Surface characteristics, equipment height, and the occurrence and severity of playground injuries

Fractures in New Zealand elementary school settings

BACKGROUND

There is a need for greater international understanding of student safety in schools. This New Zealand study investigated the causes and school location of fractures sustained by students attending elementary school, with special emphasis on the types of fractures sustained following falls from playground equipment of various heights.

METHODS

Over a 1-year period, 76 participating schools (with a combined roll of over 25,000 students) completed a questionnaire about the nature and circumstances of student fractures sustained during regular school hours.

RESULTS

Some 118 students sustained a total of 131 fractures. Injuries from playground equipment were no more frequent than those from general activities at school, and most were sustained in falls from heights less than 59 inches. Most fractures were to the upper limbs. Fractures were found to vary by gender and school size.

CONCLUSIONS

The results are discussed in terms of the conditions and policies present in local schools, and the tension that exists in maintaining safety while offering appropriate challenges to students. Improvements in school safety may be more likely to result from a greater focus on the way that students interact at school, rather than on modifications to playground equipment.

Injury prevention in child and adolescent sport: whose responsibility is it?

OBJECTIVE

Sport and recreational injuries are a leading cause of morbidity in youth. There is a significant body of literature on risk factors for sport-related injuries and a growing body of research supporting the effectiveness of sport-specific prevention strategies in youth. Given the predictability and preventability of injuries in youth sport, the purpose of this article is to develop a model that considers societal responsibility for injury prevention in youth sport, and to discuss the evidence that supports this model.

DATA SOURCES/SYNTHESIS

Previously published papers have provided a basis for expert opinion to discuss an approach to examining the shared societal responsibility for implementing countermeasures to reduce the risk of injury to youth during sports.

RESULTS

Based on a historical perspective, broad conceptual framework, and specific evidence for prevention strategies in youth sport, the authors have developed and supported a theoretical model that defines a responsibility hierarchy in preventing injuries in youth sport. An argument has been made for a hierarchy of responsibility, with the lowest level of responsibility assigned to the child, and the highest level to those organizations or groups with the potential to effect the most change. The justification for this approach has been discussed in the context of the desirability of passive prevention strategies, the limited evidence for the effectiveness of strategies relying solely on behavior change in children and parents, and the level of perceptual and cognitive development in children that inadequately prepares them to take primary responsibility for their own safety in sport.

CONCLUSIONS

The development of effective programs to reduce the burden of sport injury among youth necessitates a scientific approach, the identification of key risk factors for injury, a thorough examination of how factors interact to affect risk, and the identification of potential barriers to the effectiveness of injury-prevention programs.

Stages of development and injury patterns in the early years: a population-based analysis

Background

In Canada, there are many formal public health programs under development that aim to prevent injuries in the early years (e.g. 0–6). There are paradoxically no population-based studies that have examined patterns of injury by developmental stage among these young children. This represents a gap in the Canadian biomedical literature. The current population-based analysis explores external causes and consequences of injuries experienced by young children who present to the emergency department for assessment and treatment. This provides objective evidence about prevention priorities to be considered in anticipatory counseling and public health planning.

Methods

Four complete years of data (1999–2002; n = 5876 cases) were reviewed from the Kingston sites of the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP), an ongoing injury surveillance initiative. Epidemiological analyses were used to characterize injury patterns within and across age groups (0–6 years) that corresponded to normative developmental stages.

Results

The average annual rate of emergency department-attended childhood injury was 107 per 1000 (95% CI 91–123), with boys experiencing higher annual rates of injury than girls (122 vs. 91 per 1000; p < 0.05). External causes of injury changed substantially by developmental stage. This lead to the identification of four prevention priorities surrounding 1) the optimization of supervision; 2) limiting access to hazards; 3) protection from heights; and 4) anticipation of risks.

Conclusion

This population-based injury surveillance analysis provides a strong evidence-base to inform and enhance anticipatory counseling and other public health efforts aimed at the prevention of childhood injury during the early years.

Trauma prevention in children

Play and sports activities are important to the healthy development of children worldwide. Many accidents are the result of the normal desire of children for excitement and adventure. Injury prevention has been difficult to evaluate and manage because of many variables. The frequency of injuries can be reduced with parental input and adult supervision, as well as proper equipment design and installation, followed by regular inspection and maintenance. Current initiatives hold promise, especially with equipment designs and manufacture, but injuries continue to be a significant and costly health problem. By identifying where and how children are injured, recommendations can be made to increase the safety of play areas, gyms, and equipment.

Playground safety in South Western Sydney

OBJECTIVE

Recognition of the cost of injuries sustained in playgrounds has led to the development of Australian/New Zealand Standards for playground safety. This study assesses compliance of public playgrounds in South Western Sydney with the current Standards.

METHODS

Playgrounds in South Western Sydney were randomly audited for compliance with Australian/New Zealand Standards for playground equipment pertaining to fall height, type of undersurface material, adequacy of maintenance of undersurface materials and adequacy of the safe fall zone. Comparisons were made with an audit of playgrounds in New South Wales undertaken in 1995 by Kidsafe.

RESULTS

Of the 257 pieces of equipment from 87 playgrounds audited, only three (3.4%) playgrounds and 65 (25.3%) pieces of equipment complied with all criteria assessed. Compared with the 1995 study, there has been a significant improvement in equipment complying with height standards (84.4% vs 72.2%, P < 0.0001) and appropriate undersurface material (66.8% vs 45.4%, P < 0.0001). Pinebark is now the most common appropriate undersurface material used but is poorly maintained, particularly in high-traffic areas. Of 131 pieces of equipment with an appropriate undersurface material, only 38 (29%) had an adequate safe fall zone.

CONCLUSIONS

Improvements in playground safety have occurred; however, very few playgrounds meet the Australian/New Zealand Standards. Compliance with Standards pertaining to maintenance of undersurface materials and safe fall zone is poor. Mechanisms need to be developed to support councils in the upgrading and maintenance of existing playgrounds.

Poor neighborhoods: safe playgrounds

Although unstructured physical play is helpful to child development and physical activity is important to obesity prevention, up-to-date information about playgrounds and playground hazards in urban areas is limited. Local data are needed to identify problems and target interventions. The aim of this study was to describe the hazards in playgrounds located in low-income (median dollars 28,728-38,915) and very low-income (median dollars 18,266-18,955) Chicago neighborhoods. Using a standardized on-site survey (National Program for Playground Safety), two investigators reviewed seventy-eight public playgrounds for hazards related to playground design, safe surfaces, supervision, and equipment design and maintenance. The design of 56 playgrounds (72%) posed no hazards. One playground lacked protection from motor vehicles, and 21 had minor flaws. One playground had an asphalt surface; all others had protective surfaces, usually wood chips. The chips were too thin in many places, and in 15 playgrounds (19%), at least one concrete footing was exposed. Trash was a common surface hazard (68%). Although most equipment was safe (swings of soft materials and appropriate platform barriers), many pieces needed repairs. Equipment maintenance hazards included gaps (44%) and missing (38%) or broken parts (35%). In 13 of 39 playgrounds (33%) where children were observed playing, one or more were unsupervised. Playgrounds in very low-income neighborhoods more often had trash in the fall zone and exposed footings (P<.01 for each); there were no differences between low and very low-income neighborhoods in playground design or equipment maintenance. We conclude that playgrounds in low-income Chicago neighborhoods are of good design and have appropriate surfaces. Needed improvements include attention to wood chip depth, the removal of trash from the fall zone, and equipment repairs. Greater adult supervision is warranted.

Out on a limb: risk factors for arm fracture in playground equipment falls

OBJECTIVES

To investigate and quantify fall height, surface depth, and surface impact attenuation as risk factors for arm fracture in children who fall from playground equipment.

DESIGN

Unmatched case control study.

SETTING

Five case hospitals and 78 randomly selected control schools.

PARTICIPANTS

Children aged less than 13 years in Victoria, Australia who fell from school playground equipment and landed on their arm. Cases sustained an upper limb fracture and controls had minor or no injury. A total of 402 cases and 283 controls were included.

INTERVENTIONS

Children were interviewed in the playground as soon as possible after their fall.

MAIN OUTCOME MEASURES

Falls were recreated on site using two validated impact test devices: a headform (measuring peak G and HIC) and a novel anthropometric arm load dummy. Equipment and fall heights, as well as surface depth and substrate were measured.

RESULTS

Arm fracture risk was greatest for critical equipment heights above 1.5 m (OR 2.39, 95% CI 1.49 to 3.84, p<0.01), and critical fall heights above 1.0 m (OR 2.96, 95% CI 1.71 to 5.15, p<0.01). Peak headform deceleration below 100G was protective (OR 0.67, 95% CI 0.45 to 0.99, p = 0.04). Compliance with 20 cm surface depth recommendation was poor for both cases and controls.

CONCLUSIONS

Arm fracture-specific criteria should be considered for future standards. These include surface and height conditions where critical headform deceleration is less than 100G. Consideration should also be given to reducing maximum equipment height to 1.5 m. Improved surface depth compliance and, in particular, guidelines for surface maintenance are required.

Are current playground safety standards adequate for preventing arm fractures?

OBJECTIVE

To assess compliance with current standards of playgrounds where children have sustained a fall-related arm fracture.

DESIGN, SETTING AND PARTICIPANTS

Between October 2000 and December 2002, a consecutive prospective series of 402 children aged under 13 years who fell from playground equipment and sustained an arm fracture was identified by emergency department staff in five Victorian hospitals. Trained field testers measured playground equipment height, surface type and depth, and surface impact attenuation factors to determine compliance with safety standards.

MAIN OUTCOME MEASURES

Playground compliance with current Australian safety standards.

RESULTS

Ninety-eight percent of playgrounds had a recommended type of surface material. The mean surface depth was 11.1 cm (SD, 5.0 cm) and the mean equipment height was 2.04 m (SD, 0.43 m). Although over 85% of playgrounds complied with recommended maximum equipment height and surface impact attenuation characteristics, only 4.7% complied with recommended surface depth.

CONCLUSION

Playgrounds where children have sustained an arm fracture generally comply with all important safety recommendations except surface depth. Playground fall-related arm fracture requires specific countermeasures for prevention, distinct from head injury prevention guidelines.

Injury and frequency of use of playground equipment in public schools and parks in Brisbane, Australia

OBJECTIVE

The purpose of this study was to determine the frequency of use of play equipment in public schools and parks in Brisbane, Australia, and to estimate an annual rate of injury per use of equipment, overall and for particular types of equipment.

METHODS

Injury data on all children injured from playground equipment and seeking medical attention at the emergency department of either of the two children's hospitals in the City of Brisbane were obtained for the years 1996 and 1997. Children were observed at play on five different pieces of play equipment in a random sample of 16 parks and 16 schools in the City of Brisbane. Children injured in the 16 parks and schools were counted, and rates of injury and use were calculated.

RESULTS

The ranked order for equipment use in the 16 schools was climbing equipment (3762 uses), horizontal ladders (2309 uses), and slides (856 uses). Each horizontal ladder was used 2.6 times more often than each piece of climbing equipment. Each horizontal ladder was used 7.8 times more than each piece of climbing equipment in the sample of public parks. Slides were used 4.6 times more than climbing equipment in parks and 1.2 times more in public schools. The annual injury rate for the 16 schools and 16 parks under observation was 0.59/100 000 and 0.26/100 000 uses of equipment, respectively.

CONCLUSIONS

This study shows that annual number of injuries per standardized number of uses could be used to determine the relative risk of particular pieces of playground equipment. The low overall rate of injuries/100 000 uses of equipment in this study suggests that the benefit of further reduction of injury in this community may be marginal and outweigh the economic costs in addition to reducing challenging play opportunities.

Development of a multidisciplinary method to determine risk factors for arm fracture in falls from playground equipment

OBJECTIVES

To present the development of a novel multidisciplinary method to investigate physical risk factors for playground related arm fracture.

RATIONALE

Previous playground injury research has been limited in its ability to determine risk factors for arm fractures, despite their common and costly occurrence. Biomechanical studies have focused exclusively on head injury. Few epidemiological studies have quantified surface impact attenuation and none have investigated specific injury outcomes such as arm fracture.

DESIGN

An unmatched case-control study design was developed. An instrumented child dummy and rig were designed to simulate real playground falls in situ. Validated output from the dummy was used to quantify arm load. Other field measurements included equipment height, fall height, surface depth, headform deceleration, and head injury criterion.

DISCUSSION

Validated methods of biomechanics and epidemiology were combined in a robust design. The principle strength of this method was the use of a multidisciplinary approach to identify and quantify risk and protective factors for arm fracture in falls from playground equipment. Application of this method will enable countermeasures for prevention of playground related arm fracture to be developed.

Anthropomorphic simulations of falls, shakes, and inflicted impacts in infants

OBJECT

Rotational loading conditions have been shown to produce subdural hemorrhage and diffuse axonal injury. No experimental data are available with which to compare the rotational response of the head of an infant during accidental and inflicted head injuries. The authors sought to compare rotational deceleration sustained by the head among free falls, from different heights onto different surfaces, with those sustained during shaking and inflicted impact.

METHODS

An anthropomorphic surrogate of a 1.5-month-old human infant was constructed and used to simulate falls from 0.3 m (1 ft), 0.9 m (3 ft), and 1.5 m (5 ft), as well as vigorous shaking and inflicted head impact. During falls, the surrogate experienced occipital contact against a concrete surface, carpet pad, or foam mattress. For shakes, investigators repeatedly shook the surrogate in an anteroposterior plane; inflicted impact was defined as the terminal portion of a vigorous shake, in which the surrogate's occiput made contact with a rigid or padded surface. Rotational velocity was recorded directly and the maximum (peak-peak) change in angular velocity (delta theta(max)) and the peak angular acceleration (theta(max)) were calculated. Analysis of variance revealed significant increases in the delta theta(max) and theta(max) associated with falls onto harder surfaces and from higher heights. During inflicted impacts against rigid surfaces, the delta theta(max) and theta(max) were significantly greater than those measured under all other conditions.

CONCLUSIONS

Vigorous shakes of this infant model produced rotational responses similar to those resulting from minor falls, but inflicted impacts produced responses that were significantly higher than even a 1.5-m fall onto concrete. Because larger accelerations are associated with an increasing likelihood of injury, the findings indicate that inflicted impacts against hard surfaces are more likely to be associated with inertial brain injuries than falls from a height less than 1.5 m or from shaking.

Playground injury prevention

Playground safety recently has received increasing attention from parents and municipalities. Orthopaedic surgeons treat a large number of the more than 350,000 injuries per year sustained on the play areas of this country's school, home, and community play areas. A parent brings a child to the playground for fun, healthy exercise, and imaginative play. Unfortunately, most parents may not be aware of recommended injury prevention methods. Data from the Consumer Product Safety Commission and other epidemiologic studies document frequency, identify at-risk activities and equipment, give direction for additional research, and guide regulations. It is appropriate for the medical community to lead in this safety effort and to contribute to additional research and advocacy efforts.