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

Commemorating the monkey bars, catalyst of debate at the intersection of human evolutionary biology and public health

Play is an essential part of childhood, and growing attention has focused on the potential health benefits of 'risky' or 'thrill-seeking' play. Such play behavior is readily observed on any playground, where it can sometimes lead to injuries--most often from fall impacts--that require medical attention. Monkey bars account for ~7% of childhood arm fractures in the USA, an alarming statistic that raises difficult questions over its costs and benefits. Many authors view monkey bars as a public health hazard, but it is plausible that our childhood impulse toward thrill-seeking play is a result of selective pressures throughout our primate evolutionary history. Indeed, emerging evidence suggests that the developmental benefits of thrill-seeking play extend into adulthood, outweighing the occasional costs of injury. Disparate and consequential, these dueling perspectives have fueled debate among health professionals and policymakers, but with little attention to the work of biological anthropologists. Here we call attention to the hominin fossil record and play behaviors of non-human primates, providing a novel perspective that bolsters arguments for the adaptive significance of thrill-seeking play. The moment for such a review is timely, for it commemorates the centennial anniversaries of two playground icons: the jungle gym and monkey bars.

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.

Methodological Challenges in Investigating Supracondylar Fractures of the Humerus From a Child's Viewpoint: Evolution of Study Protocol

Background

Outdoor play and risk-taking behaviors, including play at heights, are important to children’s physical, social, and cognitive development. These aspects of play are important to consider when informing prevention policies for serious injuries that commonly occur on play structures. Supracondylar fractures of the humerus (SCH) are the most common type of elbow fractures that result from falls on an outstretched hand among healthy children. Despite being one of the leading causes of admission to the hospital and surgical intervention, the details surrounding the cause of these injuries are often not recorded. Previous research has correlated decreased overall playground safety with higher rates of SCH fractures. Play structure height and the type of undersurface have been identified as potential risk factors for severe injuries, including SCH fractures, in part due to low compliance with safety standards. This paper explores the challenges we encountered designing the study and the resulting insights and methodological modifications we made.

Objective

The aim of this paper is to discuss the challenges related specifically to clinical research in pediatrics and strategies developed to conduct a study that prioritizes the engagement and perspective of children and their families.

Methods

To explore the link between the severity of SCH fractures and children’s behavioral, environmental, and mechanistic factors, we conducted a mixed-methods study.

Results

During phase 1 (the original methodology) from April 2017 to July 2018, there were 58 eligible study participants and 17 were recruited. For phase 2 (the revised methodology) between October 2018 and October 2019, there were 116 eligible participants and 47 were recruited.

Conclusions

The changes in methodology made following the first phase of data collection were effective in our ability to recruit participants. By identifying and addressing challenges pertaining to recruitment and resource limitations, we were able to collect data in a concise manner while not compromising the quality of the data and make for an easily adoptable methodology for other sites interested in participating in the study. We hope that future studies that plan to employ a similar methodology can gain insight through the methodological challenges we have encountered and the way we adapted the methodology to build a more pragmatic approach.

International Registered Report Identifier (IRRID)

DERR1-10.2196/21816

Playground equipment-related extremity fractures in children presenting to US emergency departments, 2006-2016

Background

Despite updated playground equipment and improved industry standards, playgrounds remain a common source of childhood injury. Fractures account for 35% of all playground injuries presenting to emergency departments (EDs). We aimed to examine the time trends and epidemiologic patterns of playground equipment-related extremity fractures in children in the United States.

Methods

We analyzed data from the National Electronic Injury Surveillance System. Children ≤14 years presenting to US emergency departments from 2006 to 2016 with playground equipment-related injuries were included. We used weighted complex survey analysis to describe the epidemiologic patterns and severity of playground equipment-related extremity fractures and Joinpoint linear weighted regression analysis to determine trends in extremity fractures.

Results

An annual average of 72,889 children were treated in US EDs for playground equipment-related extremity fractures, yielding a national annual incidence rate of 119.2 per 100,000 children. Playground equipment-related extremity fractures accounted for 33.9% of ED presentations and 78.7% of hospitalizations for playground equipment-related injuries. Of patients with playground equipment-related extremity fractures, 11.2% had severe fractures requiring hospitalization. The annual rate of ED visits due to playground equipment-related extremity fractures remained stable (annual rate of change = 0.74, p = 0.14) from 2006 to 2016. Adjusted for age, injuries on monkey bars or climbing gyms were associated with significantly increased odds of extremity fractures in comparison to injuries from other playground equipment (adjusted odds ratio [aOR]: 2.0; 95% CI: 1.9–2.1). Overall, 49.8% of extremity fractures and 54.7% of severe extremity fractures (i.e. those requiring hospitalization) occurred on monkey bars or climbing gyms.

Conclusions

Despite enhanced playground safety standards, national rates of playground equipment-related extremity fractures have remained stable in the US. Extremity fractures remain the most common type of playground injury presenting to EDs and most commonly occur on monkey bars and climbing gyms.

Pediatric Playground-Related Injuries Treated in Hospital Emergency Departments in the United States

This study analyzed pediatric playground-related injuries data from the National Electronic Injury Surveillance System. An estimated 5 025 440 children <18 years were treated in US emergency departments for playground-related injuries during 1990-2012, averaging 218 497 children annually. The average patient age was 6.5 years. The overall annual injury rate declined during 1990-2007 ( P < .001) and then increased during 2007-2012 ( P < .001). The climbing equipment-related injury rate remained constant during 1990-2009 and then increased during 2007-2012 ( P = .014). The concussion/closed head injury rate increased during 1990-2008 ( P < .002) with the rate almost doubling from 2008-2012 ( P < .001). Falls accounted for 76.7% of all injuries and 87.7% of injuries to the upper extremities. Injuries resulted in hospitalization for 4.3% of patients. Despite current playground safety standards and guidelines, a large number of playground-related injuries continue to occur. Revised impact attenuation criteria for playground surfacing materials should be implemented and evaluated to more adequately prevent fall-related upper extremity fractures.

Incidence and cost of hospitalisation of children with injuries from playground equipment falls in New South Wales, Australia

AIMS

To describe the epidemiological profile and cost of hospitalised injuries caused by playground equipment falls of children aged 0-14 years, in New South Wales, Australia.

METHODS

Linked New South Wales hospitalisation data from 1 January 2010 to 30 June 2014 were used to describe the incidence of hospitalisation for playground falls, the age-standardised rate of hospitalisation per year, age group and gender, the characteristics of the injured children and the injury incident. Health outcomes, such as length of stay in hospital, and the hospital costs associated with the injuries were examined by age group. Negative binomial regression assessed the trend in hospitalisation rates over time.

RESULTS

There were 7795 hospitalisations of children for playground fall injuries. The highest hospitalisation rate was for the 5-9 year olds (220.7 per 100 000 population) and was higher in males than females (234.2 and 206.3 per 100 000 population, respectively). The majority of these injuries occurred in schools (17.1%) and homes (14.6%), and were as a result of falls from trampolines (34.3%) and climbing apparatuses (28.2%). Over half the playground falls led to fractures of the elbow and wrist (54.7%). The total hospital cost of playground fall-related injuries was $18 million.

CONCLUSION

Rates of hospitalisation of children for playground fall injuries remain high despite implementation of national playground safety standards in Australia. This research highlights where interventions should be targeted to reduce the incidence and burden of injuries following falls from playground equipment.

A systematic review of the risk factors and interventions for the prevention of playground injuries

OBJECTIVES

The primary objectives of this work were to (1) identify the risk and/or protective factors associated with playground injuries among children less than 18 years of age and (2) identify interventions/programs/policies aimed at preventing playground-related injuries among children less than 18 years of age. Secondary objectives include a summary of the data that reflect alignment with current playground standards.

METHODS

For the primary outcome, 4 databases and 12 online resources were systematically searched to include observational and experimental studies examining risk and/or protective factors or interventions associated with playground injury or outcomes related to playground injury (e.g., risky playground behaviour). Data extraction included study design, participants, outcome, exposure or intervention, data analysis, and effect estimates. The quality of evidence for all studies was assessed using the Downs and Black criteria.

RESULTS

This review included studies of moderate quality, revealing a number of risk factors and effective interventions for playground injury. Risk factors included absence of handrails and guardrails on playground equipment, non-impact-absorbing surfacing, and critical fall heights. Effective interventions included modifying playground surfacing and reducing equipment height to less than 1.5 m.

CONCLUSION

Equipment- and structure-based playgrounds should adhere to and maintain playground standards in order to reduce the risk of serious injury. Organizations responsible for installing and maintaining playgrounds should consider alternative play spaces that allow children to play outdoors, in a natural environment that supports healthy child development and promotes physical activity.

Homemade zipline and playground track ride injuries in children

BACKGROUND/PURPOSE

Playground track ride and homemade zipline-related injuries are increasingly common in the emergency department, with serious injuries and even deaths reported.

METHODS

Retrospective review of the National Electronic Injury Surveillance System (NEISS) database (2009-2015), followed by review of our academic pediatric trauma center's prospectively-maintained database (2005-2013). We included children ages 0-17years of age with zipline-related injuries. We recorded annual incidence of zipline-related injury, zipline type (homemade or playground), injuries and mechanism.

RESULTS

In the NEISS database, 9397 (95%CI 6728-12,065) total zipline-related injuries were reported (45.9% homemade, 54.1% playground). Homemade but not playground injuries increased over time. Common injuries were fracture (49.8%), contusion/laceration (21.2%) and head injury (12.7%). Fall was predominant mechanism (83%). Age 5-9 was most frequently affected (59%). Our center database (n=35, 40% homemade, 1 fatality) revealed characteristics concordant with NEISS data. Head injury was related to fall height>5ft and impact with another structure.

CONCLUSIONS

Homemade zipline injuries are increasing. Children ages 5-9 are at particular risk and should be carefully supervised. Despite protective surfaces, playground ziplines cause significant head injury, extremity fracture and high rates of hospital admission. Playground surface standards should be reviewed and revised as needed.

LEVEL OF EVIDENCE

Prognosis Study, Level III.

Shock-absorbing aggregates beneath playground equipment: grain properties and moisture content

OBJECTIVES

To assess the influence of grain size distribution and moisture condition on aggregates'Setting and methodsImpact attenuation of sands and gravels was tested using a guided headform with a uniaxial accelerometer inside. The result for impact attenuation was the acceleration value of the headform measured from four different drop heights and the Head Injury Criterion (HIC) calculated from it. The acceptable HIC value of a shock-absorbing layer is <1000, that is, less than the critical fall height. Tests were conducted with both dry and wet materials.

RESULTS

The impact attenuation of a shock-absorbing layer made of loose aggregate is determined mainly by the following material factors: maximum grain size, median grain size, uniformity coefficient, fines content, grain shape and moisture content. In addition, the moisture content of aggregate, especially sands, has a major impact on its impact attenuation capacity. Of the studied sands, coarse and gravelly ones had the best impact attenuation properties. Most of the examined sands were uniformly graded. None of the grain properties of gravels proved more significant than the others. Yet, open-graded gravel (dominant grain size 4-8 mm) containing a small amount (about10%) of sand fraction 0.06-0.6 mm, but with hardly any coarse sand (0.6-2 mm), was found to have good impact attenuation.

CONCLUSIONS

This study shows that the aggregates for shock-absorbing layer should always be tested wet in laboratory conditions corresponding the most critical situation. Standards should include a procedure for wet testing of aggregates.

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.

Trends in moderate to severe paediatric trauma in Central Netherlands

INTRODUCTION

Trend analyses of hospital discharge data can raise signals for prevention policies, but are often flawed by changes in health care consumption. This is a trend analysis of the clinical incidence of paediatric trauma that used international criteria to overcome this bias. The objective is to describe trends in clinical incidence of moderate to severe paediatric trauma, and to identify target groups for prevention activities.

PATIENTS AND METHODS

Included were all paediatric trauma patients (0-18 years) that were discharged from the hospitals of trauma care region Central Netherlands from 1996 to 2009. Selection was made on ISS ≥ 4, and on trauma related International Classification of Diseases diagnostic codes, and trauma related external causes of injury and poisoning codes. Trend analyses were performed using Poisson loglinear regression with correction for age and gender.

RESULTS

23,682 Patients were included, the mean incidence rate was 477/100,000 person-years. Since 2001 the incidence rate of moderate to severe trauma increased with 1.1% annually (95% confidence interval (CI) 0.7-1.5), caused by an increase of falls (3.9%, 95% CI 3.3-4.5), sport injuries (5.4%, 95% CI 4.3-6.5), and bicycle injuries (3.8%, 95% CI 2.8-4.8). The incidence of falls and sport injuries peaked in young children (0-9) and older boys (10-18) respectively. Bicycle injuries affected all children between 5 and 18.

CONCLUSIONS

The incidence of paediatric trauma in the centre of the Netherlands increased since 2001. Trend analyses on moderate and severe injuries may identify target groups for prevention in a trauma region.

Measurement of the Effect of Playground Surface Materials on Hand Impact Forces During Upper Limb Fall Arrests

Distal radius fractures are common on playgrounds. Yet current guidelines for the selection of playground surface materials are based only on protection against fall-related head injuries. We conducted “torso release” experiments to determine how common playground surface materials affect impact force applied to the hand during upper limb fall arrests. Trials were acquired for falls onto a rigid surface, and onto five common playground surface materials: engineered wood fiber, gravel, mulch, rubber tile, and sand. Measures were acquired for arm angles of 20 and 40 degrees from the vertical. Playground surface materials influenced the peak resultant and vertical force (P< .001), but not the peak horizontal force (P= .159). When compared with the rigid condition, peak resultant force was reduced 17% by sand (from 1039 to 864 N), 16% by gravel, 7% by mulch, 5% by engineered wood fiber, and 2% by rubber tile. The best performing surface provided only a 17% reduction in peak resultant force. These results help to explain the lack of convincing evidence from clinical studies on the effectiveness of playground surface materials in preventing distal radius fractures during playground falls, and highlight the need to develop playground surface materials that provide improved protection against these injuries.

The effect of surface and season on playground injury rates

OBJECTIVE

To examine the effect of season on playground surface injury rates.

METHODS

Injuries were identified through student incident report forms used in school districts in Calgary (Alberta) and the surrounding area. Playground surface exposure data were estimated based on school enrollment.

RESULTS

A total of 539 injuries were reported during the 2007/2008 school year. Abrasions, bruises and inflammation were the most frequently reported injuries. The head, neck or face were most commonly injured. Injury rates per 1000 student days ranged between 0.018 (rubber crumb in spring) and 0.08 (poured-in-place and natural rock in the fall). Rubber crumb surfacing, compared with natural rock, had a significantly lower rate of injury in the spring, but no other season-surface comparisons were statistically significant.

CONCLUSIONS

Rates of injury were similar for natural rock, poured-in-place, and crushed rock in the fall and winter. There was some evidence of a lower rate of injury on rubber crumb surfaces in the spring.

Playground injuries in children

Background

Rapid urbanization and unplanned population development can be detrimental to the safety of citizens, with children being a particularly vulnerable social group. In this review, we assess childhood playground injuries and suggest safety mechanisms which could be incorporated into playground planning.

Methods

Inclusion criteria were “children” as the focus group, “playground” as the main field of study, and “unintentional injury” and “safety” as the concepts of study. The keywords used for the PubMed search were “playground”, “children”, and “injury”. Initially we 182 articles. After screening according to inclusion criteria, 86 articles were found, and after reading the abstracts and then the full text, 14 articles were finally included for analysis. The papers reviewed included four case-control studies, three case studies, three descriptive studies, two interventional studies, one retrospective study, one cross-sectional study, and one systematic review.

Results

Playground-related fractures were the most common accidents among children, underscoring the importance of safety promotion and injury prevention in playgrounds, lowrisk equipment and playing hours (week days associated with higher risk), implementation of standards, preventing falls and fall-related fractures, and addressing concerns of parents about unsafe neighborhoods. With the exception of one study, all of the reviewed papers had not implemented any practical safety plan. Safe engineering approaches were also ignored.

Conclusion

We recommend a systematic safety approach based on the “safety circle” which includes three main areas, ie, equipment, environment, and children.

Trends and future projections of child injury in New South Wales: A tool for advocacy?

AIMS

To describe the trend of unintentional hospitalised injury in children aged 0-14 years in New South Wales (NSW), Australia during 1993-1994 to 2004-2005 and to estimate future projections of common child injury hospitalisations from 2006 to 2021.

METHODS

NSW hospitalisation data were used to describe injury trends of children aged 14 years or less who were residents of NSW (1993-1994 to 2004-2005). Projected injury-related hospitalisations of children for 2006-2021 were estimated assuming that the current observed rate of change in childhood injury hospitalisation rates continued to 2021.

RESULTS

During 1993-1994 to 2004-2005, there were 238 093 injury-related hospitalisations of children aged 14 years or less in NSW. Assuming the rate of change in injury hospitalisation observed between 1993-1994 and 2004-2005 continued into the future, the all hospitalised injury incidence rate for children aged 14 years or less is projected to decrease by 1.0% each year to 2021. Injury mechanisms such as burns and scalds, swimming pool non-fatal drowning and poisoning are all projected to decrease in the future, although not for all age groups. Falls (excluding those from playground equipment) and falls from playground equipment hospitalisations (excluding children less than 1 year) are projected to increase.

CONCLUSION

Although the incidence of hospitalisation for some common child-related injury mechanisms is projected to decrease over the coming years, others are projected to increase. It is possible that advocacy efforts might benefit from using projected injury trends. Co-ordinated cross-government action is needed to successfully implement child injury prevention strategies, particularly in the playground environment.

School playground surfacing and arm fractures in children: a cluster randomized trial comparing sand to wood chip surfaces

BACKGROUND

The risk of playground injuries, especially fractures, is prevalent in children, and can result in emergency room treatment and hospital admissions. Fall height and surface area are major determinants of playground fall injury risk. The primary objective was to determine if there was a difference in playground upper extremity fracture rates in school playgrounds with wood fibre surfacing versus granite sand surfacing. Secondary objectives were to determine if there were differences in overall playground injury rates or in head injury rates in school playgrounds with wood fibre surfacing compared to school playgrounds with granite sand surfacing.

METHODS AND FINDINGS

The cluster randomized trial comprised 37 elementary schools in the Toronto District School Board in Toronto, Canada with a total of 15,074 students. Each school received qualified funding for installation of new playground equipment and surfacing. The risk of arm fracture from playground falls onto granitic sand versus onto engineered wood fibre surfaces was compared, with an outcome measure of estimated arm fracture rate per 100,000 student-months. Schools were randomly assigned by computer generated list to receive either a granitic sand or an engineered wood fibre playground surface (Fibar), and were not blinded. Schools were visited to ascertain details of the playground and surface actually installed and to observe the exposure to play and to periodically monitor the depth of the surfacing material. Injury data, including details of circumstance and diagnosis, were collected at each school by a prospective surveillance system with confirmation of injury details through a validated telephone interview with parents and also through collection (with consent) of medical reports regarding treated injuries. All schools were recruited together at the beginning of the trial, which is now closed after 2.5 years of injury data collection. Compliant schools included 12 schools randomized to Fibar that installed Fibar and seven schools randomized to sand that installed sand. Noncompliant schools were added to the analysis to complete a cohort type analysis by treatment received (two schools that were randomized to Fibar but installed sand and seven schools that were randomized to sand but installed Fibar). Among compliant schools, an arm fracture rate of 1.9 (95% confidence interval [CI] 0.04-6.9) per 100,000 student-months was observed for falls into sand, compared with an arm fracture rate of 9.4 (95% CI 3.7-21.4) for falls onto Fibar surfaces (p< or =0.04905). Among all schools, the arm fracture rate was 4.5 (95% CI 0.26-15.9) per 100,000 student-months for falls into sand compared with 12.9 (95% CI 5.1-30.1) for falls onto Fibar surfaces. No serious head injuries and no fatalities were observed in either group.

CONCLUSIONS

Granitic sand playground surfaces reduce the risk of arm fractures from playground falls when compared with engineered wood fibre surfaces. Upgrading playground surfacing standards to reflect this information will prevent arm fractures.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN02647424.

The potential for brain injury on selected surfaces used by cheerleaders

CONTEXT

Although playground surfaces have been investigated for fall impact attenuation, the surfaces that cheerleaders use have received little attention.

OBJECTIVE

To determine (1) the critical height for selected surfaces used by cheerleaders at or below which a serious head impact injury from a fall is unlikely to occur, (2) the critical heights for non-impact-absorbing surfaces for comparison purposes, and (3) the effect of soil moisture and grass height on g(max) (which is defined as the multiple of g [acceleration due to gravity at the earth's surface at sea level: ie, 32.2 feet x s(-1) x s(-1)] that represents the maximum deceleration experienced during an impact) and the Head Injury Criterion (HIC) at the critical height for a dry grass surface.

DESIGN

Observational study.

SETTINGS

A local cheerleading gym, indoor locations within the authors' institution, and various outdoor locations.

MAIN OUTCOME MEASURE(S)

g(max), HIC, and critical height.

RESULTS

Critical heights for the surfaces tested ranged from 0.5 ft (0.15 m) for concrete and vinyl tile installed over concrete to more than 11 ft (3.35 m) for a spring floor. Increases in grass height and soil moisture resulted in an increase in the critical height for grass surfaces. Only spring floors and 4-in (0.10-m)-thick landing mats placed on traditional foam floors had critical heights greater than 10.5 ft (3.20 m), thus providing enough impact-absorbing capacity for performance of 2-level stunts.

CONCLUSIONS

The potential for serious head impact injuries can be minimized by increasing the shock-absorbing capacity of the surface, decreasing the height from which the person falls, or both. Cheerleaders and cheerleading coaches should use the critical heights reported in this study to compare the relative impact-absorbing capacities of the various surfaces tested, with critical height as an indicator of the impact-absorption capacity of the surface. The findings of this study can be used to select the most appropriate surface for the type of maneuver to be performed, based on the maximum height expected to be achieved by the cheerleader(s) during execution of the maneuver. Cheerleaders should not perform maneuvers at heights that exceed the critical height for the surface on which they are performing.

Epidemiology of cheerleading fall-related injuries in the United States

CONTEXT

Over the past several decades, cheerleaders have been performing fewer basic maneuvers and more gymnastic tumbling runs and stunts. As the difficulty of these maneuvers has increased, cheerleading injuries have also increased.

OBJECTIVE

To describe the epidemiology of cheerleading fall-related injuries by type of cheerleading team and event.

DESIGN

Prospective injury surveillance study.

SETTING

Participant exposure and injury data were collected from US cheerleading teams via the Cheerleading RIO (Reporting Information Online) surveillance tool.

PATIENTS OR OTHER PARTICIPANTS

Athletes from 412 enrolled cheerleading teams who participated in official, organized cheerleading practices, pep rallies, athletic events, or cheerleading competitions.

MAIN OUTCOME MEASURE(S)

The numbers and rates of cheerleading fall-related injuries during a 1-year period (2006-2007) are reported.

RESULTS

A total of 79 fall-related injuries were reported during the 1-year period. Most occurred during practice (85%, 67/79) and were sustained by high school cheerleaders (51%, 40/79). A stunt or pyramid was being attempted in 89% (70/79) of cases. Fall heights ranged from 1 to 11 ft (0.30-3.35 m) (mean = 4.7 + or - 2.0 ft [1.43 + or - 0.61 m]). Strains and sprains were the most common injuries (54%, 43/79), and 6% (5/79) of the injuries were concussions or closed head injuries. Of the 15 most serious injuries (concussions or closed head injuries, dislocations, fractures, and anterior cruciate ligament tears), 87% (13/15) were sustained while the cheerleader was performing on artificial turf, grass, a traditional foam floor, or a wood floor. The fall height ranged from 4 to 11 ft (1.22-1.52 m) for 87% of these cases (13/15).

CONCLUSIONS

Cheerleading-related falls may result in severe injuries and even death, although we report no deaths in the present study. The risk for serious injury increases as fall height increases or as the impact-absorbing capacity of the surfacing material decreases (or both).

Pediatric tree house-related injuries treated in emergency departments in the United States: 1990-2006

OBJECTIVES

The objective was to describe the epidemiology of tree house-related injuries in the United States among children and adolescents.

METHODS

The authors conducted a retrospective analysis using data from the National Electronic Injury Surveillance System for patients < or =19 years who were treated in an emergency department (ED) for a tree house-related injury from 1990 through 2006.

RESULTS

An estimated 47,351 patients < or =19 years of age were treated in EDs for tree house-related injuries over the 17-year study period. Fractures were the most common diagnosis (36.6%), and the upper extremities were the most commonly injured body part (38.8%). The odds of sustaining a head injury were increased for children aged <5 years. Falls were the most common injury mechanism (78.6%) and increased the odds of sustaining a fracture. Falls or jumps from a height > or =10 feet occurred in 29.3% of cases for which height of the fall/jump was recorded. Boys had significantly higher odds of falling or jumping from a height of > or =10 ft than girls, and children 10 to 19 years old also had significantly higher odds of falling or jumping from a height of > or =10 feet, compared to those 9 years old and younger. The odds of hospitalization were tripled if the patient fell or jumped from > or =10 feet and nearly tripled if the patient sustained a fracture.

CONCLUSIONS

This study examined tree house-related injuries on a national level. Tree house safety deserves special attention because of the potential for serious injury or death due to falls from great heights, as well as the absence of national or regional safety standards. The authors provide safety and prevention recommendations based on the successful standards developed for playground equipment.

Epidemiology of playground equipment-related injuries to children in the United States, 1996-2005

The objective of this study is to describe the epidemiology of playground equipment-related injuries. This is a retrospective analysis of data for children 18 years old and younger from the National Electronic Injury Surveillance System of the United States Consumer Product Safety Commission for 1996 through 2005. There were an estimated 2,136,800 playground equipment-related injuries to children 18 years and younger treated in hospital emergency departments in the United States during the 10-year period. The leading mechanism of injury was falls (75.1%), followed by impact/striking (10.5%), cutting/ pinching/crushing (7.7%), entrapment/ entanglement (1.4%), trip/slip (1.1%), and other/ unknown (4.1%). The leading type of injury sustained by patients was a fracture (35.4%), followed by contusion/ abrasion (19.6%) and laceration (19.6%). The consistency of the large annual number of playground equipment-related injuries to children is evidence that more needs to be done to prevent these injuries. More research should be conducted to develop and implement arm fracture-specific criteria for surface performance.

Extremity fracture characteristics in children with impulsive/hyperactive behavior

INTRODUCTION

To investigate which fracture characteristics were associated with impulsive/hyperactive behavior in children with extremity fractures.

MATERIALS AND METHODS

A clinical sample of 95 consecutive children with extremity fractures admitted to the Orthopaedics and Traumatology Outpatient Clinic of a university hospital were included in the study. The Conners Parent Rating Scale (CPRS) was used to assess children's symptoms. Fracture characteristics were grouped according to trauma type, fracture localization, hospitalization requirement, treatment type and history of previous fracture(s). Descriptive analyses were performed; t-tests and univariate ANOVAs were utilized to compare groups with respect to impulsivity/hyperactivity subscale scores on the CPRS.

RESULTS

Mean CPRS impulsivity/hyperactivity subscale score for the whole group was 6.94 (SD = 2.69). Children with fractures which occurred during solitary activities presented with more impulsive/hyperactive behavior than those with fractures which occurred during group activities. Children with more severe fractures that required open reduction also presented with more impulsive/hyperactive behavior. Children with lower extremity fractures had showed more impulsive/hyperactive behavior than children with upper extremity fractures.

CONCLUSION

Detecting behavior problems in children admitted with fractures and referring them for treatment, is critical in preventing future serious injuries.

The epidemiology and cost of falls requiring hospitalisation in children in Western Australia: a study using linked administrative data

OBJECTIVE

The aim of this study was to examine the epidemiology and health system cost of children's falls resulting in hospitalisation in 2003 in Western Australia.

METHODS

The Injury Cost Database was used to identify children who were admitted to hospital with a falls related injury. Adjusted incidence rate ratios (IRR) of hospitalisation were modelled using Poisson regression. In-patient hospital costs were assigned using the published DRG costs for Western Australia. These costs were then extrapolated to health system costs based on previously published relative proportions.

RESULTS

When adjusted for other covariates in the model males had a 53% higher incidence of falls requiring hospitalisation compared with females. Aboriginal children had a 36% higher incidence compared with their non-Aboriginal counterparts, and the incidence of falls reduced with increasing age. The total cost of in-patient hospitalisation associated with children's falls in Western Australia was A$4,554,000 with an average cost of A$1876 per case. In children aged 0-4 years and 10-14 years the highest cost resulted from falls on the flat (slips and trips). However, in children aged 5-9 years injuries resulting from falls from playground equipment resulted in both the highest cost group (A$539,000) and the highest cost per case (A$1917). The total cost to the health system of children's falls in Western Australia in 2003 were estimated to be A$21.5 million, with the total cost to the community estimated at A$108.5 million.

CONCLUSION

Children's falls impose a considerable burden and cost to both the health care system and the community. This study has provided information on where the burden of risk and the majority of costs lie, namely males, Aboriginal children and for children aged 5-9 years, unlike their younger and older peers, playground equipment.

Challenges of recruiting farm injury study participants through hospital emergency departments

BACKGROUND

Hospital emergency departments are common recruitment sites for injury studies. Yet recruitment method details, capture rates and response fractions are not consistently reported. As privacy legislation increasingly impinges on research activity, these parameters become even more important. The authors describe their experience with recruitment via emergency departments and outline subsequent adjustments to the recruitment approach.

METHODS

The FIRM study was an Australian case-control study of serious farm work-related injury. Cases were identified prospectively by hospital staff on presentation to emergency departments. Consistent with the Victorian Health Records Act, potential cases were initially approached by hospital staff, and full recruitment was subsequently undertaken by study staff. Manual hospital record audits were conducted at five recruitment sites to determine the proportion of eligible cases approached.

RESULTS

Among 660 medical records audited, 19 eligible cases were confirmed, 9 of whom were approached by hospital staff (47%, 95% CI 25 to 70%). In response, an additional process was established to capture missed cases, who were sent a letter from the hospital providing the opportunity to opt out of telephone contact by study staff. Early indications were that 34% (41/122) of missed cases actively declined to be contacted. Among those who were contacted and eligible, 84% (21/25) agree to study participation.

CONCLUSIONS

Recruitment of injury research participants via hospital emergency departments is challenging, particularly where authorities require an intermediary to make the initial contact. Removal of some constraints imposed by privacy legislation would considerably simplify recruitment and enhance scientific rigour in conducting epidemiological research.

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

OBJECTIVE

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

DATA SOURCES/SYNTHESIS

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

RESULTS

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

CONCLUSIONS

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

Trauma prevention in children

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