Severity of playground-related fractures: more than just playground factors?

Too far to fall: Exploring the relationship between playground equipment and paediatric upper limb fractures

AIM

Playground equipment, most notably monkey bars, appears to be involved in a high proportion of upper limb fractures (ULFs) in the Australian paediatric population. Despite this, in 2014, Australian playground standards increased the maximum acceptable 'free height of fall' playground equipment from 2.5 to 3.0 m, and maintained monkey bars at 2.2 m. An updated snapshot regarding playground ULFs since these changes is important. This study aimed to determine the number and severity of playground ULFs in a paediatric population, compared to other common activities involved in ULFs.

METHODS

Records of all patients aged 0-17 presenting to the Austin Hospital Paediatric Emergency Department with ULFs over a 12-month period were analysed retrospectively. ULFs included fractures to the carpal bones, radius, ulna or humerus. Variables documented included the activity involved with the fracture, and fracture management. Results were analysed using descriptive statistics.

RESULTS

A total of 725 ULF cases were collected. Playground equipment was involved in 23% (n = 162/697, missing n = 28) of fractures. Monkey bars were involved in 14% of fractures (n = 100/697, missing n = 28), 1.64 times more than the next most common activity. Monkey bars were involved in 62% (n = 100/162) of all playground fractures. In children aged 5-9, monkey bars were involved in 27% (n = 83/304) of ULFs. Monkey bars were furthermore involved in most cases of 'severe' fractures (requiring reduction/operation) (n = 33), with one-third of monkey bar fractures being severe.

CONCLUSION

Given these findings, the authors recommend a renewed focus on measures that reduce the frequency and severity of falls from monkey bars.

Playground-related Extremity Fractures in an Asian Setting over the Last Decade - Are We Safe?

The cost of playground-related injuries remains significant. Measures adopted to prevent such fractures or reduce their severity would translate into appreciable financial savings. Our study looks at the changes in playground-related extremity fracture epidemiology over the past decade after the implementation of latest playground standards. This is a retrospective case series approved by the local ethics board comparing the results of two descriptive studies; one conducted prior to the implementation of the Singapore Productivity and Standards Board Singapore Standards SS 457: 2007 and the other thereafter. The demographics have remained the same. The proportion of public playground injuries has fallen significantly from 89.6% to 76.3% (p < 0.05), whereas school playground injuries have risen from 5.9% to 18.0% (p < 0.05). Fractures related to monkey bars and the flying fox have shown a significant improvement, decreasing to 38.1% from 47.6% (p < 0.05) and 1% from 6.9% (p < 0.05), respectively. There has been a decrease of 33% in playground-related injuries. The total financial cost of sustaining one playground-related extremity fracture has generally increased by 50%. However, considering the 37.4% drop in surgeries, the actual overall costs to the healthcare system have essentially fallen. Safety standards have had a positive effect on playground safety in Singapore. There are now fewer and less severe playground-related extremity fractures.

Reported safety environment predicts injuries among children aged 1-6 years in specific communities

AIM

To measure individual and environmental risk factors predicting reported child injuries.

METHODS

A prospective, follow-up study was performed including 380 parents of children aged 1-6 years, living in various communities throughout Israel. Parents were interviewed three times, 3 months apart. Injuries were defined as including minor injuries that required parental attention and medically attended injuries: doctor or nurse visit, emergency medical services or hospitalisation. Parents reported the level of safety for both indoor and outdoor environments, covering 11 items pertaining to safety elements dedicated to prevent child injury. Socio-demographic and parents' attitudes towards child injury were also measured.

RESULTS

During the 6-month follow-up period, 37% of parents reported that their child was injured, and 29% of them received medical attention. Reported outdoor safety environment was found to be a predictor of child injury, suggesting that the risk of child injury is higher among children living in unsafe outdoor environments. However, this depended on levels of religiosity (with an odds ratio of 2.48 and 95% confidence interval of 1.09-5.64 for traditional families and an odds ratio of 3.65 and 95% confidence interval of 1.58-8.46 for religious families).

CONCLUSIONS

Safe environments play a major role in decreasing the risk of injury among children. In order to decrease injury rates among young children, attention should be given to the immediate outdoor environment in which children grow up and play. Decision makers might particularly want to pay closer attention to the influence of religious backgrounds on child safety through safe environments.

Playground Equipment Related Injuries in Preschool-Aged Children: Emergency Department-based Injury In-depth Surveillance

In this study, we investigated playground equipment related injuries in preschool-aged children. This was a retrospective observational study using Emergency Department based Injury In-depth Surveillance, (2011-2014). We included the preschool-aged children with playground equipment related injuries. We surveyed the mechanism and incidence of injuries, and estimated the odds ratio (OR) of traumatic brain injury (TBI) and upper/lower extremities fracture. There were 6,110 patients, mean age was 4.14 ± 1.95 years old. Slide and swing related injuries were 2,475 (40.5%) and 1,102 (18.0%). Fall down (48.5%) was the most common mechanism. The OR of TBI in children 0-2 years old was 1.88 times higher than children 3-7 years old, and in swing was 4.72 (OR, 4.72; 95% confidence interval [CI], 2.37-9.40) times higher than seesaw. The OR of upper extremity fracture in children 3-7 years old was 3.07 times higher than children 0-2 years old, and in climbing was 2.03 (OR, 2.03; 95% CI, 1.63-2.52) times higher than swing. The OR of lower extremity fractures in horizontal bars, tightropes, and trampolines was 2.95 (OR, 2.95; 95% CI, 1.55-5.61) times higher than swing. The most common mechanism and playground equipment were fall down and slide. TBI was associated to younger children (0-2 years old) and swing. Fracture of upper extremities was associated to older children (3-7 years old) and climbing. Fracture of lower extremities was associated to others such as horizontal bars, tightropes, and trampolines.

Childhood Injuries in Singapore: Can Local Physicians and the Healthcare System Do More to Confront This Public Health Concern?

Childhood injury is one of the leading causes of death globally. Singapore is no exception to this tragic fact, with childhood injuries accounting up to 37% of Emergency Department visits. Hence, it is important to understand the epidemiology and risk factors of childhood injuries locally. A search for relevant articles published from 1996–2016 was performed on PubMed, Cochrane Library and Google Scholar using keywords relating to childhood injury in Singapore. The epidemiology, mechanisms of injury, risk factors and recommended prevention strategies of unintentional childhood injuries were reviewed and described. Epidemiological studies have shown that childhood injury is a common, preventable and significant public health concern in Singapore. Home injuries and falls are responsible for majority of the injuries. Injuries related to childcare products, playground and road traffic accidents are also important causes. Healthcare professionals and legislators play an important role in raising awareness and reducing the incidence of childhood injuries in Singapore. For example, despite legislative requirements for many years, the low usage of child restraint seats in Singapore is worrisome. Thus, greater efforts in public health education in understanding childhood injuries, coupled with more research studies to evaluate the effectiveness and deficiencies of current prevention strategies will be necessary.

What is the Relationship between Risky Outdoor Play and Health in Children? A Systematic Review

Risky outdoor play has been associated with promoting children’s health and development, but also with injury and death. Risky outdoor play has diminished over time, concurrent with increasing concerns regarding child safety and emphasis on injury prevention. We sought to conduct a systematic review to examine the relationship between risky outdoor play and health in children, in order to inform the debate regarding its benefits and harms. We identified and evaluated 21 relevant papers for quality using the GRADE framework. Included articles addressed the effect on health indicators and behaviours from three types of risky play, as well as risky play supportive environments. The systematic review revealed overall positive effects of risky outdoor play on a variety of health indicators and behaviours, most commonly physical activity, but also social health and behaviours, injuries, and aggression. The review indicated the need for additional “good quality” studies; however, we note that even in the face of the generally exclusionary systematic review process, our findings support the promotion of risky outdoor play for healthy child development. These positive results with the marked reduction in risky outdoor play opportunities in recent generations indicate the need to encourage action to support children’s risky outdoor play opportunities. Policy and practice precedents and recommendations for action are discussed.

Pediatric fractures through the eyes of parents: an observational study

The present study is an observational cross-sectional study. The main purpose of this research was to analyze the perception and behaviors of parents in a series of pediatric upper extremity fracture cases. Hundred and seventeen patients younger than 12 years who were conservatively treated for the upper extremity fracture were included in our study. Parents of the patients were requested to answer a family-centered questionnaire related to their child's fracture and its treatment. When the parents were asked whether they believe casting would be sufficient or not as the treatment of their child's fracture, 84.6% answered 'yes', 13.7% answered 'I am not sure,' and 1.7% answered 'no.' Sixty-four of the parents were not worried about any residual defect in joint or extremity functions related to fracture, whereas 21 were worried and 32 were not sure on this. The rate of searching further information about the child's fracture was 34.2% and the mostly used source was the Internet. Twenty-eight of the 117 respondents (23.9%) emphasized that they would reduce the time their child spend outside the home at least for a while after the removal of cast. When conservatively treating a child's fracture, physicians dealing with traumatology should always consider the parents' perception and behaviors as critically important.