients had more than one single injury. The region most commonly injured was the upper limb, 63.5 % of all injuries were those of the upper limb; 27 % of all injuries were related to the lower limb. Other body regions were injured much less common (figure 2). According to the classification of injury severity, 32 % had a fracture, which had to be treated operatively (group A), 32 % had a fracture not requiring operative treatment (group B), and 36 % had sprains, bruises and abrasions (group C).
Novice skaters and skaters beyond the age of thirty had a higher incidence of severe injuries as compared to younger and experienced skaters. The rate of severe injuries was higher in skaters rating themselves as beginners and skaters with less than 1 month skating experience as compared to the subgroup of skaters with a higher self-rating or a longer experience (figure 4a and 4b). The rate of injuries that had to be treated operatively (group A) was three times as high in the subgroup of skaters older than 36 years old than in younger skaters (figure 3c).
The most common single damage was a fracture of the wrist (25.4 %), followed by sprains of the upper limb (12.7 %). Other injuries of the upper extremity included fractures of the forearm, fractures of the elbow joint, the humerus and the hand. Injuries of the lower limb included sprains of the knee and ankle joint, but also several fractures of the upper and the lower leg. Two femoral neck fractures and one pertrochanteric fracture could be observed in 3 patients aged 37 to 46 years (figure 5). Other severe injuries consisted in one distal intraarticular lower leg fracture with a compartment syndrome and a serial fracture of an arm in a 34 year old female skater with an intraarticular distal humerus fracture and an intraarticular wrist fracture. All single injuries, which had been observed in in-line-skaters during the study period are listed in figure 4a. The injuries in the group of patients older than 36 years is shown in figure 4b.
Most patients could be treated as outpatients, but 22.4 % needed hospitalization, which lasted 3 to 54 days (mean 19.2 days). The most common single operative procedure that had to be performed was closed reduction and stabilization by wires in displaced wrist fractures; 2 wrist fractures had to undergo open reduction and internal fixation. In the 2 cases with femoral neck fractures stabilization was achieved by screws and a dynamic hip screw respectively, the pertrochanteric fracture was stabilized by application of a proximal femoral nail. The fracture of the distal lower limb was stabilized by external fixation and converted to a unreamed intramedullary nail after some days of soft-tissue consolidation. The sequential fractures of the upper limb required stabilization by external fixation and sequential reconstructive surgical procedures by open reduction and plating in both joints and resulting in disability with severely reduced range of motion.
The most common cause of injury in in-line skaters seems to be a simple fall without anybody else to blame for, often related to difficulties in stopping. Similar patterns have been observed by other authors [1,9]. This mechanism leads to a fall onto the arm and wrist, which, accordingly, is the region most commonly injured. This was found by several studies and could be confirmed in our study [3,4,6,11]. On the other hand, some more severe injuries in the lower extremity have been observed by several authors [5,8] and this injuries could also be found in the present study.
Skaters who are at their very beginning in this sport seem to have a higher incidence of severe injuries. This may in part be explained by inexperienced skating and an increased susceptibility to fall. In a pediatric study 1 out of 8 injured skaters sustained a fracture during the first attempt in this sport . In another study, 30 % of injured skaters in the 10 - 14 year age group had been using in-line skates for the first time . Novice skaters, however, are inexperienced in falling as well, and they lack the correct technique in falling securely. By this mean the higher incidence of more severe injuries can be explained in this subgroup of skaters. In an observational study in college students, however, mostly minor injuries were found to occur during the first times skating, while serious injuries tended to occur after at least 50 times on in-line skates .
The age of skaters seems to be of additional interest. In our study, skaters older than 36 years old, had an increased probability of fractures, which had to be treated operatively. This is of special interest in the light of the fact that the group of skaters beyond the age of 30 is the fastest growing one. All fractures of the femur were found in patients older than 36 years. This group of skaters mostly had only limited experience in skating, and a decreased capability of falling securely may play the major role for injury severity.
Protective equipment has been recommended by several studies, and the value of wrist splints was proven in recent studies [1,12]. Some authors, however, describe problems associated with wrist guards and could not confirm their effectiveness. Generally, safety gear is not used commonly, as one can easily observe on every summer day. This impression could be confirmed in several studies [2,9,15]. We also found only a limited number of patients who made use of a complete set of protective equipment.
Indirectly, the use of safety gear may be of additional value in the prevention of severe injuries. The ability to apply secure falling techniques is increased by the protection of knees, elbows and the wrist and thus more severe injuries can be prevented. Thus, besides their direct effect [12,13], the use of a complete set of elbow-, knee- and wrist-pads may also help to reduce the probability of femoral fractures and other severe injuries