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Head, face and neck injuries in hockey: A descriptive analysis
The Journal of Emergenq
Medicine. Vol 14. No 5. pp 645-644, 1996 Copyright 0 1996 Elhewrr Science Inc. Printed in the IJSA. ,411rights reserved
~Ji36-4h7"IlYh %l5.W * .oo
PI1 SO736-4679(96) 00134-5
Candian ctives Pe
----
HEAD, FACE AND NECK INJURIES IN HOCKEY: A DEBCRIPTWE AP4ALYSlS Brian Deady,
MD,
FRCP(C)*
Robert J. Brison,
MD,
MPH
FRcP(C),tjz and Lise Chevrier,
BSCN,
MSC*
‘The Royal Columbian Hospital, New Westminster, British Columbia, Canada of Emergency Medicine, *Department of Community Health and Epidemiology, Queen’s University. Kingston, Ontario, Canada SDepartment of Community Health and Epidemiology, Queen’s University, Kingston, Ontario, Canada Reprint Address: Dr. Brian Deady, MD, FRCP(C), Emergency Department, The Royal Columbian Hopital, 330 East Columbia Street, New Westminster, BC, Canada, V3L 3W7 TDepartment
described (4,7,8,12- 1.5). Currently, minor hockey associations in Canada require that their players be equipped with approved helmets and protective face shields. Increasingly, protective neck gear is used, designed primarily to guard the soft tissues of the anterior neck. Some investigators have noted a decrease in closed head, ocular, and dental injuries since the introduction of mandatory use of helmets and face shields (l-4,7-9). Others have reported a possible link between full head and face protection and an increased risk for serious cervical spine injury (4,6). Despite more frequent use of proper craniofacial and neck protection, emergency physicians continue to encounter a wide variety of head, face, and neck in.juries resulting from playing hockey. Although the magnitude of the problem is clear. previous studies have frequently focused on specific age groups or specific levels of players, i.e., children or elite league players ( 1,2,5,9- 11.15). This study looks at hockey injuries located at the head, face, or neck treated in two urban Canadian emergency departments. All such injuries were included regardless of the age of the player, the level of play, or whether the injury occurred in a league or pick-up/shinny game. The purpose of this investigation was to document the types and mechanisms of injury related to playing
0 Abstract-Patients presenting to the emergency departments in Kingston, Ontario, between 1 October 1992 and 30 April 1993 with head, face, and neck injuries from playing ice hockey, regardless of the age of the player or whether the play was recreational or league, were enrolled in this prospective descriptive case series analysis to document the type and mechanism of injury in relation to the rise of protective head and neck gear. A total of 119 such injuries were seen, 84 (71%) of which were lacerations. Players aged 20-34 years were most frequently injured, most commonly through contact with sticks and pucks while wearing helmets but no face shields. Strict enforcement of the rules is required to minimize injuries. Further study is required to determine the reasons for the incomplete protection afforded by helmets and face shields noted here. Cl Keywords-ice neck injuries
hockey; protective head gear; head,
INTRODUCTION
Ice hockey players are frequently injured and suffer a variety of insults ( 1- 15) . Injuries to the head, face, and neck are the most commonly encountered type of injury related to playing hockey (1,4,9,10). Serious in.juries to the head, eyes, face, and neck have been
hockey.
Canadian Perspectives is coordinated by James Duchmme, MD, of the Canadian Association of Emergency Physicians (CAEP) and St. John Regional Hospital, St. John, New Brunswick, Canada ^--111-...--__--RECEIVED : 13 October 1995; FINAL SUBMISSION RECEIVED : 24 January 1996; ACCEPTED: 20 February 1996 645
B. Deady et al.
MATERIALS
AND METHODS
From 1 October 1992 to 30 April 1993, the emergency departments of the Kingston General and the Hotel Dieu Hospitals, which service Kingston, Ontario (catchment area of 125,000 people), were the sites of this study. All patients with hockey injuries presenting to either emergency department during the study period were given an information sheet that described the investigation. The information sheet also stated that those patients with injuries localized to the head, face, or neck would receive a follow-up telephone call unless they objected. All emergency-department encounters of injuries related to hockey were coded to identify types of injury. Weekly records were reviewed using hospital information systems to select those patients treated in our emergency departments for head, face, or neck injuries secondary to hockey. Data abstracted from the charts included age and sex of the player, anatomical injuries sustained, medical treatment provided, and disposition of the patient. Telephone follow up was performed with a standardized form. Parents or guardians were interviewed when patients were younger than 12 years old. More detailed data were sought to explain the mechanism of injury in correlation to the type of play (practice, league game, or pick-up/shinny game) and to the use of protective head gear at the time of injury. Once recorded, all information was then transferred to a database on a personal computer for analysis. There is no comparison group of noninjured players in this study. That is, there is no documentation of the number of players involved, the number of games played, or the number of potential injury-inducing incidents. Hence, there is no calculation of risk for different injuries via various injury mechanisms stratified by types of head, face, and neck protection. Although we believe that most players with injuries serious enough to merit medical attention would have presented to one of the emergency departments in-
Table 1. Anatomical Location of Injuries Location
No. of Injuries
Eyebrow Lip Chin Nose Neck Head Forehead Eye or eyelid Face Other Total
19 18 16 13 11 10 9 7 2 14 119
volved in this study, there are no data on players that may instead have sought care from either their family physicians or their dentists, as the case warranted. RESULTS During the study period, 119 patients with head, face, and neck injuries related to hockey were enrolled in the investigation. Seventeen of the 119 players could not be reached for telephone follow up. Data for these 17 individuals were abstracted from the original records when possible. Information unavailable because of lack of telephone follow up was recorded simply as “unknown.” Patients were 5-54 years old, with an average age of 24 years (Figure 1). All but one of the patients were male. Fifty-nine players (50%) were injured in league games, and 43 (36%) received injuries during pick-up/shinny games. Ninety-one injuries, the vast majority, occurred on indoor ice rinks. Table 1 lists 119 injuries noted at several anatomical sites, mostly on the face, including the eyebrow, lip, chin, and nose. The majority of the injuries were lacerations, totaling 84 incidents (7 1%) , 77 (92%) of which required sutures. Soft tissue injuries were the next most commonly encountered insult, resulting in 16 incidents (13%). Closed head trauma accounted
Table 2. Description of Secondary Injuries Type of Injury
AGE GNOWINGS
Figure 1. Age distribution of injuries.
Lacerations (various) Dental fracture Closed head injury Soft tissue injury Fracture of nose Query spinal injury Hyphema of eye Total
No. of Injuries 5 3 3 2 1 1 1 16
647
Head and Neck Injuries in Hockey -.-_
TYPE OF FACE
SHIELD
AGE GROUPINGS
Figure 2. Use of face shields.
Figure 3. Mechanisms of injuw.
for 6 (5%) of the 119 injuries. Sixteen players also suffered a second injury noted at the time of initial presentation, including 3 dental fractures and 1 hyphema (Table 2). At the time of injury, 78 of the 119 injured players were wearing helmets, 3 of whom had their helmets knocked off at or prior to the injury. Of the 78 players using helmets, 30 were using some form of face shield (Figure 2). Twenty-two of these 30 were equipped with full face shields, 18 of which were the “metal cage” variety and 4 were of the Plexiglas type. Eight players were equipped with the half-visor style of face shield. From these data, the greatest number of injuries occurred in players wearing a helmet with no face shield (48), followed by those wearing no helmet at all (24). Table 3 lists the anatomical location of injuries in the context of helmet and face mask use. There were 30 injuries in those players using a helmet and some form of face mask; 19 of these injuries were at the head or face regions. A total of 13 players wore neck protection, 6 of whom were goal tenders. The most common mechanism for injury was contact with a stick, which produced 45 ( 38% ) of the 119 injuries (Figure 3 ) . Puck strikes caused 34 (29%) of the insults, the second most common mechanism. Body checks caused 13 ( 11%)
injuries; body checks from behind produced 4 (3%) of the documented cases. Simple falls or trips caused 7 injuries. Fighting produced 2 injuries. Contact with skate blades caused 1 injury. Figure 3 also shows that players aged 20-34 years, the most frequently injured age group, were most often hurt through contact with pucks and sticks. The younger age groups, particularly those younger than 15 years, were much less frequently injured. In considering the mechanisms of injury in light of helmet and face mask usage, Figure 4 shows that if the injured player used either a helmet alone or no head gear at all, he was more likely injured by a stick or a puck. Of the 13 players injured by body checking, 4 were hurt by checks from behind, all of whom were wearing helmets with full face shields. All 4 of these players were lo- 19 years old. Figure 5 shows the number of injuries per age group broken down by helmet and face mask use. In the three age groups 20-34 years old, those who wore a helmet but no face shield were more commonly injured. In those younger than 20 years old, there were no recorded injuries in the category of players using helmets without face shields, but 11 players were injured while wearing no helmet or face protection. Although uncommon in this study, 2 players were injured when their face shields were broken. In the
Table 3. Anatomical Location of Injuries vs. Head Protection No Helmet/ Location Eyebrow Lip Chin Nose Neck Head Forehead Eye or eyelid Face Other Total
-_.__-_-_
No Mask
Helmet Only
9 9
3 0 4 24
10 7 2 2 1 3 1 4 48
Helmet + Face Mask 2 4 2 3 7 4 4 0 0 4 30
Unknown 2 3 3 0 2 2 1 1 1 2 17
Total 19 18 16 13 11 10 9 7 2 14 119
648
B. Deady et al.
first case, a player suffered a fractured nose when his metal face shield was struck by an opponent’s stick. In the second case, a puck struck the player’s metal face shield, resulting in a facial laceration. There were several injuries of a more serious nature in this series. Two players required operative procedures, including the individual who suffered a depressed, cornminuted nasal fracture as a result of the breakage of his metal facial shield. The other player also suffered a fractured nose, requiring closed reduction under a general anesthetic. He was struck by a puck while wearing a helmet without a face shield. Two players required admission to hospital, 1 for a significant scalp laceration after being checked. This player had taken off his helmet prior to injury because his visor had fogged up. The second was admitted because of a forehead laceration and concern about a possible cervical spine injury, later ruled out. This second player had been tripped. The one case of hyphema encountered (Table 2) occurred in a player who was not wearing a face shield. Only 1 player suffered a serious neck injury; however, he was suffering from a previously undiagnosed metastatic lesion to his cervical spine. It is unlikely that he would have sustained the cervical fracture that was documented had he not been thus afflicted. Only one player admitted to alcohol use prior to playing hockey.
DISCUSSION Although acceptanceof injuries as an unavoidable byproduct of hockey is declining, it seems unlikely that injuries will ever be completely eliminated. In this study, players aged 20-34 years formed the largest group of injured individuals treated in our emergency departments. Most often, they were injured through contact with sticks and pucks. These age
MECHANISM
OF INJURY
Figure 4. Mechanism of injury vs. use of head gear.
AGE GROUPS
Figure 5. Use of head gear by age group.
groups were more commonly injured while wearing helmets without face masks. Body checking hasbeenidentified as a common cause of injury among adolescents(2,11) . This study recorded 13 injuries due to body checking, 7 of which occurred in the adolescentcategoriesof lo- 14 and 15- 19 years. Body checking from behind hasbeendescribedasa cause of catastrophic cervical spine injury in hockey players (4,6,13,14). In this study, 4 injuries caused by checks from behind were documentedin the lo- 14 and 15- 19 age groups among players with helmets and full face masks.Fortunately, none of theseplayers suffereda serious cervical spine injury. No player younger than 20 years was injured while wearing a helmet alone without a face mask. Eleven players younger than 20 years old, however, were injured while wearing no helmet or face mask. Becauseminor hockey leagues require both head and face protection, some younger players at least occasionally may engage in recreational shinny hockey wearing no head or face protection at all. Previous studies have reported an elimination of serious eye injuries with the use of proper head and face protection (l-4,7-9). Predictably, the only serious eye injury (a hyphema) encounteredin this series occurred in an individual unequipped with a face shield. Contact with sticks was the most common mechanism for injury. Use of the stick above the level of the shoulder, therefore, should be seriously discouraged through strict enforcement of the rules. There were fewer injuries documentedin the category of players wearing some form of face protection (30 of 119 injuries). Yet, it is of concern that of these players wearing both helmets and face protection, 19 of their 30 described injuries were noted in the regions of the face and head, anatomical regions seemingly well protected. Previous studieshave shown incomplete protection when half visors were used extensively ( 10). More study is required because it is unclear from these data why full head and face protection offered only incomplete protection against head and face
649
Head and Neck Injuries in Hockey
trauma. Further study is also required into the materials used in the face shields. In 2 cases players were hurt when their metal shields were broken. Another player suffered a significant scalp laceration after removing his helmet when the face shield becamefogged. Defective face masks have been identified as a contributing factor to craniofacial injuries (1). There were no treatment implications for emergency physicians identified here. That is, one would not expect to treat a laceration, for example, secondary to hockey differently than one would treat a laceration as a result of another mechanism.
CONCLUSION Players wearing helmets with no face masks were more frequently injured through contact with sticks or pucks. Use of the stick above the shoulders must be seriously discouraged through strict rule enforcement. More study is required to addressthe reasonsfor incomplete protection afforded by the helmets equipped with face shields noted here. Acknowledgments-This study was made possible through a grant from the Emergency Health Services Branch. The Ministry of Health of the Province of Ontario,
REFERENCES 1. Bjorkenheim J-M, Syvahuoko I, Rosengerg PH. Injuries in competitive junior ice-hockey: 1437 players followed for one season. kcta O&op Stand. 19$3;64(4):439-61. 2. Brust JD. Leonard BJ. Phelev A. Roberts WO. Children’s ice hockey injuries. Am J’Dis Cl&ren 1992; 146(6):741-7. 3. Castaldi CR. Prevention of craniofacial injuries in ice hockey. Dent Clin North Am. 1991;35(4):647-56. 4. Daly PJ, Sim FH, Simonet WT. Ice hockey injuries. A review. Sports Med. 1990;10(3):122-31. 5. Kvist M, Kujala UM, Heinonen OJ, Vuori AJ, Aho AJ, Pajulo 0. Hinsta A, Parvinen T. Sports-related injuries in children. Int J Sports Med. 1989;10:81-6. 6. Murray TM, Livingston LA. Hockey helmets, face masks, and injurious behavior. Pediatrics. 1995;95( 3):419-21. 7. Pashby TJ. Eye injuries in Canadian amateur hockey. Am J Sports Med. 1979;7(4):254-7. 8. Pashby TJ. Eye injuries in Canadian amateur hockey, still a concern. Can J Ophthalmol. 1987;22:293-5. 9. Pelletier RL, Montelpaxe WJ. Stark RM. Intercollegiate ice
hockey injuries. A case for uniform detinitions and reports. Am J Sports Med. 1993;21(1):78-81. 10. PettersonM, Lorentzon R. Ice hockey injuries: a 4-year prospective study of a Swedish elite ice hockey team. Rr J Sports Med. 1993;27(4):251-4. 11. Regnier G, Boileau R, Marcotte G, Desharnais R. Larouche R. Bernard D, Roy M-A, Trudel P, Boulanger D. Effects of bodychecking in the Pee-Wee ( 12 and 13 years old ) division in the province of Quebec. In: Castaldi CR. Hoener ER, eds. Safety in ice hockey. Philadelphia: American Societv for Testing & Materials; 1989:84-103. 12. Sullivan P. Sports MDs seek CMA support m bid to make hockey safer. Can Med Assoc J. 1990; 142:157-9, 13. Tator CH, Edmonds VE. National survey of spinal injuries in hockey players. Can Med Assoc J. 1984; 130:X75--80. 14. Tator CH, Edmonds V, Lapczak L. Spinal injuries in ice hockey players 1966 to 1987. Can J Surg. 1991;34( 1):63-9. 15. Tegner Y, Lorentzon R. Ice hockey injuries: incidence. nature and causes. Br J Sports Med. 1991:25(2):85 0.
Medicine. Vol 14. No 5. pp 645-644, 1996 Copyright 0 1996 Elhewrr Science Inc. Printed in the IJSA. ,411rights reserved
~Ji36-4h7"IlYh %l5.W * .oo
PI1 SO736-4679(96) 00134-5
Candian ctives Pe
----
HEAD, FACE AND NECK INJURIES IN HOCKEY: A DEBCRIPTWE AP4ALYSlS Brian Deady,
MD,
FRCP(C)*
Robert J. Brison,
MD,
MPH
FRcP(C),tjz and Lise Chevrier,
BSCN,
MSC*
‘The Royal Columbian Hospital, New Westminster, British Columbia, Canada of Emergency Medicine, *Department of Community Health and Epidemiology, Queen’s University. Kingston, Ontario, Canada SDepartment of Community Health and Epidemiology, Queen’s University, Kingston, Ontario, Canada Reprint Address: Dr. Brian Deady, MD, FRCP(C), Emergency Department, The Royal Columbian Hopital, 330 East Columbia Street, New Westminster, BC, Canada, V3L 3W7 TDepartment
described (4,7,8,12- 1.5). Currently, minor hockey associations in Canada require that their players be equipped with approved helmets and protective face shields. Increasingly, protective neck gear is used, designed primarily to guard the soft tissues of the anterior neck. Some investigators have noted a decrease in closed head, ocular, and dental injuries since the introduction of mandatory use of helmets and face shields (l-4,7-9). Others have reported a possible link between full head and face protection and an increased risk for serious cervical spine injury (4,6). Despite more frequent use of proper craniofacial and neck protection, emergency physicians continue to encounter a wide variety of head, face, and neck in.juries resulting from playing hockey. Although the magnitude of the problem is clear. previous studies have frequently focused on specific age groups or specific levels of players, i.e., children or elite league players ( 1,2,5,9- 11.15). This study looks at hockey injuries located at the head, face, or neck treated in two urban Canadian emergency departments. All such injuries were included regardless of the age of the player, the level of play, or whether the injury occurred in a league or pick-up/shinny game. The purpose of this investigation was to document the types and mechanisms of injury related to playing
0 Abstract-Patients presenting to the emergency departments in Kingston, Ontario, between 1 October 1992 and 30 April 1993 with head, face, and neck injuries from playing ice hockey, regardless of the age of the player or whether the play was recreational or league, were enrolled in this prospective descriptive case series analysis to document the type and mechanism of injury in relation to the rise of protective head and neck gear. A total of 119 such injuries were seen, 84 (71%) of which were lacerations. Players aged 20-34 years were most frequently injured, most commonly through contact with sticks and pucks while wearing helmets but no face shields. Strict enforcement of the rules is required to minimize injuries. Further study is required to determine the reasons for the incomplete protection afforded by helmets and face shields noted here. Cl Keywords-ice neck injuries
hockey; protective head gear; head,
INTRODUCTION
Ice hockey players are frequently injured and suffer a variety of insults ( 1- 15) . Injuries to the head, face, and neck are the most commonly encountered type of injury related to playing hockey (1,4,9,10). Serious in.juries to the head, eyes, face, and neck have been
hockey.
Canadian Perspectives is coordinated by James Duchmme, MD, of the Canadian Association of Emergency Physicians (CAEP) and St. John Regional Hospital, St. John, New Brunswick, Canada ^--111-...--__--RECEIVED : 13 October 1995; FINAL SUBMISSION RECEIVED : 24 January 1996; ACCEPTED: 20 February 1996 645
B. Deady et al.
MATERIALS
AND METHODS
From 1 October 1992 to 30 April 1993, the emergency departments of the Kingston General and the Hotel Dieu Hospitals, which service Kingston, Ontario (catchment area of 125,000 people), were the sites of this study. All patients with hockey injuries presenting to either emergency department during the study period were given an information sheet that described the investigation. The information sheet also stated that those patients with injuries localized to the head, face, or neck would receive a follow-up telephone call unless they objected. All emergency-department encounters of injuries related to hockey were coded to identify types of injury. Weekly records were reviewed using hospital information systems to select those patients treated in our emergency departments for head, face, or neck injuries secondary to hockey. Data abstracted from the charts included age and sex of the player, anatomical injuries sustained, medical treatment provided, and disposition of the patient. Telephone follow up was performed with a standardized form. Parents or guardians were interviewed when patients were younger than 12 years old. More detailed data were sought to explain the mechanism of injury in correlation to the type of play (practice, league game, or pick-up/shinny game) and to the use of protective head gear at the time of injury. Once recorded, all information was then transferred to a database on a personal computer for analysis. There is no comparison group of noninjured players in this study. That is, there is no documentation of the number of players involved, the number of games played, or the number of potential injury-inducing incidents. Hence, there is no calculation of risk for different injuries via various injury mechanisms stratified by types of head, face, and neck protection. Although we believe that most players with injuries serious enough to merit medical attention would have presented to one of the emergency departments in-
Table 1. Anatomical Location of Injuries Location
No. of Injuries
Eyebrow Lip Chin Nose Neck Head Forehead Eye or eyelid Face Other Total
19 18 16 13 11 10 9 7 2 14 119
volved in this study, there are no data on players that may instead have sought care from either their family physicians or their dentists, as the case warranted. RESULTS During the study period, 119 patients with head, face, and neck injuries related to hockey were enrolled in the investigation. Seventeen of the 119 players could not be reached for telephone follow up. Data for these 17 individuals were abstracted from the original records when possible. Information unavailable because of lack of telephone follow up was recorded simply as “unknown.” Patients were 5-54 years old, with an average age of 24 years (Figure 1). All but one of the patients were male. Fifty-nine players (50%) were injured in league games, and 43 (36%) received injuries during pick-up/shinny games. Ninety-one injuries, the vast majority, occurred on indoor ice rinks. Table 1 lists 119 injuries noted at several anatomical sites, mostly on the face, including the eyebrow, lip, chin, and nose. The majority of the injuries were lacerations, totaling 84 incidents (7 1%) , 77 (92%) of which required sutures. Soft tissue injuries were the next most commonly encountered insult, resulting in 16 incidents (13%). Closed head trauma accounted
Table 2. Description of Secondary Injuries Type of Injury
AGE GNOWINGS
Figure 1. Age distribution of injuries.
Lacerations (various) Dental fracture Closed head injury Soft tissue injury Fracture of nose Query spinal injury Hyphema of eye Total
No. of Injuries 5 3 3 2 1 1 1 16
647
Head and Neck Injuries in Hockey -.-_
TYPE OF FACE
SHIELD
AGE GROUPINGS
Figure 2. Use of face shields.
Figure 3. Mechanisms of injuw.
for 6 (5%) of the 119 injuries. Sixteen players also suffered a second injury noted at the time of initial presentation, including 3 dental fractures and 1 hyphema (Table 2). At the time of injury, 78 of the 119 injured players were wearing helmets, 3 of whom had their helmets knocked off at or prior to the injury. Of the 78 players using helmets, 30 were using some form of face shield (Figure 2). Twenty-two of these 30 were equipped with full face shields, 18 of which were the “metal cage” variety and 4 were of the Plexiglas type. Eight players were equipped with the half-visor style of face shield. From these data, the greatest number of injuries occurred in players wearing a helmet with no face shield (48), followed by those wearing no helmet at all (24). Table 3 lists the anatomical location of injuries in the context of helmet and face mask use. There were 30 injuries in those players using a helmet and some form of face mask; 19 of these injuries were at the head or face regions. A total of 13 players wore neck protection, 6 of whom were goal tenders. The most common mechanism for injury was contact with a stick, which produced 45 ( 38% ) of the 119 injuries (Figure 3 ) . Puck strikes caused 34 (29%) of the insults, the second most common mechanism. Body checks caused 13 ( 11%)
injuries; body checks from behind produced 4 (3%) of the documented cases. Simple falls or trips caused 7 injuries. Fighting produced 2 injuries. Contact with skate blades caused 1 injury. Figure 3 also shows that players aged 20-34 years, the most frequently injured age group, were most often hurt through contact with pucks and sticks. The younger age groups, particularly those younger than 15 years, were much less frequently injured. In considering the mechanisms of injury in light of helmet and face mask usage, Figure 4 shows that if the injured player used either a helmet alone or no head gear at all, he was more likely injured by a stick or a puck. Of the 13 players injured by body checking, 4 were hurt by checks from behind, all of whom were wearing helmets with full face shields. All 4 of these players were lo- 19 years old. Figure 5 shows the number of injuries per age group broken down by helmet and face mask use. In the three age groups 20-34 years old, those who wore a helmet but no face shield were more commonly injured. In those younger than 20 years old, there were no recorded injuries in the category of players using helmets without face shields, but 11 players were injured while wearing no helmet or face protection. Although uncommon in this study, 2 players were injured when their face shields were broken. In the
Table 3. Anatomical Location of Injuries vs. Head Protection No Helmet/ Location Eyebrow Lip Chin Nose Neck Head Forehead Eye or eyelid Face Other Total
-_.__-_-_
No Mask
Helmet Only
9 9
3 0 4 24
10 7 2 2 1 3 1 4 48
Helmet + Face Mask 2 4 2 3 7 4 4 0 0 4 30
Unknown 2 3 3 0 2 2 1 1 1 2 17
Total 19 18 16 13 11 10 9 7 2 14 119
648
B. Deady et al.
first case, a player suffered a fractured nose when his metal face shield was struck by an opponent’s stick. In the second case, a puck struck the player’s metal face shield, resulting in a facial laceration. There were several injuries of a more serious nature in this series. Two players required operative procedures, including the individual who suffered a depressed, cornminuted nasal fracture as a result of the breakage of his metal facial shield. The other player also suffered a fractured nose, requiring closed reduction under a general anesthetic. He was struck by a puck while wearing a helmet without a face shield. Two players required admission to hospital, 1 for a significant scalp laceration after being checked. This player had taken off his helmet prior to injury because his visor had fogged up. The second was admitted because of a forehead laceration and concern about a possible cervical spine injury, later ruled out. This second player had been tripped. The one case of hyphema encountered (Table 2) occurred in a player who was not wearing a face shield. Only 1 player suffered a serious neck injury; however, he was suffering from a previously undiagnosed metastatic lesion to his cervical spine. It is unlikely that he would have sustained the cervical fracture that was documented had he not been thus afflicted. Only one player admitted to alcohol use prior to playing hockey.
DISCUSSION Although acceptanceof injuries as an unavoidable byproduct of hockey is declining, it seems unlikely that injuries will ever be completely eliminated. In this study, players aged 20-34 years formed the largest group of injured individuals treated in our emergency departments. Most often, they were injured through contact with sticks and pucks. These age
MECHANISM
OF INJURY
Figure 4. Mechanism of injury vs. use of head gear.
AGE GROUPS
Figure 5. Use of head gear by age group.
groups were more commonly injured while wearing helmets without face masks. Body checking hasbeenidentified as a common cause of injury among adolescents(2,11) . This study recorded 13 injuries due to body checking, 7 of which occurred in the adolescentcategoriesof lo- 14 and 15- 19 years. Body checking from behind hasbeendescribedasa cause of catastrophic cervical spine injury in hockey players (4,6,13,14). In this study, 4 injuries caused by checks from behind were documentedin the lo- 14 and 15- 19 age groups among players with helmets and full face masks.Fortunately, none of theseplayers suffereda serious cervical spine injury. No player younger than 20 years was injured while wearing a helmet alone without a face mask. Eleven players younger than 20 years old, however, were injured while wearing no helmet or face mask. Becauseminor hockey leagues require both head and face protection, some younger players at least occasionally may engage in recreational shinny hockey wearing no head or face protection at all. Previous studies have reported an elimination of serious eye injuries with the use of proper head and face protection (l-4,7-9). Predictably, the only serious eye injury (a hyphema) encounteredin this series occurred in an individual unequipped with a face shield. Contact with sticks was the most common mechanism for injury. Use of the stick above the level of the shoulder, therefore, should be seriously discouraged through strict enforcement of the rules. There were fewer injuries documentedin the category of players wearing some form of face protection (30 of 119 injuries). Yet, it is of concern that of these players wearing both helmets and face protection, 19 of their 30 described injuries were noted in the regions of the face and head, anatomical regions seemingly well protected. Previous studieshave shown incomplete protection when half visors were used extensively ( 10). More study is required because it is unclear from these data why full head and face protection offered only incomplete protection against head and face
649
Head and Neck Injuries in Hockey
trauma. Further study is also required into the materials used in the face shields. In 2 cases players were hurt when their metal shields were broken. Another player suffered a significant scalp laceration after removing his helmet when the face shield becamefogged. Defective face masks have been identified as a contributing factor to craniofacial injuries (1). There were no treatment implications for emergency physicians identified here. That is, one would not expect to treat a laceration, for example, secondary to hockey differently than one would treat a laceration as a result of another mechanism.
CONCLUSION Players wearing helmets with no face masks were more frequently injured through contact with sticks or pucks. Use of the stick above the shoulders must be seriously discouraged through strict rule enforcement. More study is required to addressthe reasonsfor incomplete protection afforded by the helmets equipped with face shields noted here. Acknowledgments-This study was made possible through a grant from the Emergency Health Services Branch. The Ministry of Health of the Province of Ontario,
REFERENCES 1. Bjorkenheim J-M, Syvahuoko I, Rosengerg PH. Injuries in competitive junior ice-hockey: 1437 players followed for one season. kcta O&op Stand. 19$3;64(4):439-61. 2. Brust JD. Leonard BJ. Phelev A. Roberts WO. Children’s ice hockey injuries. Am J’Dis Cl&ren 1992; 146(6):741-7. 3. Castaldi CR. Prevention of craniofacial injuries in ice hockey. Dent Clin North Am. 1991;35(4):647-56. 4. Daly PJ, Sim FH, Simonet WT. Ice hockey injuries. A review. Sports Med. 1990;10(3):122-31. 5. Kvist M, Kujala UM, Heinonen OJ, Vuori AJ, Aho AJ, Pajulo 0. Hinsta A, Parvinen T. Sports-related injuries in children. Int J Sports Med. 1989;10:81-6. 6. Murray TM, Livingston LA. Hockey helmets, face masks, and injurious behavior. Pediatrics. 1995;95( 3):419-21. 7. Pashby TJ. Eye injuries in Canadian amateur hockey. Am J Sports Med. 1979;7(4):254-7. 8. Pashby TJ. Eye injuries in Canadian amateur hockey, still a concern. Can J Ophthalmol. 1987;22:293-5. 9. Pelletier RL, Montelpaxe WJ. Stark RM. Intercollegiate ice
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