PURPOSE: Skiing and snowboarding are popular competitive and recreational sports, but could potentially be associated with significant injury. In 2014/15, there were 53.6 million ski and snowboarder visits to United States (US) resorts. Previous studies of skiing and snowboarding injuries have been conducted, but studies evaluating injury patterns over long periods of time are needed to drive effective injury prevention efforts. The purpose of this study is to compare patterns of skiing and snowboarding injuries presenting to emergency departments (EDs) over a 20-year period. METHODS: This was a retrospective descriptive analysis. Case reports were obtained from a large national hospital surveillance system that included sample weighting factors enabling calculation of national estimates. All patients injured between 2000 to 2019 from skiing or snowboarding who sought medical care in US EDs were included in the patient cohort. RESULTS: From 2000-2019, 34,797 injured skiers (52.6%) and snowboarders (47.4%) presented to US EDs representing an estimated 1,624,137 visits nationwide. Most injured skiers (60.0%) and snowboarders (72.7%) were men. On average, injured skiers were a decade older than snowboarders (mean 30.1 vs. 20.0 years; p < 0.001). Total number of visits over the 20-year time period decreased (β: -79.73; P-value: 0.000). Common diagnoses included fractures (32.9%), sprains/strains (26.8.0%), and contusion/abrasion (11.6%). Knee (19.9%), shoulder (13.0%), and head (12.2%) were most commonly injured in skiers compared to wrist (20.0%), shoulder (15.8%), and head (14%) in snowboarders. Individuals most often hospitalized following ED presentation were male (66.3%) and 15-19 years old (49.7%). Compared to all other injuries, fractures (OR = 3.40, 95% CI = 3.08-3.75) and head injuries (OR = 1.78, 95% CI = 1.57-2.00) more often resulted in hospitalization. After controlling for age, sex, body part, and diagnosis, skiers were more likely to be hospitalized than snowboarders (OR = 1.26, 95% CI = 1.11-1.43). CONCLUSIONS: Injury patterns and severity vary between skiers and snowboarders. Understanding the epidemiology of injuries presenting to EDs can help guide prehospital care and medical coverage allocation for resorts, as well as identify areas for targeted injury prevention efforts.