All-terrain vehicle injury in children: strategies for prevention

All-terrain vehicle exposure and the association of certified training on adolescent safety behaviors and crash experiences

BACKGROUND

Certified training courses in all-terrain vehicle (ATV) operation are recommended, but little has been published regarding how they affect riding behaviors. Our objectives were to determine adolescents' ATV riding exposures, crashes and injuries, and the association of completing certified ATV training on riding behaviors.

METHODS

Respondents completed an anonymous paper survey at 30 school districts approximately one year after participating in the Safety Tips for ATV Riders (STARs) program. Survey data were compiled using Qualtrics™. Frequency, chi-square, Fisher's exact test, and logistic regression analyses were performed using SAS, V.9.4.

RESULTS

4,891 students completed the survey from Fall 2012-Fall 2019. Respondents were 10-18 years old, and similar numbers of participants were male and female. Fifty-nine percent lived in town, 18% on a farm, and 22% in the country but not on farm. Forty-two percent reported their families owned an ATV. Seventy-seven percent had ridden an ATV, 40% of whom reported riding at least weekly. The vast majority (94%) used ATVs for recreation and 49% used them for work purposes. In the previous year, 22% of riders reported having been in a crash, with 7% of crash victims requiring medical attention for injuries. Greater crash likelihood was seen in males, recreational riders, more frequent riders, competitive racers and those who had ridden with passengers or on roads. Only 8% of riders had completed certified ATV safety training (note, STARs is not a certification program). Those whose families owned ATVs, more frequent riders, and public park users had greater likelihoods of course completion. Relative to their peers, respondents who completed a certification course had higher proportions that always/almost always wore helmets (39% vs. 20%, p < 0.0001) and lower proportions that never/almost never wore helmets (29% vs 58%, p < 0.0001), had ridden with passengers (63% vs. 96%, p < 0.0001), and had driven on public roads (41% vs 50%, p = 0.0065).

CONCLUSIONS

ATV safety training certification among Iowa adolescents in the study was infrequent but those that received training reported higher helmet use, less riding with passengers, and less driving on public roads. These data suggest completing safety training certification may promote safer riding behaviors among youth.

Pediatric spinal injury patterns and management in all-terrain vehicle and dirt bike crashes, 2010-2019

OBJECTIVE

Pediatric spinal injuries in all-terrain vehicle (ATV) and dirt bike crashes are relatively uncommon but may be associated with significant morbidity. There are no recent studies examining these injuries, their management, and outcomes. Therefore, a retrospective study was performed to characterize pediatric spinal injuries related to ATV and dirt bike crashes over the last decade.

METHODS

Data on all patients involved in ATV or dirt bike crashes evaluated at a regional level 1 pediatric trauma center over a 10-year period (2010-2019) were analyzed. Descriptive statistics were analyzed and chi-square, Fisher exact, and Mann-Whitney U-tests were performed comparing the demographics, injury characteristics, and clinical outcomes in patients with versus those without spinal injuries.

RESULTS

Of 680 patients evaluated, 35 (5.1%) were diagnosed with spinal injuries. Over the study period, both spinal injuries and emergency department visits related to ATV or dirt bike crashes increased in frequency. All spinal injuries were initially diagnosed on CT scans, and 57.9% underwent spinal MRI. Injuries were most commonly thoracic (50%), followed by cervical (36.8%). The injuries of most patients were classified as American Spinal Injury Association (ASIA) grade E on presentation (86.8%), while 2 (5.3%) had complete spinal cord injuries (ASIA grade A) and 3 patients (8.6%) were ASIA grade B-D. Operative management was required for 13 patients (28.9%). Nonoperative management was used in 71.1% of injuries, including bracing in 33% of all injuries. Patients with spinal injuries were older than those without (13.4 ± 3.35 vs 11.5 ± 3.79 years, p = 0.003). Spinal injuries occurred via similar crash mechanisms (p = 0.48) and in similar locations (p = 0.29) to nonspinal injuries. Patients with spinal injuries more frequently required admission to the intensive care unit (ICU; 34.2% vs 14.6%, p = 0.011) and had longer hospital stays (mean 4.7 ± 5.5 vs 2.7 ± 4.0 days, p = 0.0025).

CONCLUSIONS

Although infrequent among young ATV and dirt bike riders, spinal injuries are associated with longer hospital stays, increased ICU use, and required operative intervention in 29%. Increasing awareness among ATV and dirt bike riders about the severity of riding-related injuries may encourage safer riding behaviors.

A Comprehensive Report on All-Terrain Vehicles and Youth: Continuing Challenges for Injury Prevention

All-terrain vehicles (ATVs) represent a serious and ongoing public health and safety concern for children and adolescents. Survey studies indicate that high proportions of youth ride ATVs in both rural and nonrural populations. The significant human and economic costs of pediatric ATV-related deaths and injuries result from a number of major risk factors that are highly common in pediatric ATV crashes: operating adult-size vehicles, riding with or as passengers, lack of protective equipment, and riding on public roads. Other less well-studied but potentially significant risk factors are speed, riding at night, alcohol use among older teenagers, and lack of training and supervision. Although potentially safer than adult ATVs, youth models present a number of safety concerns that have not been addressed with rigorous study. The most common ATV crash mechanism is a noncollision event-for example, a rollover. Common injury mechanisms include ejection from the vehicle, resulting in extremity and head injuries, and being pinned or crushed by the vehicle with resulting multiorgan trauma and/or compression asphyxia. Traumatic brain injury and multisystem trauma are the 2 most common causes of death and disabling injury. Taken together, a large multidecade body of evidence is the basis for the American Academy of Pediatrics policy statement recommendation that no child younger than 16 years of age ride on an ATV. Because children continue to be allowed to ride these vehicles, however, efforts to prevent pediatric ATV-related deaths and injuries require multipronged strategies, including education of both youth and parents, safety-based engineering, and enforcement of evidence-based safety laws.

Factors Affecting Neurological Presentation and Severity in Pediatric Off-Highway Vehicle Accidents in Texas

OBJECTIVES

The purpose was to evaluate the characteristics of off-highway vehicle (OHV) crashes correlated with neurological injury and accident severity in the pediatric population in El Paso, Texas.

METHODS

A retrospective review of 213 patients who were victims of an OHV crash attended at a regional Level I trauma center from 2012 to 2020 was performed. OHVs were defined as vehicles designated for use outside public roads. Neurological outcomes included any traumatic brain injury (TBI) or a brain hemorrhage/hematoma. Severe injury was defined as a Glasgow Coma Scale less than 8, a length of stay longer than 7 days, a Pediatric Trauma Score lower than 8, and requiring pediatric intensive care unit admission. Bivariate and multivariate analyses by logistic regression models were conducted to determine the factors related to the neurological outcomes and accident severity.

RESULTS

Of 213 OHV crash patients, 104 (48.8%) had TBI and 22 (10.3%) had brain hemorrhages or hematomas. Risk analyses demonstrated that children younger than age 6 years and occupants of recreational OHVs have a significantly higher risk of severe injuries. Off-highway motorcycles and all-terrain vehicles were risk factors for TBI, whereas helmets were a protective factor.

CONCLUSIONS

OHVs are associated with both TBIs and severe injuries. Stricter laws requiring helmets and forbidding children younger than 6 to ride are required, as modifying these factors could reduce the incidence of OHV crashes and their complications.

Risk factors associated with quadbike crashes: a systematic review

Background

Quadbikes or all-terrain vehicles are known for their propensity for crashes resulting in injury, disability, and death. The control of these needless losses resulting from quadbike crashes has become an essential contributor to sustainable development goals. Understanding the risk factors for such injuries is essential for developing preventive policies and strategies. The aim of this review was to identify the risk factors associated with quadbike crashes at multiple levels through a systematic review of a wide range of study designs.

Methods

The study incorporated a mixed-method systematic review approach and followed the PRISMA 2020 guidelines for reporting systematic reviews, including a peer reviewed  protocol. This systematic review included observational studies investigating the risk factors associated with quadbike crashes, injuries, or deaths. Seven electronic databases were searched from inception to October 2021. Studies were screened and extracted by three researchers. Quality appraisal was conducted using the Mixed Methods Appraisal Tool (MMAT). Due to extensive heterogeneity, meta-analysis was not conducted. All the risk factors have been presented in a narrative synthesis for discussion following the guidelines for Synthesis without Meta-analysis (SWiM).

Results

Thirty-nine studies combining an aggregate of 65,170 participants were included in this systematic review. The results indicate that modifiable risk factors, such as the increasing age of driving initiation, reducing substance use, and the use of organized riding parks, could reduce quadbike injuries. Riding practices such as avoiding passengers, avoiding nighttime riding, and using helmets could significantly reduce crashes and injuries among riders. Vehicle modifications such as increasing the wheelbase and limiting engine displacement could also help reduce crash incidence. Traditional interventional methods, such as legislation and training, had a weak influence on reducing quadbike injuries.

Conclusion

Multiple risk factors are associated with quadbike injuries, with most of them modifiable. Strengthening policies and awareness to minimize risk factors would help in reducing accidents associated with quadbikes.

PROSPERO registration number CRD42020170245

All-Terrain Vehicle-Related Emergency Department Visits: Interaction of Sex and Age, NEISS, 2019

BACKGROUND

Epidemiologic patterns of all-terrain vehicle (ATV)-related emergency department (ED) visits by male and female individuals may vary at different ages. To our knowledge, this has not been researched previously.

OBJECTIVE

The purpose of this study was to determine the interaction of sex and age differences in their association with ATV-related ED visits.

METHODS

Data from the 2019 National Electronic Injury Surveillance System were extracted for ATV-related ED visits, including sex, age, race, location of crash, injured body part, and whether alcohol was involved. Descriptive statistics and logistic regression analyses were conducted. We modeled sex in separate multivariable models, adjusting for the same independent variables.

RESULTS

There were an estimated 95,995 (unweighted n = 1999) ATV-related ED visits. There was a significant age-by-sex interaction in the association between ATV-related ED visits vs. other ED injuries, indicating that the effect of age on ATV-related ED visits differed by sex and vice versa. Overall, male individuals were 1.7 times as likely to have an ATV-related ED visit as female individuals. In the stratified analysis for female individuals, odds were substantially greater for girls younger than 18 years (adjusted odds ratio [AOR] 2.33; 95% confidence interval [CI] 1.61-3.69) and women aged 18-35 years (AOR 4.76; 95% CI 3.48-6.51) compared with woman older than 35 years. For men, odds were significant for ages 18-35 years (AOR 2.21; 95% CI 1.72-2.85) compared with men older than 35 years.

CONCLUSIONS

As newer ATVs become more powerful and faster, there is a need to know who is at greatest risk for ATV-related ED visits to develop policies and safety measures.

Socioeconomic factors associated with helmet use in pediatric ATV and dirt bike trauma

Objectives

Recreational off-road vehicle crashes can produce severe injury and death among children, often from head trauma sustained while riding unhelmeted. Although required for competition, recreational riders commonly forego helmets. This study aimed to identify socioeconomic factors associated with unhelmeted injuries among children riding all-terrain vehicles (ATVs) and dirt bikes recreationally, thus informing injury prevention efforts.

Methods

A retrospective review was completed of patients younger than 18 years who presented after recreational ATV or dirt bike crash to a single American College of Surgeons-verified level 1 pediatric trauma center (2010-2019). Demographic, injury, and outcome data were collected. US Census data regarding median and per capita income, poverty prevalence, and scholastic graduation rates were recorded for each patient's home county. Relationships between helmet use at the time of injury, demographics, and socioeconomic variables were examined.

Results

The cohort comprised 680 injured recreational ATV (n=510; 75%) and dirt bike (170; 25%) riders. Unhelmeted riders (n=450) were significantly older (median age 13 vs 11 years; p=0.008) and more often rode ATVs (n=399). Significantly greater percentages of females (77.9%; p<0.001) and passengers (89.5%; p<0.001) were unhelmeted at the time of injury. Residents of counties with lower median and per capita income, higher poverty prevalence, and lower high school and college graduation rates were significantly more likely to be unhelmeted at the time of their crash (p=0.003). In multivariable analysis, unhelmeted injuries were independently associated with ATV use (OR=6.757; p<0.0001), passenger status (OR=6.457; p<0.0001), and older age (OR=1.219; p<0.0001).

Conclusion

In children, ATV use, passenger status, and older age associated independently with unhelmeted riding in recreational vehicle crash. Residence in a county with both lower median income and scholastic graduation rates associated with unhelmeted crashes, and lower median income significantly predicted unhelmeted crashes. This study revealed socioeconomic factors that identify communities with greatest need for injury prevention initiatives.

Level of evidence

III-retrospective comparative epidemiological study.

The impact of helmet use on neurosurgical care and outcomes after pediatric all-terrain vehicle and dirt bike crashes: a 10-year single-center experience

OBJECTIVE

All-terrain vehicle (ATV) and dirt bike crashes frequently result in traumatic brain injury. The authors performed a retrospective study to evaluate the role of helmets in the neurosurgical outcomes of pediatric patients involved in ATV and dirt bike crashes who were treated at their institution during the last decade.

METHODS

The authors analyzed data on all pediatric patients involved in ATV or dirt bike crashes who were evaluated at a single regional level I pediatric trauma center between 2010 and 2019. Patients were excluded if the crash occurred in a competition (n = 70) or if helmet status could not be determined (n = 18). Multivariable logistic regression was used to analyze the association of helmet status with the primary outcomes of 1) neurosurgical consultation, 2) intracranial injury (including skull fracture), and 3) moderate or severe traumatic brain injury (MSTBI) and to control for literature-based, potentially confounding variables.

RESULTS

In total, 680 patients were included (230 [34%] helmeted patients and 450 [66%] unhelmeted patients). Helmeted patients were more frequently male (81% vs 66%). Drivers were more frequently helmeted (44.3%) than passengers (10.5%, p < 0.001). Head imaging was performed to evaluate 70.9% of unhelmeted patients and 48.3% of helmeted patients (p < 0.001). MSTBI (8.0% vs 1.7%, p = 0.001) and neurosurgical consultation (26.2% vs 9.1%, p < 0.001) were more frequent among unhelmeted patients. Neurosurgical injuries, including intracranial hemorrhage (16% vs 4%, p < 0.001) and skull fracture (18% vs 4%, p < 0.001), were more common in unhelmeted patients. Neurosurgical procedures were required by 2.7% of unhelmeted patients. One helmeted patient (0.4%) required placement of an intracranial pressure monitor, and no other helmeted patients required neurosurgical procedures. After adjustment for age, sex, driver status, vehicle type, and injury mechanism, helmet use significantly reduced the odds of neurosurgical consultation (OR 0.250, 95% CI 0.140-0.447, p < 0.001), intracranial injury (OR 0.172, 95% CI 0.087-0.337, p < 0.001), and MSTBI (OR 0.244, 95% CI 0.079-0.758, p = 0.015). The unadjusted absolute risk reduction provided by helmet use equated to a number-needed-to-helmet of 6 riders to prevent 1 neurosurgical consultation, 4 riders to prevent 1 intracranial injury, and 16 riders to prevent 1 MSTBI.

CONCLUSIONS

Helmet use remains problematically low among young ATV and dirt bike riders, especially passengers. Expanding helmet use among these children could significantly reduce the rates of intracranial injury and MSTBI, as well as the subsequent need for neurosurgical procedures. Promoting helmet use among recreational ATV and dirt bike riders must remain a priority for neurosurgeons, public health officials, and injury prevention professionals.

The dark side of nighttime all-terrain vehicle use

BACKGROUND

Driving at night is considered a risk factor for all-terrain vehicle (ATV) crashes and injuries but few studies have addressed this issue. Our objective was to compare daytime and nighttime ATV crashes to better understand the potential risk factors associated with riding at night.

METHODS

A retrospective study was conducted on Iowa ATV-related crashes and injuries from January 1, 2002 through December 31, 2019 using four statewide datasets: the Iowa Department of Transportation (2002-2019), the Iowa Department of Natural Resources (2002-2019), the Iowa State Trauma Registry (2002-2018) and Iowa newspaper clippings (2009-2019). A standardized coding system was developed, and matching records were identified using Link Plus®. Descriptive (frequencies) and bivariate (chi-square, Fisher's exact test) analyses were performed using VassarStats (Statistical Computation Website).

RESULTS

Among crash victims where light conditions were documented (2125/3752, 57%), about one-quarter (485/2125, 23%) were injured at night. Nighttime crash victims were less likely youth (14% vs. 30%, p < 0.0001), less likely to be wearing helmets (11% vs. 18%, p = 0.003), and less frequently involved in motor vehicle crashes (7% vs. 14%, p < 0.0001) as compared to daytime victims. Nighttime victims were also more likely to be passengers (22% vs. 15%, p = 0.002), to test positive for alcohol (44% vs. 13% in adults, p < 0.0001), and to be injured on a roadway (53% vs. 45%, p = 0.007) and on weekends (76% vs. 63%, p < 0.0001). Numerous differences between daytime and nighttime characteristics were observed for males, females, and adults, whereas most characteristics were similar for youth. The severity of injuries and proportion of fatalities were similar among daytime and nighttime crash victims.

CONCLUSIONS

Nighttime crash victims, particularly adults, were characterized by more frequent risky behaviors like carrying passengers, roadway riding, alcohol use, and lack of helmets. Whereas the frequency of risky behaviors among youth was similar for daytime and nighttime crashes, these behaviors put children at potential risk for injury. Multi-factorial, targeted injury prevention strategies are needed, including improved vehicle design, education about the dangers of nighttime operation, and passage and enforcement of ATV safety laws. Particularly relevant to our study are laws that prohibit nighttime riding.

Nonfatal All-Terrain Vehicle-Related Head and Neck Injuries to Children Treated in US Emergency Departments

This study investigates children <18 years old with nonfatal all-terrain vehicle (ATV)-related head and neck injuries treated in United States emergency departments by analyzing data from the National Electronic Injury Surveillance System from 1990 to 2014. An estimated 279 391 children received emergency treatment during the 25-year study period. The number of injuries remained relatively constant from 1990 to 1997, increased by 142.9% from 1997 to 2007, and then decreased by 37.4% from 2007 to 2014. The most common diagnoses were concussion/closed head injury (32.6%) and fracture (32.6%); 15.4% of children were admitted. The most common injury mechanisms include ejection (30.0%), crash (18.8%), and rollover (15.8%). Patients who were injured on a street/highway were 1.49 times (95% confidence interval = 1.11-1.99) more likely to be admitted than patients injured at other locations. Although the number of nonfatal ATV-related head and neck injuries decreased during the latter part of the study period, they remain common and can have serious medical outcomes.

Pediatric hospitalizations and in-patient mortality from all-terrain vehicle crashes, 2006–2016

Purpose

To evaluate trends in national frequency of hospitalizations and in-patient mortality in the United States for children injured in all-terrain vehicle crashes during the past decade.

Methods

Retrospective review of the 2006, 2009, 2012, and 2016 Kids' Inpatient Databases to identify hospitalizations of patients <19 years of age for all-terrain vehicle-related injuries. External-cause-of-injury codes were used to identify patients hospitalized for injuries sustained in all-terrain vehicle crashes. Odds ratios for in-patient mortality were calculated by logistic regression incorporating multiple individual demographic and hospital variables.

Results

Estimated all-terrain vehicle-related hospitalizations ranged from 3666 in 2006 (5.2/100,000 persons <19 years of age) to 2558 in 2012 (3.3/100,000). Crude in-patient mortality was low, and varied slightly from year to year (range, 0.55–1.04%). Patients hospitalized for all-terrain vehicle-related injuries were 76.8–78.4% White and 72.1–77.2% male. Totally 61.0–64.3% had private insurance, 35.3–39.3% were from rural areas, 37.4–38.3% were in the 10–14-year age group, and patients from the West region accounted for 40.4–43.6% of patients. There were no risk factors identified as being consistently associated with mortality in this cohort. Average total charges increased from $26,996 to $67,370 over the course of the study ( p < 0.001).

Conclusions

Hospitalizations for all-terrain vehicle-related injuries in children have fallen in the past decade although the reasons for this change are unknown. In-patient mortality rates have stayed relatively constant and while no factors were predictive of in-patient mortality, demographic data may provide an opportunity for targeted interventions to further reduce injuries and associated hospital costs.

Enforcement of Off-Road Vehicle Laws in Iowa

Safety laws are among the most successful means of reducing injuries, but their effectiveness is strongly influenced by the level of enforcement. To characterize enforcement of off-road vehicle (ORV) laws statewide, analyses of citations were performed using Iowa Court Information System data. From 2005–2015, 5173 individuals were charged with 5643 citations issued. Citations averaged <5/county/year, decreased dramatically over time, and varied by county when normalized to registered all-terrain vehicles (ATVs). Over 90% of operators cited were male and Caucasian. One-fifth were <18 years old. The top five violations were: operation on a highway/snowmobile trail (51%), registration/identification number not documented/displayed (19%), prohibited use in a park/preserve (5.5%), and operation with more persons than the vehicle is designed to carry (4.4%). The Department of Natural Resources issued the highest percentage of citations, followed in decreasing order by Sheriff, Police, State Patrol, and Conservation officers. Significant differences were identified when citations were compared by sex, age, race, enforcement agency, disposition (guilty vs. not guilty), and when comparing counties with or without an ORV park. These characteristics suggest limited and variable enforcement of laws statewide that may reduce their potential to prevent deaths and injuries, and that improved strategies to support ORV law enforcement are needed.

Pediatric and adolescent injury in all-terrain vehicles

All-terrain vehicles (ATVs) remain a significant source of death and injury among youth. The purpose of this review is to provide an overview of the scope of the problem, the risk factors involved, crash-related outcomes and costs, and injury prevention strategies. There are currently more than 100 pediatric ATV-related fatalities each year and over 30,000 emergency department visits, with a potential annual cost for deaths and injuries approaching $1 billion. Major risk factors include lack of training, operating adult-size ATVs, riding as or carrying passengers, riding on the road, and not wearing a helmet. Extremity injuries are highly common, and the leading causes of death include brain injuries and multi-organ trauma. The latter increasingly involves being crushed by or pinned under the ATV. Reducing ATV-related deaths and injuries will require multiple strategies that integrate approaches from education, engineering, and evidence-based safety laws and their enforcement.

Age Legislation and Off-Road Vehicle Injuries in Children

BACKGROUND AND OBJECTIVES

In 2010, the Massachusetts Legislature passed a comprehensive law that restricted off-road vehicle (ORV) use by children <14 years old and regulated ORV use by children up to the age of 18 years. We aimed to examine the impact of the 2010 Massachusetts law on the rates of ORV-related injuries.

METHODS

A retrospective analysis was performed of Massachusetts emergency department (ED) and inpatient discharges between 2002 and 2013 as found in the Center for Health Information and Analysis database by using external causes of injury codes specific to ORV-related injuries. Yearly population-based rates were compared before and after the implementation of the law (2002-2010 vs 2011-2013) by using Poisson regression analysis and segmented regression.

RESULTS

There were 3638 ED discharges and 481 inpatient discharges for ORV-related injuries in children across the 12-year study period. After the implementation of the law, the rate of ED discharges declined by 33% in 0- to 9-year-olds, 50% in 10- to 13-year-olds, and 39% in 14 to 17-year-olds (P < .0001). There was no significant decline in ED discharges for 25- to 34-year-olds. Inpatient hospital discharges were also reduced by 41% in 0- to 17-year-olds after implementation (P < .001).

CONCLUSIONS

As compared with adults (ages 25-34 years), the population-based ORV-related injury rate of residents <18 years old significantly declined after the passage of legislation that imposed age restrictions and other safeguards for youth riders.

Using Geospatial Mapping to Determine the Impact of All-Terrain Vehicle Crashes on Both Rural and Urban Communities

INTRODUCTION

Deaths and injuries from all-terrain vehicle (ATV) crashes result in approximately 700 deaths each year and more than 100,000 emergency department (ED) visits. Common misconceptions about ATV crashes are a significant barrier to injury prevention efforts, as is the lack of key information about where and how crashes occur. The purpose of this study was to determine ATV crash patterns within a state, and to compare and contrast characteristics of these crashes as a function of crash-site rurality.

METHODS

We performed descriptive, comparative, and regression analyses using a statewide off-road vehicle crash and injury database (2002-2013). Comparisons were performed by rurality as defined using the Rural Urban Commuting Area (RUCA) coding system, and we used geographic information system (GIS) software to map crash patterns at the zip code and county levels.

RESULTS

ATV crashes occurred throughout the state; 46% occurred in urban and 54% in rural zip code areas. Comparisons of rider and crash characteristics by rurality showed similarities by sex, age, seating position, on vs. off the road, and crash mechanism. Conversely, helmet use was significantly lower among victims of isolated rural crashes as compared to other victims (p=0.004). Crashes in isolated rural and small rural areas accounted for only 39% of all crashes but resulted in 62% of fatalities. In both rural and urban areas, less than one-quarter of roadway injuries were traffic related. Relative crash rates varied by county, and unique patterns were observed for crashes involving youth and roadway riders. During the study period, 10% and 50% of all crashes occurred in 2% and 20% of the state's counties, respectively.

CONCLUSION

This study suggests that ATV crashes are a public health concern for both rural and urban communities. However, isolated rural ATV crash victims were less likely to be helmeted, and rural victims were over-represented among fatalities. Traffic was not the major factor in roadway crashes in either rural or urban areas. Unique crash patterns for different riding populations suggest that injury prevention experts and public policy makers should consider the potential impact of geographical location when developing injury prevention interventions.

This Much Water: a qualitative study using behavioural theory to develop a community service video to prevent child drowning in Western Australia

OBJECTIVES

Drowning in children under the age of 5 is a frequently occurring, yet preventable event. This research used behavioural theory to test the suitability and appropriateness of a drowning prevention message in a community service video.

DESIGN

This qualitative study used content analysis of focus groups. Constructs from the Health Belief Model guided the data analysis.

SETTING

Community organisations and playgrounds in Perth, Western Australia.

PARTICIPANTS

Participants were parents or carers of at least one child under 5 years residing in Western Australia. Seven focus groups (n=57) were conducted with eight participants in each group. Most participants were parents (96%), female (95%), aged between 25 and 34 years (63%) and were born in Australia (68%).

RESULTS

Participants indicated the community service video was credible in communicating the message that young children were susceptible to drowning in shallow water and that various water hazards existed in and around the home. However, a range of external factors, such as the child's age, type of water hazard, presence of siblings and other environmental factors, influenced risk perceptions. Child drowning was seen as a serious issue. Controlling access to water and the role of supervision were understood to be important factors in preventing drowning.

CONCLUSIONS

The lack of published drowning prevention interventions shaped by behavioural theory limits the understanding of best practice. Using constructs from the Health Belief Model, this research confirmed the perceived seriousness, devastating and unforgettable consequence of drowning; however, findings were mixed regarding cues to action. Future development of drowning prevention media messages should test strategies to increase susceptibility and self-efficacy among the target group and explore the impact of different message senders. The findings provide a valuable understanding of possible messages and their execution for use in media campaigns, as one component of an effective public health intervention to prevent child drowning underpinned by behavioural theory.

Engaging Agribusinesses: Feasibility and Cost of an ATV Safety Poster Project

OBJECTIVES

All-terrain vehicle (ATV)-related deaths and injuries continue to be a significant problem. Influential change agents such as agribusinesses could be important partners for improving safety behaviors among rural ATV users. Our objective was to determine how effectively an injury prevention project could engage agribusinesses through the postal service and to assess their willingness to display a safety poster.

METHODS

One thousand two hundred forty-four agribusinesses received an ATV safety poster and a postcard survey by mail. A randomized sampling of these businesses was surveyed by telephone 4-7 weeks later. Telephone survey questions included whether they recalled receiving the poster, and if so, whether, where and how long the poster was displayed.

RESULTS

One hundred six postcards were returned. Of the 192 eligible business persons contacted by telephone, 89% agreed to participate. Approximately one-third of telephone survey participants recalled receiving the poster. Among these, 81% with walk-in customers posted it, and 74% still had it displayed 1 month later. Of participants who did not recall receiving the poster, 83% stated they would have displayed the poster. The cost of displaying each poster in a business was 16.6 cents/day during the first month. Final costs/day would be much less because of continued display.

CONCLUSION

A high percentage of agribusinesses displayed or would have displayed an ATV safety poster, and most displayed it beyond 1 month. Unfortunately, participant recruitment via postal delivery alone was challenging. Nevertheless, mass mailing of injury prevention materials to be displayed in the retail setting may be a low cost method for raising safety awareness.

Analysis of All-Terrain Vehicle Trauma Data: Implications for Increased Regulation and Injury Prevention

To determine the incidence and severity of all-terrain vehicle crashes (ATVCs) compared with motorcycle crashes (MCCs) in all critically injured patients. Prospective data were retrospectively reviewed on 1840 patients involved in ATVCs and MCCs admitted to a rural level one trauma center over 16 years. ATVC patients (n = 655) were younger (25 vs 38, P < 0.0001), more likely female (20% vs 11%, P < 0.001), less severely injured (13.5 vs 16, P < 0.0001), had similar Glasgow Coma Score (13.3 vs 13.4, p = NS), less helmet use (6% vs 69%, P < 0.0001), more closed head injuries (59.7% vs 54.3%, P < 0.05), more facial injuries (16.9% vs 12.5%, P < 0.05), and lower mortality rate (2.8% vs 5.9%, P < 0.01) compared with MCC patients (n = 1172). Pediatric patients involved in ATVC were more common (29.8% vs 4.8%, P < 0.001), had decreased helmet use (12% vs 59%, P < 0.001) and decreased mortality (3.5% vs 14.3%, P < 0.01). Further injury prevention efforts regarding helmet use and increased regulations regarding ATVCs are needed to decrease the morbidity associated with these recreational vehicles.

Rural Kentucky High School Students' Exposure to All-Terrain Vehicle Riding and Injuries

From 1982 to 2007, Kentucky had 459 deaths related to all-terrain vehicles (ATVs), fifth highest among US states. By 2012, Kentucky ranked fourth highest, with 578 ATV-related deaths. Following the sentinel event of an ATV-related traumatic brain injury to an unhelmeted high school student, the authors developed a 19-item survey that collected data regarding rural Kentucky high school students' years of ATV driving, second-rider frequency, typical duration of riding events, estimated weekly number of riding events, and frequency of helmet use. Of the 159 students involved, males scored significantly higher on each of these items, except frequency of any ATV driving and frequency of helmet use, which showed no gender differences. Overall, 9.3% of students reported always wearing a helmet when driving and/or riding; 61.2% reported never wearing a helmet; 132 (83.0%) reported that they either drove ATVs or rode as a second rider, and 72 of these (57.1%) reported having had an ATV incident, 33 (45.8%) of which resulted in an injury. Twenty-one of these were serious injuries, including concussions; unconsciousness; fractures to skull, nose, collarbones, arms, ribs, and legs; elbow and hip dislocations; lacerations to head, eyes, arms, legs, and back; and multiple contusions and sprains. Findings have implications for the design of responsibility to protect (R2P) interventions that will reduce exposure and prevent ATV injury and fatality. A method that leverages the relevance of a sentinel event as a community public-health surveillance opportunity is described. Study surveillance data showed higher exposure to ATV hazards than previously reported.

Off-Road Vehicle Crash Risk during the Six Months after a Birthday

Background

Off-road vehicles are popular and thrilling for youth outside urban settings, yet sometimes result in a serious crash that requires emergency medical care. The relation between birthdays and the subsequent risk of an off-road vehicle crash is unknown.

Methods

We conducted a population-based before-and-after longitudinal analysis of youth who received emergency medical care in Ontario, Canada, due to an off-road vehicle crash between April 1, 2002, and March 31, 2014. We identified youth injured in an off-road vehicle crash through population-based health-care databases of individuals treated for medical emergencies. We included youth aged 19 years or younger, distinguishing juniors (age ≤ 15 years) from juveniles (age ≥ 16 years).

Results

A total 32,777 youths accounted for 35,202 emergencies due to off-road vehicle crashes within six months of their nearest birthday. Comparing the six months following a birthday to the six months prior to a birthday, crashes increased by about 2.7 events per 1000 juniors (18.3 vs 21.0, p < 0.0001). The difference equaled a 15% increase in relative risk (95% confidence interval 12 to 18). The increase extended for months following a birthday, was not observed for traffic crashes due to on-road vehicles, and was partially explained by a lack of helmet wearing. As expected, off-road crash risks did not change significantly following a birthday among juveniles (19.2 vs 19.8, p = 0.61).

Conclusions

Off-road vehicle crashes leading to emergency medical care increase following a birthday in youth below age 16 years. An awareness of this association might inform public health messages, gift-giving practices, age-related parental permissions, and prevention by primary care physicians.

Video intervention changes parent perception of all-terrain vehicle (ATV) safety for children

BACKGROUND

Children aged <16 years account for 25% of deaths on all-terrain vehicles (ATVs), despite public health and industry warning against paediatric use. Parents often underestimate instability and other risks associated with ATVs.

OBJECTIVE

To determine if a brief intervention consisting of validated computer simulations of ATV performance with a child driver changes attitudes, beliefs and planned safety behaviours of parents of children who ride ATVs.

DESIGN/METHODS

Participants were parents of children presenting to a children's hospital emergency department. All participants had children who had ridden an ATV in the past year. Subjects viewed a video simulation of ATVs in scenarios featuring 6-year-old and 10-year-old biofidelic anthropomorphic test devices. Parents completed a survey both before and after viewing the video to report attitudes/beliefs on ATV safety for children, use of safety equipment and family ATV use, as well as risk and safety perception.

RESULTS

Surveys were collected from 99 parents, mostly mothers (79%), Caucasian (61%) and had high school education or less (64%). The intervention shifted parents' belief in overall ATV safety (48% unsafe pre-intervention, 73% unsafe post-intervention, p<0.001). After viewing the video simulation, parents were almost six times more likely to perceive ATVs as unsafe (OR 5.96, 95% CI 2.32 to 15.31, p<0.001) and many parents (71%) planned to change family ATV safety rules.

CONCLUSION

Video simulations of ATV performance with child riders changed short-term risk perception and planned safety behaviours of parents whose children ride ATVs. Similar educational interventions hold promise for larger-scale studies in at-risk populations.

All-terrain vehicle fatalities on paved roads, unpaved roads, and off-road: Evidence for informed roadway safety warnings and legislation

OBJECTIVE

All-terrain vehicles (ATVs) are designed for off-highway use only, and many of their features create increased risk with roadway travel. Over half of all ATV-related fatalities occur on roadways, and nonfatal roadway crashes result in more serious injuries than those off the road. A number of jurisdictions have passed or have considered legislation allowing ATVs on public roadways, sometimes limiting them to those unpaved, arguing that they are safe for ATVs. However, no studies have determined the epidemiology of ATV-related fatalities on different road surface types. The objective of the study was to compare ATV-related deaths on paved versus unpaved roads and to contrast them with off-road fatalities.

METHODS

Retrospective descriptive and multivariable analyses were performed using U.S. Consumer Product Safety Commission fatality data from 1982 through 2012.

RESULTS

After 1998, ATV-related deaths increased at twice the rate on paved versus unpaved roads. Still, 42% of all roadway deaths during the study period occurred on unpaved surfaces. States varied considerably, ranging from 18% to 79% of their ATV-related roadway deaths occurring on unpaved roads. Paved road crashes were more likely than those on unpaved surfaces to involve males, adolescents and younger adults, passengers, and collisions with other vehicles. Both the pattern of other vehicles involved in collisions and which vehicle hit the other were different for the 2 road types. Alcohol use was higher, helmet use was lower, and head injuries were more likely in paved versus unpaved roadway crashes. However, head injuries still occurred in 76% of fatalities on unpaved roads. Helmets were associated with lower proportions of head injuries among riders, regardless of road surface type. Relative to off-road crashes, both paved and unpaved roads were more likely to involve collisions with another vehicle. The vast majority of roadway crashes, however, did not involve a traffic collision on either paved or unpaved roads.

CONCLUSIONS

Although differences were observed between paved and unpaved roads, our results show that riding on either represented significantly greater dangers than riding off the road. Many vehicle warnings specifically mention the risks of paved but not unpaved roads, yet we found 23 states with half or more of their roadway deaths on unpaved surfaces. Safety warnings should explicitly state the dangers of roadway riding regardless of surface type. These data further support laws/ordinances greatly restricting ATV riding on all types of public roadways.

A comparison of injuries sustained from recreational compared to organized motorized vehicle use in children

PURPOSE

To examine the injury severity and patterns of injury for pediatric motorized recreational vehicle (MRV) drivers injured during organized events (OE) compared to recreational use (RU).

METHODS

All pediatric MRV injuries between 2006 and 2012 in our institutional trauma registry were studied for mechanism of injury, initial evaluation, and treatment. Injuries with an Abbreviated Injury Scale ≥2 were categorized by body region and diagnosis.

RESULTS

Out of 589 collisions, 92 (16%) occurred during an OE. Compared to RU drivers, OE drivers were more likely to wear helmets (92% vs. 40%, p<0.001) and other protective equipment (79% vs. 6%, p<0.001). There was no difference in rates of hospital admission, rates of surgical intervention, injury severity scores, rates of intensive care unit admission, or lengths of stay. There were no differences in injuries by body region or injury type, except that dislocations were more common in OE drivers (2% vs. 0%, p=0.038).

CONCLUSION

Despite higher rates of helmet and protective gear use, pediatric MRV drivers participating in OEs sustain similarly severe injuries as drivers using MRVs recreationally. No differences were observed in body regions involved or outcomes. Public perception that OE use of MRV for children is safe should be addressed.

Larger ATV engine size correlates with an increased rate of traumatic brain injury

INTRODUCTION

Since the introduction of all-terrain vehicles (ATV) to the United States in 1971, injuries and mortalities related to their use have increased significantly. Furthermore, these vehicles have become larger and more powerful. As there are no helmet requirements or limitations on engine-size in the State of Alabama, we hypothesised that larger engine size would correlate with an increased incidence of traumatic brain injury (TBI) in patients following an ATV crash.

METHODS

Patient and ATV data were prospectively collected on all ATV crashes presenting to a level one trauma centre from September 2010 to May 2013. Collected data included: demographics, age of driver, ATV engine size, presence of helmet, injuries, and outcomes. The data were grouped according to the ATV engine size in cubic centimetres (cc). For the purposes of this study, TBI was defined as any type of intracranial haemorrhage on the initial computed tomography scan.

RESULTS

There were 61 patients identified during the study period. Two patients (3%) were wearing a helmet at the time of injury. Patients on an ATV with an engine size of 350 cc or greater had higher Injury Severity Scores (13.9 vs. 7.5, p ≤ 0.05) and an increased incidence of TBI (26% vs. 0%, p ≤ 0.05) when compared to patients on ATV's with an engine size less than 350 cc.

CONCLUSIONS

Patients on an ATV with an engine size of 350 cc or greater were more likely to have a TBI. The use of a helmet was rarely present in this cohort. Legislative efforts to implement rider protection laws for ATVs are warranted.

Age-based risk factors for pediatric ATV-related fatalities

OBJECTIVES

To compare and contrast characteristics and determinants of fatal all-terrain vehicle (ATV) crashes among pediatric age groups.

METHODS

Retrospective descriptive and multivariable analyses of Consumer Product Safety Commission fatality data (1985-2009) were performed.

RESULTS

Relative to 1985-1989 (baseline), pediatric deaths over the subsequent 4-year periods were lower until 2001-2004, when they markedly increased. Also, the proportion of vehicles involved in fatalities with engine sizes >350 cubic centimeter increased, reaching ∼50% of crashes in 2007-2009. Ninety-five percent of all pediatric fatalities were on adult-size vehicles. Victims <6 years old had the highest proportion of girls (24%) and passengers (76%), and the lowest helmet use (17%). More than half of 6- to 11-year-old children were vehicle operators; 1 in 4 were carrying passengers in their own age range. Over the study period, 12- to 15-year-old children accounted for more than half of all pediatric ATV-related fatalities. The proportion of youth riding on the road increased with age, as did the proportion of collisions with other vehicles. Older teens had the highest proportions of roadway fatalities (72%) and collision events (63%), and 19% of their crashes involved alcohol. Head injuries occurred in 63% of victims (the major determinant being roadway riding), and helmets reduced the likelihood of head injury among fatal crash victims by 58%.

CONCLUSIONS

There were significant differences between pediatric age groups in the relative contribution of known risk factors for ATV-related fatalities. Future injury prevention efforts must recognize these differences and develop interventions based on the age range targeted.

The Safety Tips for ATV Riders (STARs) programme: short-term impact of a school-based educational intervention

BACKGROUND

Since 1985, one-third of all US all-terrain vehicle (ATV)-related injuries and one-quarter of deaths involved victims <16 years of age. ATV safety education of youth could help reduce these tragedies.

OBJECTIVES

To assess the efficacy of the Safety Tips for ATV Riders (STARs) school-based programme targeting adolescents.

METHODS

A survey was anonymously administered before and after the programme to determine demographics, knowledge and reported likelihood of using the information learned.

RESULTS

Over 4600 students in 30 Iowa schools participated from November 2010 to April 2013. Initially, 52% knew most ATVs are designed for one rider, 25% knew the recommended vehicle size for their age range and 42% knew riding on Iowa's roads was legal only for agricultural purposes. After the programme, this increased to 92%, 82% and 76%, respectively (p<0.0001 in each case), with 61% of students correct on all three. Better preintervention scores were associated with being males, higher riding frequency and being from isolated rural communities. After the programme, 48% and 32% said they were likely/very likely versus unlikely/very unlikely to use the safety information learned, respectively; younger students, females and infrequent riders reported higher likelihoods.

CONCLUSIONS

STARs increased short-term ATV safety knowledge and almost half the participants reported they would use the safety information presented. Males and frequent riders seemed more resistant, but some groups that may be more vulnerable to potential ATV crash and injury appeared amenable to the training with higher increases in postprogramme scores and greater intention of improving safety behaviours.

A school-based study of adolescent all-terrain vehicle exposure, safety behaviors, and crash experience

PURPOSE

More youth are killed every year in the United States in all-terrain vehicle (ATV) crashes than on bicycles, and since 2001, one-fifth of all ATV fatalities have involved victims aged 15 years or younger. Effectively preventing pediatric ATV-related deaths and injuries requires knowledge about youth riding practices. Our objective was to examine ATV use, crash prevalence, and riding behaviors among adolescent students in a rural state.

METHODS

We administered a cross-sectional survey to 4,684 youths aged 11 to 16 years at 30 schools across Iowa from November 2010 to April 2013. Descriptive and comparative analyses were performed.

RESULTS

Regardless of rurality, at least 75% of students reported having been on an ATV, with 38% of those riding daily or weekly. Among ATV riders, 57% had been in a crash. Most riders engaged in risky behaviors, including riding with passengers (92%), on public roads (81%), or without a helmet (64%). Almost 60% reported engaging in all 3 behaviors; only 2% engaged in none. Multivariable modeling revealed male youth, students riding daily/weekly, and those reporting both riding on public roads and with passengers were 1.61 (95% CI, 1.36-1.91), 3.73 (95% CI, 3.10-4.50), and 3.24 (95% CI, 2.09-5.04) times more likely to report a crash, respectively.

CONCLUSIONS

Three-fourths of youths surveyed were exposed to ATVs. The majority of riders had engaged in unsafe behaviors and experienced a crash. Given this widespread use and the potentially considerable morbidity of pediatric ATV crashes, prevention efforts, including anticipatory guidance by primary care clinicians serving families at risk, should be a higher priority.

Legislation in Québec for all-terrain vehicles: are we doing enough?

OBJECTIVES

All-terrain vehicle (ATV) legislation in Québec is among the most restrictive in Canada. The purpose of our study was to characterize the pediatric ATV traumas in our center and determine the impact of legislation.

METHODS

Retrospective chart review of all patients seen in the emergency department after an ATV injury was done from 2005 to 2011.

RESULTS

Seventy-tree patients (50 boys and 23 girls) with a mean age of 11 years (range, 3-17 years) were identified. Forty-nine percent were drivers, 40% were passengers, and 11% unknown. Forty-five percent did not reach the legal age of 16 years. Helmet use was documented in 36%. Eighty-five percent were admitted to the floor, and 15% were discharged from the emergency department. Intensive care unit stay was necessary in 21%, and 60% were operated on. Most of the surgeries were for orthopedic, either extremities, spine, or pelvic (80%). The most frequent types of trauma were extremities (30%), head (30%), and face (25%). Head trauma was severe in 23%. Hospitalization rates for ATV injuries have remained unchanged in the last years.

CONCLUSIONS

Despite implementation of ATV legislation regarding helmet use and minimal legal age, a lot of our patients did not obey these rules. This study demonstrates that strong legislation did not have a real impact on ATV morbidity in children. It is essential to develop strategies to enforce ATV users to respect legislation.

All-terrain vehicle-related nonfatal injuries among young riders in the United States, 2001-2010

OBJECTIVE

To estimate the numbers and rates of all-terrain vehicle (ATV)-related nonfatal injuries among riders aged ≤ 15 years treated in hospital emergency departments (EDs) in the United States during 2001-2010.

METHODS

National Electronic Injury Surveillance System-All Injury Program data for 2001-2010 were analyzed. Numbers and rates of injuries were examined by age group, gender, primary body part injured, diagnosis, and hospital admission status.

RESULTS

During 2001-2010, an estimated 361,161 ATV riders aged ≤ 15 years were treated in EDs for ATV-related injuries. The injury rate peaked at 67 per 100,000 children in 2004 and then declined to 42 per 100,000 children by 2010. The annualized injury rate for boys was double that of girls (73 vs 37 per 100,000). Children aged 11 to 15 years accounted for two-thirds of all ED visits and hospitalizations. Fractures accounted for 28% of ED visits and 45% of hospitalizations.

CONCLUSIONS

The reasons for the decline in ATV-related injuries among young riders are not well understood but might be related to the economic recession of the mid-2000s and decreased sales of new ATVs. Although many states have regulations governing children's use of ATVs, their effectiveness in reducing injuries is unclear. Broader use of known effective safety measures, including prohibiting children aged ≤ 15 years from riding adult-sized ATVs, always wearing a helmet while riding, not riding on paved roads, and not riding as or carrying a passenger could additionally reduce ATV-related injuries among children. Last, more research to better understand ATV crash dynamics might lead to safer designs for ATVs.

Optimising seat design for all-terrain vehicle injury prevention: wide variability illustrates need for evidence-based standardisation

BACKGROUND

All-terrain vehicle (ATV)-related deaths and injuries are a growing public health concern, particularly in rural and suburban communities. More engineering approaches that address vehicle safety and promote injury prevention are critically needed.

OBJECTIVES

Our study was designed to determine the variability in seat characteristics among 2012 model-year, adult-size ATVs.

METHODS

Measurements of 67 models were performed using an image-based method. Seat characteristics were compared by manufacturer and by ATV type (sport vs utility).

RESULTS

There were significant differences in seat length and seat placement among manufacturers and between sport and utility ATVs. Seat lengths ranged from 19.8 to 37.0 inches, with sport models significantly longer than utility models. Longer seats resulted from the back of the seat extending further beyond the rear axle and/or the seat front extending closer to the handle grips. Seat front to handle grip distances ranged from 3.25 to 16.5 inches. Combined data showed a strong inverse correlation between seat length and the distance from the seat front to the handle grips, but no significant correlation with wheelbase or engine size.

CONCLUSIONS

We found wide variability in seat length and placement for adult-size ATVs. However, existing seat specifications were identified that may be a good starting point for improved seat design. Optimal design would allow for safe operation while reducing the likelihood of multiple riders and use by underaged operators, both major risk factors for ATV-related deaths and injuries. Ultimately, regulations may be needed to ensure standardised seat design is incorporated throughout the ATV industry.

An image-based method to measure all-terrain vehicle dimensions for engineering safety purposes

BACKGROUND

All-terrain vehicle (ATV) crashes are a serious public health and safety concern. Engineering approaches that address ATV injury prevention are critically needed. Avenues to pursue include evidence-based seat design that decreases risky behaviours, such as carrying passengers and operation of adult-size vehicles by children.

OBJECTIVES

The goal of this study was to create and validate an image-based method to measure ATV seat length and placement.

METHODS

Publicly available ATV images were downloaded. Adobe Photoshop was then used to generate a vertical grid through the centre of the vehicle, to define the grid scale using the manufacturer's reported wheelbase, and to determine seat length and placement relative to the front and rear axles using this scale. Images that yielded a difference greater than 5% between the calculated and the manufacturer's reported ATV lengths were excluded from further analysis.

RESULTS

For the 77 images that met inclusion criteria, the mean±SD for the difference in calculated versus reported vehicle length was 1.8%±1.2%. The Pearson correlation coefficient for comparing image-based seat lengths determined by two independent measurers (20 models) and image-based lengths versus lengths measured at dealerships (12 models) were 0.95 and 0.96, respectively.

CONCLUSIONS

The image-based method provides accurate and reproducible results for determining ATV measurements, including seat length and placement. This method greatly expands the number of ATV models that can be studied, and may be generalisable to other motor vehicle types. These measurements can be used to guide engineering approaches that improve ATV safety design.

What features of images affect parents' appraisal of safety messages? Examining images from the A Million Messages programme in Canada

BACKGROUND

Enhancing caregivers' awareness of children's injury risks and increasing knowledge about strategies for injury prevention often involve presenting parents with written materials and accompanying images.

OBJECTIVES

To assess parents' appraisals of different variations of images and identify those features that enhance their attention to safety messages.

METHODS

Eight images showing risk situations were taken from the A Million Messages safety education parent-directed programme in Canada and modified to create a corresponding image that clearly showed negative consequences for the child, and facial expressions of fear and/or upset. Mothers with young children were presented with the eight pairs of images (negative consequence vs risk situation) and asked to select the best accompaniment to a safety message and to provide an explanation for their choice. Each image was then also rated for fit to the safety message, communication of danger, emotional arousal and attention elicitation.

RESULTS

The images depicting negative consequences were chosen for most comparisons (78%) and higher scores were assigned to these images for all four features rated by parents (danger communicated, emotions evoked, attention elicitation and fit to the safety message). Moreover, ratings of danger, emotions and attention predicted 'fit to safety message' scores.

CONCLUSIONS

Depicting negative consequences and showing negative emotions is important to maximise the effectiveness of images in communicating danger and evoking attention and concern when targeting parents with child-safety messaging.

Off-highway vehicle parks: combining environment, knowledge, and enforcement for all-terrain vehicle injury prevention

The number of off-highway vehicle (OHV) parks continues to grow to meet the recreational needs of ATV enthusiasts and the increasing popularity of the vehicle. Little is known about how OHV park regulations and enforcement affect ATV safety among their users. This study was designed to determine whether there were differences in crash mechanisms and/or compliance with ATV safety laws and regulations when comparing off-road ATV crashes inside and outside state OHV parks. Relative to outside the parks, a smaller percentage of park victims were under the age of sixteen, a lower percentage were passengers, and a dramatically higher percentage were helmeted. Mean injury severity scores were not different inside and outside the parks, but 5% of outside victims had severe brain injuries, as compared to no park victims. Overall, park victims exhibited better compliance with ATV safety laws and regulations and suffered less severe brain injury outcomes. However, park crashes involved more jump-related injuries, suggesting that additional approaches are needed to improve park safety. These findings support the hypothesis that riding environments with safety regulations and effective enforcement can promote safe behaviors and may prevent injuries.

All-terrain vehicles (ATVs) on the road: a serious traffic safety and public health concern

OBJECTIVES

On-road all-terrain vehicle (ATV) crashes are frequent occurrences that disproportionately impact rural communities. These crashes occur despite most states having laws restricting on-road ATV use. A number of overall risk factors for ATV-related injuries have been identified (e.g., lack of helmet, carrying passengers). However, few studies have determined the relative contribution of these and other factors to on-road crashes and injuries. The objective of our study was to determine whether there were differences between on- and off-road ATV crashes in their demographics and/or mechanisms and outcomes of injuries.

METHODS

Data were derived from our statewide ATV injury surveillance database (2002-2009). Crash location and crash and injury mechanisms were coded using a modification of the Department of Transportation (DOT) coding system. Descriptive analyses and statistical comparisons (chi-square test) of variables were performed. Multivariate logistic regression analysis was used to determine relative risk.

RESULTS

976 records were included in the final analysis, with 38 percent of the injured individuals from on-road crashes. Demographics were similar for crashes at each location, with approximately 80 percent males, 30 percent under the age of 16, and 15 percent passengers. However, females and youths under 16 were over 4 times more likely to be passengers (P ≤ 0.0001), regardless of crash location. Compared to those off-road, on-road crash victims were approximately 10 times more likely to be involved in a vehicle-vehicle collision (P < 0.001), 3 times more likely to have a severe brain injury (P < 0.001), and twice as likely to have suffered major trauma (P < 0.001). Adult operators in on-road crashes were also twice as likely to test positive for alcohol as those off-road (P < 0.05). Helmet use significantly reduced the odds of sustaining a brain injury and on-road victims were only half as likely to be helmeted (P < 0.01).

CONCLUSIONS

More than 1 in 3 on-road crashes involved a collision with another vehicle, suggesting that ATVs on the road represent a potential traffic safety concern. Of note, helmets were associated with reduced risk for the number and severity of brain injuries, providing further support for the importance of helmet use. Finally, even controlling for helmet use, on-road crash victims suffered more major trauma and severe brain injuries than those off-road. Overall, our data reinforce the importance of laws restricting ATV road use and the need for effective enforcement, as well as the need to increase user education about ATV road-use laws and the dangers of riding on the roads.

More fatal all-terrain vehicle crashes occur on the roadway than off: increased risk-taking characterises roadway fatalities

Background

All-terrain vehicles (ATVs) have steadily increased in popularity, size and speed, characteristics that likely contribute to the alarming rise in ATV-related fatalities. One potentially high-risk activity is riding on the road.

Objectives

To compare fatal ATV crashes that occur on the roadway and off, to more fully understand factors that contribute to fatalities at each location.

Methods

Fatality data from the US Consumer Product Safety Commission (CPSC) were used for descriptive and comparative analyses. Multivariate logistic regression analysis was performed to determine relative risk.

Results

Over 60% of all fatalities (1985–2009) resulted from roadway crashes. After 1998, roadway fatalities increased at over twice the rate of off-road fatalities. Roadway crashes were more likely than off-road crashes to involve multiple fatalities, carrying passengers, alcohol use, collisions and head injuries. Roadway victims were less likely to be helmeted than off-road victims. Passengers and operators with passengers were also less likely to be helmeted than operators riding alone. Helmeted victims were half as likely to suffer a head injury.

Conclusions

Fatal roadway crashes were more likely than off-road crashes to involve risk-taking behaviours (eg, carrying passengers) that could exacerbate the inherent difficulty of operating ATVs on roadway surfaces. Higher crash forces from greater speed, and lower use of protective equipment, may also have contributed to higher roadway mortality rates. Eliminating non-essential ATV road use may be an effective way to reduce ATV-related fatalities. This will likely require a substantial investment in rider education and better enforcement of ATV road use restriction laws.

State-specific ATV-related fatality rates: an update in the new millennium

OBJECTIVES

We compared state-specific all-terrain vehicle (ATV) fatality rates from 2000-2007 with 1990-1999 data, grouping states according to helmet, training, and licensure requirements.

METHODS

We used the CDC WONDER online database to identify ATV cases from 2000-2007 and calculate rates per 100,000 population by state, gender, and age.

RESULTS

ATV deaths (n=7,231) occurred at a rate of 0.32 per 100,000 population. Males accounted for 86% of ATV-related deaths at a rate that was six times that for females (0.55 vs. 0.09 per 100,000 population, respectively); 60% of the male deaths occurred in the 15- to 44-year age group. With the exception of the two oldest age categories, rates were consistently higher in the no-helmet-law group. Both the number and rate of ATV-related deaths increased more than threefold between 1990-1999 and 2000-2007. West Virginia and Alaska continue to have the highest ATV fatality rates (1.63 and 2.67 ATV deaths per 100,000 population, respectively).

CONCLUSIONS

Helmet-use requirements seem to slightly mitigate ATV-related death, but training requirements do not. For policy to be effective, it must be enforced.

Ocular injuries in all-terrain-vehicle accidents

OBJECTIVE

To examine the occurrence and extent of ocular injuries in ATV accidents in southwestern Pennsylvania.

METHODS

This was a retrospective chart review of 37 adults and 43 children at UPMC Mercy Hospital, UMPC Presbyterian Hospital, and Children's Hospital of Pittsburgh Trauma Registry. The Trauma Registry was searched for patients sustaining ocular injuries related to an ATV accident. Records were de-identified by an honest broker and analysed in this study.

RESULTS

Eighty percent (80%) of patients suffered orbital fracture; 40% had periorbital ecchymoses, and 25% had lid lacerations. Injuries ranged in severity from subconjunctival haemorrhages to traumatic avulsion of the optic nerves.

CONCLUSIONS

Ocular trauma frequently accompanies ATV accidents and can have a significant impact on patient outcomes. An educational programme (except 'program' in computers) promoting eye protection could reduce the number of eye injuries associated with these recreational vehicles.

Evaluation of a Standardized All-Terrain Vehicle Safety Education Intervention for Youth in Rural Central Illinois

Background: Although research investigating all-terrain vehicle (ATV) riders and ATV injury patterns has led to support for legislative and educational efforts to decrease injuries in users younger than 16 years, there is little published data regarding the utility of ATV safety education programs. This study investigates the effectiveness of a standardized adolescent ATV safety program in changing the safety knowledge and safe ATV riding practices reported by rural Central Illinois youths. Methods: A convenience sample of 260 rural Central Illinois middle and high school students received an ATV safety presentation with both didactic and interactive features during the 2009-2010 school year. Preintervention and postintervention surveys were distributed and collected by teachers. Survey questions consisted of multiple-choice questions pertaining to demographics, ATV safety knowledge, and ATV riding practices. More than 200 surveys were collected prior to the intervention and 165 surveys were collected 12 to 24 weeks after the intervention. Percentages are reported, with differences in nominal variables tested by χ2 test and interval variables by t test. Results: Following the intervention, there was a significant increase in the correct response rate for ATV safety knowledge questions (45.2% vs 56.2%, P < .001). For adolescents who reported riding ATVs, both safety gear use (11.8% to 21.2%, P = .05) and helmet use (25.4% to 29.0%, P = .56) increased; changes were not significant. Adolescent ATV riders reporting 2 or more accidents showed a slight nonsignificant decrease (25.2% vs 23.4%, P = .77) between the time of the pretest and posttest. Conclusion: This safety program was effective at increasing ATV safety knowledge but demonstrates limited effect on safe riding practices.

All-terrain vehicle injuries in Texas, mapping the path to intervention with a geographic information system

The state of Texas was ranked 10th for all-terrain vehicle-related deaths among all states from 2007-2009. Health Service Region 4/5N of eastern Texas has a statistically significant higher rate of all-terrain vehicle-related injuries in children under the age of 18 than Texas as a whole (p < 0.001.) It is unknown why east Texas has a higher all-terrain vehicle-related injury rate. A retrospective analysis of the registry of the Texas Trauma Service Area G, which serves the east Texas area, from the years 2004-2010 was performed. Variations within the region were assessed using a geographic information system and the analysis demonstrated that the highest rates of all-terrain vehicle-related injuries in east Texas are found in two neighboring rural eastern counties. Recording mechanism of injury was an important adjunct to identifying all-terrain vehicle-related injuries. Using E-codes alone underestimated the actual injuries. Other findings demonstrated that children under age 16 had a high rate of injury, one third of those injured sustained a head injury, and helmet use was very low. This analysis can be used by the Texas Department of State Health Services in conjunction with key regional partners to direct further investigation in these areas into the role of the rural environment, other factors associated with the high injury rates, and to plan and conduct preventive intervention at the community level.

Making the message meaningful: a qualitative assessment of media promoting all-terrain vehicle safety

BACKGROUND

Millions of all-terrain vehicles (ATV) are used around the world for recreation by both adults and youth. This increase in use has led to a substantial increase in the number of injuries and fatalities each year. Effective strategies for reducing this incidence are clearly needed; however, minimal research exists regarding effective educational interventions.

OBJECTIVE

This study was designed to assess rural ATV riders' preferences for and assessment of safety messages.

METHODS

13 focus group discussions with youth and adult ATV riders were conducted. 88 formative research participants provided feedback on existing ATV safety materials, which was used to develop more useful ATV safety messages. 60 evaluative focus group participants critiqued the materials developed for this project.

RESULTS

Existing ATV safety materials have limited effectiveness, in part because they may not address the content or design needs of the target population. ATV riders want educational and action-oriented safety messages that inform youth and adult riders about their responsibilities to learn, educate and implement safety behaviours (eg, appropriate-sized ATV, safety gear, solo riding, speed limits, riding locations). In addition, messages should be clear, realistic, visually appealing and easily accessible. Newly designed ATV safety materials using the acronym TRIPSS (training, ride off-road, impairment, plan ahead, safety gear, single rider) meet ATV riders' safety messaging needs.

CONCLUSIONS

To reach a target population, it is crucial to include them in the development and assessment of safety messages. Germane to this particular study, ATV riders provided essential information for creating useful ATV safety materials.

Open fractures of the femur in children: analysis of various treatment methods

PURPOSE

To describe the demographic and clinical characteristics of children who presented with open femur fractures.

METHODS

A retrospective chart review of all children treated for open femur fractures at the McGill University Health Center between 1980 and 2009 was conducted. Thirty-seven patients (28 males and 9 females) were identified. Union was determined clinically by the absence of pain, tenderness to palpation and crepitus with motion. Complications were reported.

RESULTS

The mean age of the patients was 11.5 years (range 2.8-18.1 years). The mechanism of injury involved motor vehicle-related injuries in 70% of cases. There were 13 Grade I, 15 Grade II and 9 Grade III fractures. The treatment involved traction and hip spica in 11 patients, external fixator in nine patients, intramedullary nailing in seven patients, open reduction and internal fixation in six patients, and traction and an ischial weight bearing brace in four patients. Average time to union was 5.1 months (range 1.5-14.4 months). Infections occurred in ten patients, nine had delayed unions, two developed malunions, four had a refracture and four patients developed a limb length discrepancy >2 cm.

CONCLUSIONS

Open fractures of the femur are often accompanied by associated injuries, indicating the importance of early and comprehensive treatment. Treatment may include hip spica application in school-age children and solid intramedullary nails in adolescents. In children with multiple injuries, specifically those with higher fracture grades, treatment with an external fixator provides immediate stability of the fracture and allows early mobilization and ease of management of associated injuries.