Ten Years of Equine-related Injuries: Severity and Implications for Emergency Physicians

The psychological responses of British amateur point-to-point jockeys to personal injury

Previous research has reported significant psychological consequences of injury on rehabilitation success, performance, and wellbeing in athletes, although little is known within horse-based sports. There is a high prevalence of injury reported in point-to-point (P2P) jockeys, but despite this, comparatively little research exists examining the psychological implications resulting from physical trauma within horseracing. The aim of this study was to investigate the psychological responses to personal injury in British amateur P2P jockeys. Five amateur P2P jockeys (two male, three female, x- age 25 years old) were interviewed about their experiences post an injury sustained during racing in the preceding 12 months. Interview questions explored their pre-injury career, the rehabilitation phase, pre-return to racing phase issues and coping strategies used by jockeys. Thematic analysis revealed three higher order themes: emotional responses, coping strategies, and factors affecting recovery. Subjects universally cited negative emotional responses following injury, including grief, a sense of loss, and frustration, and all experienced denial at the onset of injury. Typical coping strategies included strong support networks of family, friends and racing staff, and goal setting. Fear of reinjury was identified by all athletes, particularly on return to the saddle, and the attitudes towards injury management, such as denial, seen in this study may provide opportunities to develop targeted education campaigns for P2P jockeys on injury services. Targeted marketing for P2P jockeys on available injury support is recommended, such as seen for professional jockeys, as well as the creation of career development resources to offer alternative routes for P2P jockeys following injury.

A national trauma data bank analysis of large animal-related injuries

INTRODUCTION

Large animal-related injuries (LARI) are relatively uncommon, but, nevertheless, a public hazard. The objective of this study was to better understand LARI injury patterns and outcomes.

MATERIALS AND METHODS

We performed a retrospective review of the 2016 National Trauma Data Bank and used ICD-10 codes to identify patients injured by a large animal. The primary outcome was severe injury pattern, while secondary outcomes included mortality, hospital length of stay, ICU admission, and mechanical ventilation usage.

RESULTS

There were 6,662 LARI included in our analysis. Most LARI (66%) occurred while riding the animal, and the most common type of LARI was fall from horse (63%). The median ISS was 9 and the most severe injuries (AIS ≥ 3) were to the chest (19%), head (10%), and lower extremities (10%). The overall mortality was low at 0.8%. Compared to non-riders, riders sustained more severe injuries to the chest (21% vs. 16%, p<0.001) and spine (4% vs. 2%, p<0.001). Compared to motor vehicle collisions (MVC), riders sustained fewer severe injuries to the head (10% vs. 12%, p<0.001) and lower extremity (10% vs. 12%, p=0.01). Compared to auto-pedestrian accidents, non-riders sustained fewer severe injuries to the head (11% vs. 19%, p<0.001) and lower extremity (10% vs. 20%, p<0.001).

CONCLUSION

Patients involved in a LARI are moderately injured with more complex injuries occurring in the chest, head, and lower extremities. Fall from horse was the most common LARI mechanism. Overall mortality was low. Compared to non-riders, riders were more likely to sustain severe injuries to the chest and spine. Severe injury patterns were similar when comparing riders to MVC and, given that most LARI are riding injuries, we recommend trauma teams approach LARI as they would an MVC.

Craniofacial Fractures in Equine-Related Injuries: What Should a Maxillofacial Surgeon Expect?

ABSTRACT

Patients with equine-related injuries (ERI) have high rates of hospitalization and often require surgical treatment. This study aimed to clarify the injury profiles of patients sustaining ERI-related craniofacial fractures and their relationship with other severe head and neck injuries.This retrospective study included all patients with craniofacial fractures admitted to a tertiary trauma center during 2013 to 2018. Out of 3256 patients, a total of 39 patients were included in the study (1.2%). Demographic and clinically relevant variables were reported and statistically evaluated.Males represented only 7.7% of the study population. Isolated facial fractures were over-represented in this study population at 84.6% whereas only 7.7% of patients sustained isolated cranial fractures and 7.7% of patients sustained combined craniofacial fractures, respectively. Surgical intervention for craniofacial fractures was required in 48.7% of patients. In total, 17.9% of patients sustained severe head and neck injuries. Periods of unconsciousness and/or post-traumatic amnesia were seen in 41% of patients. Helmet use could only be confirmed in 17.9% of patients.As trauma mechanisms behind ERI are often multifactorial and patients are at a high risk of sustaining associated injuries, attentive examination, and exclusion of serious life-threatening injuries through a multi-disciplinary approach is imperative for this specific patient population.

Patterns of injury following equine trauma: a non-trauma centre experience

INTRODUCTION

Horse riding carries risk of injury which can result in fatality. The majority of published literature describes major trauma centre experience. We aimed to characterise injury patterns following equine trauma at a Scottish district general hospital.

METHODS

A retrospective review of admissions following equine trauma was undertaken from 2014 to 2019. Mechanism and nature of injuries were noted. Patient management and outcomes were recorded and analysed to determine correlation.

RESULTS

Of the 162 patients identified, 121 (74.7 per cent) were female. The commonest mechanism and injury sustained were falling from a horse (86.4 per cent) and head injury (17.9 per cent) respectively. Forty-four (27.2 per cent) had multiple injuries identified. Being crushed or kicked resulted in more abdominal visceral injuries (22.7 vs 0.7 per cent, p = <0.05) and ITU admissions (18.2 vs 6.4 per cent, p = 0.06) when compared with falling from alone. Eight (4.9 per cent) required transfer to a major trauma centre and 30-day mortality was 0.6 per cent.

CONCLUSION

Although variable, injuries following equine trauma can be life threatening. Increased awareness and development of safety legislation is needed. In addition, research could be directed at assessing functional outcomes given the large number of orthopaedic injuries.

Injuries outside of horseracing: is it time to focus on injury prevention of jockeys outside of races?

Objectives: Falls and injuries are frequent in professional horseracing. However, professional jockeys spend a large part of their week in horse-related activities outside of racing such as schooling, exercise riding, and yard-related activities. The injury risk related to these activities remains largely unknown internationally. This study aimed to identify the injury prevalence and injury profile of flat and jump jockeys during non-racing activities. Methods: In total 45.6% and 38.5% of all licensed Irish professional flat and jump jockeys completed a cross-sectional self-recall questionnaire examining injuries that occurred outside of racing during 2018. Injury proportion, repeat incidence proportion, and descriptive statistics were calculated. Results: Fifteen percent of professional jockeys sustained an injury outside of a race, half of those injured receiving at least another injury in 2018 and 66.52 injuries per 1,000 falls were noted. Injuries frequently occurred to the upper limb (36.67%), with fractures common (32.00%). Most injuries occurred due to a fall (60.00%) and 77.27% occurred in the gallops. Half of injuries resulted in the jockey missing racing, with 31.00 ± 47.18 (4-180) days lost on average. Twenty-three percent of jockeys attended hospital and 16.67% required surgery due to injury. Interestingly, just under a third did not report their injury to anyone. Conclusion: Injuries to professional jockeys, whilst not as frequent outside of racing, tend to be serious and can affect jockeys financially and impact their availability to ride. Prioritizing injury prevention strategies to maximize availability of jockeys to race is important. Education on the importance of reporting all injuries regardless of where they occur is important to ensure their management and rehabilitation.

Equestrian Road Safety in the United Kingdom: Factors Associated with Collisions and Horse Fatalities

Over 60% of UK horse riders report having experienced a road-related near-miss or accident. The aim of this study was to describe horse-related road incidents (n = 4107) reported to the British Horse Society (2010-2020) and to identify factors associated with higher odds of collisions with another vehicle and horse fatalities using multivariable logistic regression modelling. Drivers passed the horse too closely in 84.2% of incidents while road rage and speeding were reported in 40.3% and 40.1% of incidents, respectively. Close passing distance alone (odds ratio [OR] 18.3, 95% confidence interval [CI] 6.5, 51.6) or in combination with speeding (OR 4.4, CI 1.7, 11.7) was associated with higher collision odds compared to speeding alone. Speeding was, however, associated with higher horse fatality odds (OR 2.3, CI 1.2, 4.6). Wearing high visibility clothing reduced odds of collision (OR 0.2, CI 0.1, 0.4). A fatal injury to a horse was almost 12 times as likely to result in severe to fatal rider/handler injury. Loose horses contribute significantly to road-related horse fatalities. Driver behaviour of how to pass horses safely on UK roads needs further improvement and will help reduce the risk of collisions and horse and human fatalities.

Retrospective analysis of 15 years of horse-related maxillofacial fracture data at a major German trauma center

Purpose

The purpose of this study was to estimate the effect of the mechanism of trauma (fall versus kick), rider demographics, equestrian experience, protective equipment, and whether or not a horse was shod on the anatomic site of a horse-related maxillofacial fracture, operating time, postoperative complication rate, and length of hospital stay.

Methods

We retrospectively reviewed the medical records of patients treated for horse-related maxillofacial fractures at a single institution in Germany between January 2000 and March 2015. We used linear and logistic regression to test the above-mentioned variables for statistical correlations.

Results

During the study period, we treated 138 horse-related facial fractures in 71 patients. The mean patient age was 34.5 years, and 80.3% of the injuries occurred in women. Most of the maxillofacial fractures were the result of a horse kick (71.8%) when unmounted and the majority occurred in more experienced riders (70.4%). There was a significant association of wearing of protective equipment with a shorter hospital stay and lower risk of postoperative complications.

Conclusion

More education is needed in the equestrian community regarding the use of protective equipment when unmounted. Safety helmets should be redesigned to include a faceguard and be worn at all times.

Head and Spinal Injuries in Equestrian Sports: Update on Epidemiology, Clinical Outcomes, and Injury Prevention

Equestrian sports represent a variety of activities involving a horse and rider. Due to the unpredictable nature of horses, their height, and potential high speeds involved, equestrian athletes are at risk of head and spinal injuries. This review describes the epidemiology, injury mechanisms, and risk factors for equestrian sports-related head and spinal injuries. Traumatic brain injuries, including concussions, are more common than spinal injuries. Both injury types are most commonly related to a rider fall from a horse. Spinal injuries are less common but are associated with potentially significant neurological morbidity when spinal cord injury occurs. An improved understanding of preventable injury mechanisms, increased certified helmet use, improved helmet technologies, and educational outreach may help to address the risk of head and spinal injuries in equestrian sports.

Nonfatal horse-related injuries treated in emergency departments in the United States, 1990-2017

BACKGROUND

Horse-related injuries can cause severe morbidity and mortality. The objective of this study is to investigate the epidemiological features of horse-related injuries treated in emergency departments (EDs) in the United States.

METHODS

A retrospective analysis of horse-related injuries from 1990 through 2017 was conducted utilizing the National Electronic Injury Surveillance System (NEISS). Cases were identified using the NEISS code 1239 (Horseback Riding: Activity, Apparel, or Equipment). Analyses performed included calculation of national injury estimates, relative risks (RRs) with 95% confidence intervals (CIs), and linear regression.

RESULTS

From 1990 through 2017, an estimated 1,836,536 (95% CI: 1,494,788-2,178,284) individuals presented to United States EDs with horse-related injuries. The annual injury rate decreased by 30.8% from 1990 to 1996, increased by 33.0% from 1996 to 2000, and then decreased by 46.0% from 2000 to 2017. Among older adults >60 years of age, the annual injury rate increased by 139.6% during the study period. The number of concussion and closed head injury diagnoses increased by 337.2% from 1990 to 2009. The most common mounted mechanism of injury was a fall or being thrown (73.9%), while the most common unmounted mechanism was being kicked (42.1%). Mounted injuries were more likely to lead to hospitalization than unmounted injuries (RR, 2.10, 95% CI: 1.59-2.77).

CONCLUSIONS

Despite the recent decline in horse-related injuries, these injuries are still common. Clinicians should be aware of the spectrum of ED presentations of horse-related injuries. Prevention efforts focused on older adults and concussions and closed head injuries warrant special attention.

Conspicuity Equipment and Its Contribution to the Welfare of Horse and Rider Combinations Using the Road System in the United Kingdom

Limited research exists regarding proximity of vehicles to "vulnerable road users" and effects of "conspicuity equipment". Previous studies stated over 60% of horse/rider combinations experience near-miss traffic collisions in any one year, whereas use of fluorescent/reflective (FR) equipment did not decrease occurrences. Similarly, research into vehicle proximity to bicycles reported no significance in cyclists wearing FR. This study undertook a similar field experiment using a horse/rider combination wearing different conspicuity equipment to test proximity distance. Two horses with similar height, age, base coat color, and temperament were ridden using four conspicuity measures 60 times each (n = 240) along a straight 0.8 km lane. Measures were chosen by random crossover with two selected for each separate trip. These were an FR "tabard", a novel black/white pattern (BW), flashing lights on a helmet (L), and control of mid-blue (C). A novel proximity meter was used on the saddle pommel and distance/approach either front or rear were logged into a voice recorder. Analysis reported a significant difference between all measures and proximities observed (P = .000). Mann-Whitney tests concluded significant differences in proximity in C versus L and BW (P = .000; P = .000), respectively. FR versus C showed no significant difference in proximity (P = .005). L versus BW reported no significant difference in proximity (W = 3640.0, P = .958). Results may suggest wearing conspicuity equipment of L or BW outperforms both C and FR. Further study is recommended to test these findings, and it is pertinent to still consider suggesting the use of FR equipment due to previous positive findings with other road users.

Equestrian-related injuries, predictors of fatalities, and the impact on the public health system in Sweden

OBJECTIVES

Horse riding is a popular activity but has also been found to lead to many injuries and even fatalities. No reduction in the numbers of those being admitted to hospital for equestrian-related injuries have been seen in Sweden in recent years. The aim of this work was to examine injuries, fatalities, and predictors of fatalities in equestrian-related activities and to investigate the cost of these injuries to the public health system.

STUDY DESIGN

The study is a retrospective analysis of hospital data.

METHODS

National Swedish hospital and mortality registers were retrospectively examined, inclusive of the years 1997-2014. Logistic regression was used to examine the predictors of fatal injuries, and cost of hospital treatment was considered.

RESULTS

Over the study period, there were an observed 29,850 injured cases and 51 fatalities. Women comprized almost 90% of those injured and 70% of fatalities. The average age was 26.8 years (range 0-91, standard deviation [SD] = 16.1) for injured and 43 years (range 7-78 years, SD = 20.5) for fatal cases. Men dominated both injured and fatal samples in the older age ranges (Fatal: >50 years; Injured: >70 years), although overall numbers were small. Injuries to the head contributed more than any other body region for both injured and fatal cases, and fractures were the most frequently seen injury type. A chi-squared analysis confirmed that injury type and injured body region were not independent of age. Logistic regression examining the association between fatality and age, gender, home region, and year of injury, indicating trends over time, found that there was an increase of 5.1% in the odds of fatality for every year increase in age of the patient and men had 2.2 times higher odds to be in the fatal sample than women. The conservative estimated cost of injury was 1800 Euro per injury event, equating to over 3 million Euro per year.

CONCLUSION

Equestrian-related injury events present a major public health concern. Observed decreases in fatalities suggest improved health care, yet head injury and fatality rates are still high, indicating a need for further intervention. The type of injury changes with the age group, and a better understanding of injury patterns with age is needed to identify protective measures for the different user groups.

Horse-related incidents and factors for predicting injuries to the head

Objectives

Head injuries are the leading cause of death in horse-related injury events and, even since the introduction of helmets, represent a sizeable proportion of all horse-related injuries. Falls from horseback and kicks to the head are the most frequent type of incident causing head injuries, but it is unknown whether these incidents are predictors of head injury. This study aimed to investigate head injuries and the association between incident type and head injury.

Method

Retrospective review of 7815 horse-related injury events was conducted. Data were gathered from hospitals, local healthcare centres and public dental services in Skaraborg, Sweden. Binary logistic regression was used to analyse the association between the incident type and occurrence of head injury while controlling for risk factors.

Results

Approximately 20% of riders sustained a head injury, mostly soft tissue injuries (56.3%) and concussions (33.4%). A fall from or with the horse was the primary cause of head injury (63.9%). Those who fell from a carriage or other height or who were injured through contact with the horse had no difference in the likelihood of head injury when compared with those that fell from or with the horse. However, those who sustained an injury without any horse contact had lower odd of head injury (OR: 0.640, p<0.00005, 95% CI 0.497 to 0.734). Additionally, the older the rider, the lower the odds of head injury (OR=0.989, p<0.00005, 95% CI 0.985 to 0.993).

Conclusion

Improved protection for those suffering falls from horseback as well as those who are kicked in the head should be investigated.

A Retrospective Cohort Study of Traumatic Brain Injury and Usage of Protective Headgear During Equestrian Activities

Some of the more popular sporting activities for those living in rural areas include equestrian activities such as rodeo events and horseback riding. The lack of helmet use poses a concern for those who participate in these activities due to the risk of sustaining a traumatic brain injury (TBI) and ultimately having a negative effect on their future. A retrospective cohort study was conducted at a trauma center comparing the data on animal-riding patients and their use or lack of use of headgear and incidence of TBI. Of the patients identified, 16.2% sustained a head injury, ranking TBI fourth among all injuries sustained by the animal-riding population. Males were predominantly affected; however, females of pediatric age 5-17 years (54.5%) ranked high among the TBI population. Among all the patients identified with TBI, none of the patients were wearing a helmet and all sustained a head injury. The average injury severity score was 11, with hospital length of stay averaging less than 2 days and the overall mortality was 3.6%. Findings from the study should be considered for the purpose of implementing an age-specific educational program focused on head injury prevention and utilization of protective headgear. Current literature supports the use of protective headgear to reduce the risk of head injuries. Animal riders should be educated on the importance of using headgear as a preventive measure. Future studies are needed to indicate the effectiveness of injury prevention in regard to head injury severity and the use of protective headgear.

Hospital-treated injuries from horse riding in Victoria, Australia: time to refocus on injury prevention?

BACKGROUND

The most recent report on hospital-treated horse-riding injuries in Victoria was published 20 years ago. Since then, injury countermeasures and new technology have aimed to make horse riding safer for participants. This study provides an update of horse-riding injuries that required hospital treatment in Victoria and examines changes in injury patterns compared with the earlier study.

METHODS

Horse-riding injuries that required hospital treatment (hospital admission (HA) or emergency department (ED) presentations) were extracted from routinely collected data from public and private hospitals in Victoria from 2002-2003 to 2015-2016. Injury incidence rates per 100 000 Victorian population per financial year and age-stratified and sex-stratified injury incidence rates are presented. Poisson regression was used to examine trends in injury rates over the study period.

RESULTS

ED presentation and HA rates were 31.1 and 6.6 per 100 000 person-years, increasing by 28.8% and 47.6% from 2002 to 2016, respectively. Female riders (47.3 ED and 10.1 HA per 100 000 person-years) and those aged between 10 and 14 years (87.8 ED and 15.7 HA per 100 000 person-years) had the highest incidence rates. Fractures (ED 29.4%; HA 56.5%) and head injuries (ED 15.4%; HA 18.9%) were the most common injuries. HA had a mean stay of 2.6±4.1 days, and the mean cost per HA was $A5096±8345.

CONCLUSION

Horse-riding injuries have remained similar in their pattern (eg, types of injuries) since last reported in Victoria. HA and ED incidence rates have increased over the last 14 years. Refocusing on injury prevention countermeasures is recommended along with a clear plan for implementation and evaluation of their effectiveness in reducing injury.

Blunt injuries related to equestrian sports: results from an international prospective trauma database analysis

INTRODUCTION

The objective of this study was to investigate the nature, management, and outcome of major injuries related to equestrian sports and to define the at-risk groups for serious and life-threatening injuries.

METHODS

We analyzed demographic, pre-hospital, clinical, and outcome data from an international population-based prospective trauma database (TraumaRegister DGU®). Patients with major injuries (Injury Severity Score [ISS] ≥9 points) related to equestrian sports activities were included (January 1, 1993, to December 31, 2012). Clinical and outcome parameters were stratified for four different types of injury mechanisms: fall from horse (FFH), horse-kick (HK), horse crush (HC), and carriage-related accidents (CRA). Participating countries included Germany, Austria, Switzerland, Finland, Slovenia, Belgium, Luxembourg, and The Netherlands. Statistical analyses were performed with SPSS (Version 22, IBM Inc., Armonk, NY).

RESULTS

The Database identified 122,000 documented patients, of whom 679 were equestrian incidents. Among these, the four major injury mechanisms were: FFH (n = 427), HK (n = 188), HC (n = 34), and the CRA (n = 30). Females were more likely to sustain FFH (75.5%, p < 0.001), leading to head injuries (n = 204, 47.8%) and spinal fractures (n = 109, 25.5%). HK injuries often resulted in facial fractures (29.3%, p < 0.001). Individuals sustaining HC injuries had a high risk for pelvic (32.4%, p < 0.001) and abdominal injuries (35.2%, p < 0.001). In contrast to the FFH cohort, the CRA cohort involved older males (57 ± 13 years), with chest (63.3% p = 0.001), and extremity injuries, resulting in significant injury severity (ISS 20.7 ± 10.6). In the CRA cohort, 16% were in haemorrhagic shock on scene, and also the highest in-hospital mortality (14.8%, p = 0.006) was observed.

CONCLUSIONS

Young female riders are at risk from falling, horse-kicks, and crush-injuries. Older males in carriage-related accidents sustained the highest injury severity and mortality rate, and must specifically be targeted by future prevention initiatives. Level of evidence Descriptive Epidemiologic Study, Level II.