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There is uncertainty regarding the efficacy of ski helmets in preventing traumatic injury. We investigated the relationship between helmet use, injury types, and injury severity among skiers and snowboarders.The trauma registry at a Northeast American College of Surgeons Level I trauma center was queried by International Classification of Diseases Codes—9th or 10th Revision for skiing and snowboarding injury between 2010 and 2018. The primary exposure was helmet use and primary outcome was severe injury (Injury Severity Score >15). We performed univariate and multivariable logistic regression to assess for injury types and severity associated with helmet use.Seven hundred twenty-one patients (65% helmeted, 35% unhelmeted) met inclusion criteria. Helmet use doubled during the study period (43% to 81%, p < 0.001), but the rate of any head injury did not significantly change (49% to 43%, p = 0.499). On multivariable regression, helmeted patients were significantly more likely to suffer severe injury (odds ratio [OR], 2.01; 95% confidence interval [CI], 1.30–3.11), intracranial hemorrhage (OR, 1.81; 95% CI, 1.10–2.96), chest injury (OR, 1.66; 95% CI, 1.05–2.61), and/or lumbosacral spine injury (OR, 1.84; 95% CI, 1.04–3.25) than unhelmeted patients. Helmeted patients were half as likely to suffer cervical spine injury (OR, 0.51; 95% CI, 0.30–0.89) and a third as likely to sustain skull fracture and/or scalp laceration (OR, 0.30; 95% CI, 0.14–0.64). More patients who hit a stationary object were helmeted compared with those who fell from standing height onto snow (70% vs. 56% respectively, p < 0.001). After adjustment, hitting a stationary object was the injury mechanism most significantly associated with severe injury (OR, 2.80; 95% CI, 1.79–4.38).Helmeted skiers and snowboarders evaluated at a Level I trauma center were more likely to suffer severe injury, including intracranial hemorrhage, as compared with unhelmeted participants. However, they were less likely to sustain skull fractures or cervical spine injuries. Helmeted patients were also more likely to hit a stationary object. Our findings reinforce the importance of safe skiing practices and trauma evaluation after high-impact injury, regardless of helmet use.Prognostic and epidemiological, level IV.