Do helmets worn for hurling fail to protect the ear? Identification of an emerging injury pattern
- James D Martin-Smith1,
- Jeffery C Y Chan1,
- Kieran T Power1,
- Paddy J Crowley2,
- Anthony James P Clover1
- 1Department of Plastic and Reconstructive Surgery, Cork University Hospital, Cork, Ireland
- 2General Practitioner, Ballincollig, Cork, Ireland
- Correspondence to Dr James D Martin-Smith, Department of Plastic and Reconstructive Surgery, Cork University Hospital, Wilton, Cork, Ireland;
- Received 15 April 2012
- Accepted 13 August 2012
- Published Online First 12 September 2012
Hurling is an Irish national game of stick and ball known for its ferocity, played by 190 000 players. Facial injuries were common but have been significantly reduced by legislation enforcing compulsory helmet wearing. Current standard helmets worn by hurlers do not offer protection to the external ear. Here we describe an emerging pattern of ear injuries and demonstrate the risk of external ear injuries in hurlers complying with current helmet safety standards. A 6-month retrospective analysis was carried out of patients attending Cork University Hospital (CUH) with ear lacerations sustained while hurling. Patient notes were reviewed and helmet manufacturers were interviewed. Seven patients were identified, all of whom sustained complex through ear lacerations while wearing helmets complying with current safety standards. Current helmet design fails to protect the external ear placing it at an increased risk of injury, a potential solution is to include ear protection in the helmet design.
Hurling is an Irish national game of stick and ball known for its speed, skill and ferocity, played by an estimated 190 000 people. Hurling remains an amateur sport regulated by the Gaelic Athletic Association (GAA). It is a team sport of 15 players played with 1 m long stick with a flat curved head weighing approximately 0.6 kg1 and a hard leather covered ball (figure 1). In contrast to hockey, players can handle the ball and have no restriction on the height to which the stick can be raised or to which the ball can be played; indeed playing the ball overhead is a defining skill of the game.2
Historically, hurling-related facial fractures accounted for between 25% and 40% of sports-related facial fractures treated.1 ,3 ,4 The incidence of facial injuries dropped sharply to 5% with the introduction of head and face protection3 attributed at least in part to the introduction of facial protection with helmets.5On the basis of a publication showing significant reduction in ocular injuries by wearing helmets in the sport,2 the Gaelic Athletic Association Congress of 2005 passed a motion making the wearing of protective helmets with facemasks compulsory for all hurlers up to the age of 21. Subsequently, national legislation was introduced in 2010 to enforce the mandatory use of protective helmets for all hurlers to shield the face and skull.6 Ear injuries were not previously reported among the incidence of hurling-related facial injuries.1
Current standard helmets worn by hurlers do not offer protection to the external ear. We recently observed an apparent increase in injuries to the external ear. The report highlights this new emerging injury pattern and suggests modification of the current helmet design to reduce the risk of ear injuries.
A 6-month retrospective analysis was carried out of patients attending Cork University Hospital (CUH) with ear lacerations sustained while hurling. Patients were identified by retrospective analysis of operating records, trauma referrals and subsequent chart review of all ear lacerations from any cause during the period. CUH is the only level one trauma centre in the Republic of Ireland and the tertiary referral centre for Munster; serving a population of approximately 1.18 million.7
The medical notes were reviewed for patient demographics, mechanism of injury, preoperative description of ear injury, operation notes and findings at postoperative review. Patients were interviewed via telephone to establish the protection worn during injury (including manufacturer of helmet) and aesthetic and functional outcome. Team doctors and local protection equipment manufacturers were interviewed.
Seven patients presented with hurling-related ear lacerations between March and September 2011. All patients were males with a mean age of 22 years (range 15–34 years). All wore helmets complying with current legislation including a faceguard although none were using additional ear protection. All injuries were classified as complex, involving lacerations of the anterior skin, cartilage and posterior skin (through and through laceration; figure 2). Furthermore, three patients had extension of the wound onto the skull in the posterior auricular area. All patients reported being struck by an opponent's hurl. No other injuries were sustained. All patients had their injuries repaired under local anaesthetic in our unit. Postoperatively, all recovered well and were satisfied with their outcome.
This report highlights a new pattern of hurling-related ear injuries; current helmet design does not sufficiently protect hurling players from external ear injury. Although facial injuries were previously common in hurling before the introduction of headgear, no ear lacerations were reported in the most comprehensive analysis of hurling injuries.1 Current helmet design, complying to enforced safety standards, leaves the external ears exposed and potentially positioned over the edge of the helmet. When a player is struck by an opponent's hurl, the ear is crushed between the stick and the edge of the helmet. This lacerates the pinna as it is crushed between the hurl and the bony mastoid process (figure 3). The isolated nature of these injuries suggests that the head gear is achieving their primary objective of protecting the rest of the head, even though the forces involved are high enough to split the ear and in some cases post auricular skin.
The positive impact of altering player protection has already been well documented in hurling5 ,8 and in other sports such as ice hockey.9 ,10 Specifically in hurling, a significant reduction in injuries was noted with the introduction of legislation for the compulsory use of head protection and face masks,5 ,8 reducing levels of head injuries and ocular injuries.
Although injuries to the external ear have not been studied in isolation, anecdotal evidence from team doctors and helmet manufacturers suggests that this is an increasing trend. Team doctors are familiar with this type of injury and anecdotally report treating some of the hurling-related ear lacerations in the community or in peripheral emergency departments. This is reflected in the lack of simple lacerations seen by our unit. Referral to a tertiary referral unit is evidently only warranted for complex lacerations, thus this series probably only represents a small percentage of overall incidence.
Three hypothesised causes might explain the increase in the more complex ear injuries described. First, following the mandatory use of protective helmets, players are less afraid of putting their head in the contact zone and thus exposing the ears. Second, those wielding the hurls are less conscientious of inflicting injury due to the presumed protection. Finally, there is now less emphasis on personal protection in players training as head safety is now theoretically addressed.
Helmet manufacturers have already identified this potential weakness in the current helmets and have a prototype solution. They have developed an ear protection shield that can be fitted onto the wire cage framework of all standard hurling helmets, regardless of variation in design (figure 4). These were initially developed in response to specific customer requests to protect hearing aids, but are currently considered not cost-effective for general release. Although there is a potential for the ear guards to be used on all helmets, we have only explored this with one manufacturer, albeit the majority producer of helmets for hurling. Before mass production of this safety alteration, performance stress testing will be necessary, which is in progress. A combination of load distribution testing utilising force transducers to assess a defined force applied to the area around the ear of a headform of a standard test dummy,11 and rigidity assessment involving a similar impact with high speed visual assessment of deformation would be a viable method of determining engineering-based guidelines for manufacturers. This is turn would assist in the argument for an alteration of the head protection regulations.
Further study is necessary to investigate the true incidence of this injury. We would recommend that the GAA put in place a mechanism for reporting injuries so that the true incidence of new and emerging injury patterns can be identified early. This would provide accurate data to support a change in the legislation to provide ear protection as well as head and face protection.
In sports-related injuries, there is often a fine line between legislation and safety regulations, and preserving the flow and tradition of the game. Injuries are often seen as ‘part of the game’, however in many sports it has been possible to improve safety without a major impact on game play. This has been shown in stick games like hurling and ice-hockey as well as in rugby where measures have been effective in reducing the risk of spinal injury.12
This study highlights the inadequacy of current helmet design in protecting the players from significant ear injuries. These injuries could be avoided if the standard helmet specification is modified to include ear protection.
Contributors JDM-S initiated the study, obtained charts and wrote multiple drafts. JC wrote multiple drafts, arranged pictures and helped obtain raw data. KP wrote multiple drafts and helped obtain raw data. PC researched the discussion and references. He directed the layout and content of the discussion. JC helped initiate the study, wrote multiple drafts, defined objectives of study and managed overall progress.
Competing interests None.
Patient consent Obtained.
Ethics approval Retrospective review of injuries sustatined.
Provenance and peer review Not commissioned; externally peer reviewed.