Impact of helmet use in equestrian-related traumatic brain injury: a matched-pairs analysis

Equestrian Sports Safety: An Update on Safety Equipment and Event Medical Coverage

ABSTRACT

Equestrian sports are associated with high rates of major injury compared to collision and powered two-wheel sports. Advancements in rider and horse safety equipment and the implementation of comprehensive emergency action planning standards may help mitigate injuries, particularly in regard to the Olympic disciplines of dressage, show jumping, and three-day eventing covered in this review. Personal safety equipment to consider includes helmets, safety and air vests, and horse tack including safety stirrups, acoustic dampeners, and breakaway reins. Equestrian event medical coverage requires emergency action planning, partnership with local emergency medical services, and cooperation of interprofessional teams. Safety coordinators and medical providers may be tasked with providing first aid to spectators in addition to stabilizing and triaging crush trauma, traumatic brain injuries or spinal injuries, or fractures in competitors. Stationary and mobile medical units, proper medical equipment, acute spine stabilization protocols, and communication systems are critical components of equestrian medical coverage.

CNS and Thorax Injury and Associated Risks Factors in Equestrian Sports

CONTEXT

Equestrian sports continue to gain popularity in the United States and are associated with a high injury rate, especially involving the central nervous system and thorax. Due to this high rate of injury and the potential for long-term consequences associated with participation, an understanding of the unique risks of this sport is needed.

OBJECTIVE

To describe severe injury in equestrian sports and review the role that protective gear plays in injury mitigation.

DATA SOURCES

The PubMed Database was searched using the search terms "equestrian" and "horse" combined with "spinal cord injury," "head injury," "traumatic brain injury," "experience levels," and "demographics."

STUDY SELECTION

A total of 53 papers were selected based on their relevance of epidemiology, risk factors, and management of injuries sustained during equestrian activities. Case studies, randomized controlled trials, prospective studies, and retrospective studies were all included for further review.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

None.

RESULTS

Injuries to the thorax, including fractures, pneumothoraces, internal organ contusions, and crush injuries, have been cited in multiple national and international trauma registries as the most prevalent injury location in equestrians; however, head and neck injuries, high cervical spine fractures, and closed head injuries are reported to be associated with the highest rates of mortality. Helmets provide protection against skull fracture and traumatic brain injury. Vests were not associated with diminished rates of spinal cord injuries; however, they may provide protection to the thorax. Riding experience also plays a role in reducing the prevalence of injury.

CONCLUSION

Equestrian-related activities are associated with a high risk of injury despite protective measures. Protective gear can mitigate some injury risk but does not protect against spinal injury. Continued investigation into improving protective equipment, rider education, and preventative strategies to mitigate this risk is needed.

Neurosurgical Injuries Associated with Recreational Horseback Riding: A 6-year Retrospective Analysis

INTRODUCTION

Horseback riding can cause severe brain and spinal injuries. This study aimed to identify the spectrum of neurosurgical injuries related to recreational horseback riding.

METHODS

A retrospective study was performed utilizing the University of Puerto Rico neurosurgery database to identify patients who were consulted to the neurosurgery service between 2018 and 2023 after a horse fall during recreational activities. The outcome upon discharge using the modified Rankin scale (mRS) was documented. Descriptive statistics were used to report frequency and median values.

RESULTS

The neurosurgery service evaluated and managed 112 patients with a horseback riding fall-related injury during 6 years. Ninety-eight (87.5%) patients were male. The patients' median age was 31.5 (IQR 22-40). There were 89 head injuries (79.5%), 19 spinal injuries (17%), and 4 combined head/spine injuries (3.5%). Forty percent of the patients were admitted to inpatient care with a median length of stay of 7 days (IQR 3-17). Twenty-four patients (21%) required surgery. Upon discharge, 86.6% of the patients had an mRS grade of 0-2, 3.6% had a grade of 3, 1.8% had a grade of 4, and 1.8% had a grade of 5. Seven patients (6%) died (mRS grade 6).

CONCLUSIONS

Most neurologic injuries involve isolated trauma to the head. Fifteen percent of the riders' falls were caused after the horse was impacted by a motor vehicle. Forty percent of the patients require admission and 21% undergo surgery. Ten percent of the patients had a poor mRS grade of 4- to 6 when discharged.

Maxillofacial Horse Trauma: A 10-Year Retrospective Study at a UK Major Trauma Center

Introduction/Objecive

There are very few studies that have investigated equestrian-related maxillofacial injuries. A retrospective review was performed to investigate maxillofacial horse trauma at a Level 1 Trauma Centre at the Royal Stoke Hospital over the last 10 years between 2010 and 2020.

Study Design/Methods

Search of the hospital's major trauma database as well as ED records showed 51 patients who sustained maxillofacial injuries related to horses. Statistical analysis was performed using Chi Squared tests.

Results

41 patients were female and the remaining 10 were male. 43% of patients were female and aged 30 and under. Kicks from horses accounted for 64.4% of equine-related maxillofacial injuries. A total of 90 injuries were recorded. Hard tissue injuries which include all fractures accounted for 66.3% of injuries sustained. 70.5% patients sustained isolated maxillofacial trauma. There was an association between patients sustaining non-isolated maxillofacial trauma and hard tissue maxillofacial injuries (P = 0.04). 65.6% of injuries were managed operatively. Patients aged 30 and under were more likely to be managed operatively (P = 0.03).

Conclusion

Equestrian related maxillofacial trauma represents a proportion of trauma workload. The safety aspect of horse riding should be considered and education in safe riding and the use of appropriate safety equipment is vital.

Helmet Use in Preventing Head Injuries in Bicycling, Snow Sports, and Other Recreational Activities and Sports

Bicycling, snow sports, and other recreational activities and sports are important activities to keep children and youth active as part of a healthy lifestyle. These activities can be associated with serious and fatal head and facial injuries. Helmets, when worn correctly, are effective in decreasing head injuries and fatalities related to these activities. Legislation for helmet use is effective in increasing helmet use in children and, ultimately, in decreasing deaths and head and facial injuries. A multipronged strategy employing legislation, enforcement of laws, and medical clinicians and community programs is important for increasing helmet use to decrease deaths and injuries from recreational sports.

Helmet Use in Preventing Head Injuries in Bicycling, Snow Sports, and Other Recreational Activities and Sports

Recreational activities and sports are a common and popular way for youth to enjoy physical activity; however, there are risks related to physical injury. Injuries can potentially result in death and long-term disability, especially from traumatic brain injury. Helmet use can significantly decrease the risk of fatal and nonfatal head injury, including severe traumatic brain injury and facial injuries when participating in recreational sports. The most robust evidence of helmet effectiveness has been demonstrated with bicycling and snow sports (eg, skiing, snowboarding). Despite this evidence, helmets are not worn consistently with all recreational sports. A multipronged approach is necessary to increase helmet use by children and youth participating in recreational sports. This approach includes legislation and enforcement, public educational campaigns, child education programs, and anticipatory guidance from clinicians. This policy statement guides clinicians, public health advocates, and policymakers on best practices for increasing helmet use in recreational sports, including bicycling and snow sports.

Injury patterns of equine-related trauma: A fifteen-year review of hospital admissions to a level 1 trauma center

OBJECTIVE

Little information exists about horse-related injury admissions to Level 1 trauma centers in the Western United States. This study describes injury patterns in this population, to reveal potential areas for injury prevention initiatives.

METHODS

A retrospective database review of 512 non-fatal equine-related injuries over a 15-year period was conducted, using a Level 1 hospital trauma registry. To determine patterns of injury, patients injured by riding or being near a horse were classified according to age, sex, helmet use, abbreviated injury score, anatomical region injured, and length of stay.

RESULTS

Equine-related injury was more frequent among females than males, the anatomical region most at risk among adults was the lower extremity (including pelvis), and among children and youth, the head. 75% of head-injured patients were not wearing a helmet at the time of injury and those with the most severe head injuries were least likely to be wearing a helmet.

CONCLUSION

Preventable equine-related injuries occur across all ages, are more frequent among females, and affect all regions of the body. Despite head-injury risks associated with horse activities, helmet use was not common among most of the injured. Decreasing the risk of these injuries requires use of appropriate protective equipment and enhanced education campaigns aimed at those in the horse industry and the general public.

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.

Helmet use in equestrian athletes: opportunities for intervention

Background:

Equestrian athletes (horse riders) are at high risk for head injury, including concussions.

Materials & methods:

Adults riders were recruited via social media posting to complete a branching survey collecting data on demographics, riding experience, helmet use, injury history and concussion symptom knowledge. Results are reported as frequencies and percentages, with associations tested using chi-square with significance level p < 0.05.

Results:

Of the 2598 subjects, about 75% reported always wearing a helmet. Of those who did not, the most common reasons were that helmets are unnecessary (57.4%) or do not fit well (48.6%). Many indicated improper storage conditions and/or did not follow manufacturer’s replacement recommendations. Most (75.4%) reported a high level of comfort with recognizing concussion signs, with half experiencing a prior head injury.

Conclusion:

This information suggests opportunities for intervention to improve helmet use through increased fit, while the responses indicate a need for further education on proper helmet use.

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.

Neurosurgical management of head injuries incurred during sports: a single centre experience

Introduction: Accidents during sporting activities are a common cause of head injury, particularly in children and young adults. Whilst most sporting head injuries are minor, there remains a proportion which is associated with high morbidity and mortality. The epidemiology of sports associated head injuries is variable based on geographical region so the aim of this study was to review the management and outcomes of sporting head injuries managed by a single neurosurgical unit in the South of England.Method: A retrospective review of the Trauma Audit and Research Network database was conducted for all patients admitted to a tertiary neurosurgical centre over a six-year period (January 2011-December 2016). Case notes were reviewed for demographics, mechanism of injury, injury severity score, intensive care admission, surgical interventions and Glasgow Outcome Score at discharge.Results: Seventy-six patients (mean age: 37.6 ± 18.4 years, male gender n = 43; 56.6%) were eligible for inclusion in this series. Horse riding accidents were identified as the most common cause of head injury (n = 31; 40.8%). Fifteen patients (19.7%) in this series had a severe head injury (GCS 3-8 on admission). Twenty-eight (36.8%) patients required admission to an intensive care unit and 26 (34.2%) patients underwent neurosurgical intervention. At discharge, 68 (89.5%) patients had a Glasgow Outcome Score 4-5.Conclusion: The majority of patients with head injuries admitted to a neurosurgical unit can expect a good functional outcome despite the need for intensive care or neurosurgical intervention. The range of sports resulting in head injury is likely influenced by geographic location; however, further national study is required for wider comparison.

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.

The influence of impact surface on head kinematics and brain tissue response during impacts with equestrian helmets

Current equestrian standards employ a drop test to a rigid steel anvil. However, falls in equestrian sports often result in impacts with soft ground. The purpose of this study was to compare head kinematics and brain tissue response associated with surfaces impacted during equestrian accidents and corresponding helmet certification tests. A helmeted Hybrid III headform was dropped freely onto three different anvils (steel, turf and sand) at three impact locations. Peak linear acceleration, rotational acceleration and impact duration of the headform were measured. Resulting accelerations served as input into a three-dimensional finite element head model, which calculated Maximum principal strain (MPS) and von Mises stress (VMS) in the cerebrum. The results indicated that impacts to a steel anvil produced peak head kinematics and brain tissue responses that were two to three times greater than impacts against both turf and sand. Steel impacts were less than half the duration of turf and sand impacts. The observed response magnitudes obtained in this study suggest that equestrian helmet design should be improved, not only for impacts to rigid surfaces but also to compliant surfaces as response magnitudes for impacts to soft surfaces were still within the reported range for concussion in the literature.