Surface characteristics, equipment height, and the occurrence and severity of playground injuries

A 10-Year Retrospective Review of Playground-Associated Craniofacial Injuries in the Pediatric Patient Population

This retrospective study utilized the National Electronic Injury Surveillance System (NEISS) database to identify pediatric emergency department (ED) patients with playground-associated craniofacial injuries between January 2012 and December 2021. A total of 25 414 patients were identified. The majority of injuries occurred in preschool and elementary school-age children (90.3%) and patients were more commonly boys (59.3%). Injuries most often involved the head/scalp (52.4%), face (30.4%), and mouth (11.9%). Infant (32.7%) and teen (40.0%) injuries most commonly involved swings, whereas preschool (23.1%) and elementary school (28.1%) injuries were mostly associated with slides and climbers, respectively. Most patients were treated in the ED and discharged to home (96.5%), a small portion required hospitalization (1.6%), and one death was reported. Although the majority of the injuries were relatively minor and resulted in same-day discharges, these injuries can result in serious physical harm, emotional stress, and unexpected financial burdens. Proper education and supervision regarding safe play is important to prevent these injuries.

Injury hazard assessment in schools: Findings from a pilot study in Karachi, Pakistan

INTRODUCTION

Injuries are a major public health concern and one of the leading causes of death and disability worldwide. Childhood injuries contribute to a major proportion of this burden.

OBJECTIVE

To identify injury hazards within school premises and playgrounds in Karachi, Pakistan.

METHODS

This observational cross-sectional study took place in 107 public and private schools of Karachi, Pakistan using a self-structured standard injury risk assessment tool. This tool was developed after an extensive literature review, expert consultation, and field visits to a few local schools. Data related to school demographics, administrative data and injury hazards within the school boundaries were collected in schools offering education from nursery to secondary grades (through 10th grade, matriculation). Descriptive analysis were calculated.

RESULTS

Out of 107 schools, only 12 were recording school-related injuries. A quarter (25%) of schools had some type of disaster drill exercises and built-in fire exits. Fire alarms were placed in 10 schools (9%), all of which were private. In 16 schools (15%), students had access to rooftop doors. There were multiple injury hazards in the school playgrounds. More than half of the schools had hazardous playground surfaces, such as slippery, concrete and uneven ground. Over 80% of schools were not supervising the children during playtime and did not have a separate play area for children under 6 years old. In 38 schools (22%), there were multiple injury hazards in the play rides, such as broken equipment, rusted parts, and sharp edges. Moreover, nine schools (7%) had loose nuts, bolts, edges, belts, steps, or rails in their play rides. Inside, almost a quarter (24%, n = 76) of schools did not have proper insulation of electric wires. Protruded metal nails, which could be high risk for prick and cut injuries, were observed in 20% of the observed furniture.

CONCLUSION

In conclusion, there are multiple injury hazards in the private and public schools of Karachi, Pakistan.

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.

Paediatric elbow fractures and public play spaces: adherence to standards for children's playground equipment and surfacing

BACKGROUND

Supracondylar humerus fractures (SCHF) are the most common fractures sustained following a fall onto an outstretched hand among healthy children, and one of the leading causes of hospital admission and surgical intervention. The aim of this study was to examine SCHF occurring at public play spaces-particularly to determine whether or not the playground equipment implicated in injurious falls aligned with Canadian playground safety standards.

METHODS

Cases of children who attended the provincial paediatric orthopaedic clinic following SCHF at a public playground between April 2017 and October 2019 were included in the study. A research assistant visited each playground to measure the play structure type and dimensions, height of the equipment at the point from which the child fell and the type and depth of the surface material, and compare measurements to the 2016 safety standards. Child demographics and injury classification were also noted. Descriptive statistics were calculated and a scatterplot of fall height and surface depth was generated.

RESULTS

Forty-three sites, representing 47 SCHF cases (18 female, 29 male), were included in the final analysis. Fourteen children sustained type 1 fracture, 23 had type 2 fracture and the remaining 10 had type 3 fracture. Five children with type 2 fracture and all 10 children with type 3 fracture required surgery. The majority of sites had engineered wood fibre surfacing, with surfacing at 35 sites being less than 300 mm deep. Twenty-six play structures were upper body equipment (ie, monkey bars or similar), seven were track rides, five were rotating structures and the rest comprised a variety of classified and unclassified structures. Twenty-seven children fell from a height exceeding 2 m.

CONCLUSIONS

The majority of SCHF cases occurred at playgrounds with insufficient surface depth and/or non-compliant equipment. Upper body equipment, track rides and rotating play structures were of particular concern, as the children fell from heights exceeding the recommended standard, likely reflecting the degradation and compaction of the surfacing material over time.

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.

Child school injury in Lebanon: A study to assess injury incidence, severity and risk factors

BACKGROUND

School-based injuries represent a sizeable portion of child injuries. This study investigated the rates of school-based injuries in Lebanon, examining injury mechanisms, outcomes and associated risk factors.

METHODS

Data were prospectively collected by intern school nurses at 11 private schools for the 2018-2019 academic year. Descriptive and inferential analyses were performed. Chi-square comparisons were conducted to determine the significance of any differences in injury rates between boys and girls for each category of school.

RESULTS

4,619 injury cases were collected. The yearly rate for school injuries was 419.1 per 1,000 children for the year 2018-2019. Boys demonstrated a significantly higher injury rate for all mechanisms of injuries, with the exception of being injured while walking, injured in the gym/sports areas, and other areas outside the playground and classroom. Elementary school children had the highest rate of injuries, nearly 2.4 times higher than kindergarten, 2.8 times higher than middle school, and 14.5 times higher than high school. Injuries to the face, upper extremities, and lower extremities were nearly 3 times more common than injuries to other areas of the body. Bumps/hits and bruises were most common-almost 3 times more likely than all other injury types. Injuries were mainly minor or moderate in severity-severe injuries were about 10 times less likely. Most injuries were unintentional, with rates nearly 5 times higher than those with unclear intent and 12 times higher than intentional injuries.

CONCLUSIONS

School injuries represent a relatively common problem. Compliance with playground safety standards coupled with the implementation of injury prevention strategies and active supervision at schools can curtail child injuries and ensure a safe and injury-free school environment.

Incidence and circumstances of pediatric fall-related injuries: Which fall variables matter?

BACKGROUND

This study's purpose was to determine if age, fall height, fall mechanism, landing surface, and landing position are associated with injury severity and hospital outcomes among pediatric fall patients.

METHODS

A retrospective review was conducted of patients aged ≤18 years who sustained fall-related injuries admitted to an American College of Surgeons verified Level 1 trauma center from January 1, 2006 through December 31, 2015.

RESULTS

Patient age, fall mechanism, landing position, and landing surface were associated with the need for surgery. Patient age, fall mechanism, and landing position were also associated with intensive care unit admissions. Fall mechanism was the only variable associated with injury severity. No variables were associated with the need for mechanical ventilation or mortality.

CONCLUSIONS

Patient age, fall mechanism, landing surface, and landing position need to be considered with regard to injury severity and patient outcomes among pediatric fall patients.

Playground equipment-related head injuries requiring hospitalization in children

BACKGROUND

The aim of this study was to investigate the circumstances of playground equipment-related head injuries in children and consider preventive measures based on the associated characteristics.

METHODS

The survey period was from February 1988 to January 2017. The study participants were children <15 years of age who had been hospitalized for playground equipment-related head injury. The following factors were investigated retrospectively: age; sex; fall height; material of the surface under the equipment; mechanism and diagnosis of the head injury; neurological signs at admission; and neurological outcome.

RESULTS

A total of 42 children (median age, 5 years; M/F: 26/16) were treated for head injuries, which involved a slide in 20 cases (47.6%), a swing in 11 (26.2%), a jungle gym in five (11.9%), monkey bars, iron bars, and a trampoline in one each, and unspecified equipment in six (14.3%). Falls ranged from a height of 1.2 to 2.5 m. Most of the falls occurred on hard soil or concrete. Head injuries depended on the age of the child, the injury mechanisms, and the characteristics of the equipment.

CONCLUSIONS

The playground equipment-related head injuries found in the present study involved not only skull fractures and concussions, but also intracranial hemorrhage and surgical cases. Children routinely use playground equipment, so effective strategies to reduce the occurrence of playground equipment-related head injuries need to be formulated.

Safety of School Playgrounds: Field Analysis From a Randomized Sample

Research supports recess, however, playground injuries are prevalent with more than 200,000 cases per year requiring medical attention. School playgrounds are among the leading location for injury. The purpose was to identify the safety and risk factors of playground environments and impact attenuation characteristics of surfacing materials. Results demonstrated 46% playground spaces protected students from traffic. Results found 75% of playgrounds were exposed to full sun, and unitary surface materials were up to 49°F warmer than the air temperature. There was an increase in the probability of risk whether equipment height was over 9 ft for loose fill surfacing materials or over 6 ft for unitary surfaces. Loose strings or ropes looped over equipment were found on 23% of playgrounds. This study provides discussion and data pertaining to numerous aspects of playground safety. Strategies for school nurses are shared to shape policies and education for playground safety practices.

Outdoor Fitness Equipment Usage Behaviors in Natural Settings

Outdoor fitness equipment (OFE) areas have become a popular form of built environment infrastructure in public open spaces as a means to improve public health through increased physical activity. However, the benefits of using OFE are not consistent, and several OFE accidents have been reported. In this study, we videotaped how OFE users operate OFE in parks and selected four types of popular OFE (the waist twister, air walker, ski machine, and waist/back massager) for video content analysis. Furthermore, we established coding schemes and compared results with the instructions provided by OFE manufacturers. The results revealed various usage behaviors for the same OFE types. In addition, we observed that a significant portion of user behaviors did not follow manufacturers' instructions, which might pose potential risks or actually cause injuries. Children are especially prone to act improperly. This study provides empirical evidence indicating the existence of potential safety risks due to inappropriate usage behaviors that might lead to accidents and injuries while using OFE. This study provides crucial information that can be used to evaluate the effectiveness of OFE and to develop future park or open space initiatives.

Epidemiology of playground equipment related/unrelated injuries to children: A registry-based cohort study from 6 emergency departments in Korea

The aim of study was to understand the epidemiology of playground injury and to find the factors related to the clinically significant injuries. This retrospective observational study enrolled children (age 0-18 years old) who visited the emergency departments (ED) of 6 hospitals in Korea.We obtained and analyzed the data from the ED injury surveillance system, which was supported by the Korea Centers for Disease Control. Clinically significant injury (Cs injury) was defined as the injuries that caused hospital admission for more than one day. The factors associated with injury and clinical outcome were compared between admitted and discharged patient groups. Multivariable logistic regression and the population attributable fraction were used to identify significant factors for hospitalization.A total of 1458 patients were enrolled. The proportion of patients who visited ED due to injuries unrelated to the playground equipment use was 57.8%. The majority of Cs injury was upper extremity fractures (68.1%). The risk factors for admission were the 6- to 11-year old age group (OR 5.7, 95% CI 1.3-25.0) and public playground (OR 2.4, 95% CI 1.1-5.3); the population attributable factor of these factors was 51.3% and 36.0%, respectively.This study shows that approximately 60% of the patients visited ED due to injury unrelated to the playground equipment use. The risk factors of Cs injuries were ages 6 to 11 and public playgrounds. The results of the study can be helpful to formulate the prevention policy against playground injury.

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.

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.

'I fell off and landed badly': Children's experiences of forearm fracture and injury prevention

Forearm fractures are one of the most common injuries sustained by children. Our descriptive study addressed, from the perspective of a child, the following research objectives: (1) to describe their fracture experience and (2) to describe how fractures might be prevented. Photovoice is a unique research strategy by which people create and discuss photographs. This technique has been used to elicit the perspectives of those whose voices are often 'not heard' in research, like children. Participants were recruited from a larger three-year prospective trial and included 10 boys (12.3 ± 1.6 years) and 7 girls (11.3 ± 1.6 years). We asked participants to take pictures to explain where their injury occurred (place), what they were doing at the time (context) and how the fracture had happened (mechanism). We also used semi-structured interview techniques. The following key themes emerged from our interviews: (1) the built environment as a key factor that 'caused' their fracture, (2) the fracture experienced as a journey not an event and (3) strategies to prevent fractures. A simple clinical step to potentially reduce subsequent fractures will be for clinicians to have a brief conversation with their young patients and to listen to the child's personal preventive strategies.

An evaluation of the Cool 2 Be Safe program: an evidence-based community-disseminated program to positively impact children's beliefs about injury risk on playgrounds

Falls from playground equipment during play are a leading cause of injury for elementary school children. Changes to playground design and surfacing materials can reduce injury risk. However, there is also a need for intervention programs to reduce risky play behaviors by children that are associated with falls. The Cool 2 Be Safe program was developed based on past research that identified effective strategies for targeting injury beliefs that predict risk behaviors on playgrounds among individually tested elementary school children. The current study evaluated the effectiveness of delivering these activities as an integrated program and in a group format in after school programs organized by Boys and Girls Clubs of Canada. The clubs were provided all program and extensive training materials, and a webinar training session was conducted for facilitators. Observations of sessions provided data on fidelity of program delivery. Pre- and post-intervention data assessing children's injury beliefs were collected via survey, with children participating in four structured activity sessions in small groups between premeasures and post-measures. The training materials proved to be quite effective; observational data indicated 88 % compliance with the procedures. Comparing children's pre- and post-responses revealed positive changes in injury-risk beliefs that have been shown to predict reduced risk taking on playgrounds. This initial evaluation suggests that the Cool 2 Be Safe community program holds much promise as a means for addressing the issue of fall-risk behaviors by elementary school children on playgrounds.

THE STANDARD OF PLAYGROUNDS AND SAFETY MEASURES IN PREVENTION OF TRAUMATIC DENTAL INJURIES IN NIGERIAN PRIMARY SCHOOLS

BACKGROUND

Playgrounds provide a recreational refuge for children and play a role in the development of their cognitive, psychosocial, and physical coordination skills. Unfortunately, it may also be a source of traumatic dental injuries (TDI).

AIM

To assess the standards of playgrounds in primary schools in Southern Nigeria.

SETTING

Selected public and private primary schools in Lagos (Southwest), Enugu (Southeast) and Rivers (Southsouth) states of Nigeria.

MATERIALS & METHODS

Multi-stage sampling was used to select 180 schools (30 private and 30 public schools in each state) spread across the 3 study states of Lagos, Enugu and Rivers of Nigeria. A structured questionnaire which was interview administered was used to obtain information from the head teachers of 180 selected schools in Southern geo-political zones of Nigeria. The presence or absence of playgrounds & play equipment; quality of playgrounds and equipment; and supervision of the pupils during play were assessed. Statistical comparison of public and private schools, as well as comparison between the three geopolitical zones was by chi square statistics and one way ANOVA respectively.

RESULTS

Playgrounds were present in 147(81.7%) schools; 83 (56.5%) and 64 (43.5%) were public and private schools respectively. Ninety three (51.7%) schools had teachers or minders at the play grounds during recreation. Most of the public schools had no minders. Majority (69.7%) of the playgrounds surfaces were bare earth. Ninety three (55.4%) schools had play equipment with about 7.5% of them padded. The maintenance of the play equipment was not regular in 54.3% of the schools. The impact absorbing surfaces under the play equipment were majorly (66.6%) pits filled with sand in the three zones while rubber matting was found only in 7.7% of schools which were exclusively in the Southwestern zone of the country.

CONCLUSION

Most of the schools had playgrounds but inadequate consideration was given to safety measures in terms of playground size, surfaces, equipment type, height and supervisions by teachers. We therefore recommended that playgrounds should be standardized in Nigerian primary schools and more awareness about the occurrence and prevention of TDI during recreation should be created in schools.

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.

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

INTRODUCTION

Despite the establishment of playground safety standards, playground-related injuries are still a significant cause of extremity fractures in Singapore. This prospective study evaluates the dimensions and characteristics of our playgrounds, and their effect on fracture severity in an Asian population. We aim to correlate various playground risk factors with severity of the fractures and give recommendations on future safety standards. Our data also allows us to compare the demographics of patients in our study group with that collected in our earlier study in 2004.

METHODS

From June 2005 to 2006, children who presented with extremity fractures to KK Women's and Children's Hospital after a playground injury were enrolled. Their clinical data were collected prospectively. Relevant playground details were collected on-site independently by another investigator. For analysis of severity, fractures were "major" if they required reduction or operative fixation and were "minor" if they did not.

RESULTS

Supervision at time of injury, especially from the child's parents or siblings, resulted in a lower likelihood of "major" fractures (P=0.002, likelihood ratio=1.97). Conversely, supervision from grandparents or maids was found to result in a higher likelihood of "major" fractures. Increased weight of patients was directly related to severity of fractures (P=0.000), and a body mass index (BMI) of less than 19.8 kg/m resulted in lower likelihood of "major" fractures (P=0.010, likelihood ratio=2.22). Height of equipments and other playground-related factors were not linked to severity of fractures.

CONCLUSIONS

Supervision at the playground, preferably from the child's parents or siblings, and keeping a child's BMI within limits as guided by the BMI charts, may potentially reduce the occurrence of severe fractures.

LEVEL OF EVIDENCE

Level I-prognostic study.

Only kids who are fools would do that! Peer social norms influence children's risk-taking decisions

OBJECTIVES

The current research examined the impact of peer social norms on the physical risk-taking decisions of elementary-school children.

METHOD

Children 6-12 years of age completed a novel video-viewing decision task in which they observed risk and non-risk child behaviors on a playground and, after each behavior, indicated their willingness to model each of the behaviors in their own video, both before and after exposure to peer-communicated social norms (encouragement, discouragement).

RESULTS

Exposure to peer social norms resulted in significant changes in risk taking, with changes predicted from ratings of perceived social norms and appraisals of injury vulnerability and severity.

CONCLUSION

Exposure to peer social norms can provide another means by which injury prevention programs can aim to reduce injury-risk behaviors among school-age children.

Temporal variation in pediatric supracondylar humerus fractures requiring surgical intervention

BACKGROUND

Pediatric supracondylar humerus fractures commonly require surgical intervention and hospital admission, which is costly and consumes significant health care resources. There are few data regarding temporal characteristics (month, day and hour of injury) of this particular pediatric fracture. We wished to investigate the month, day of the week, and time of occurrence of these fractures to guide appropriate use of health care resources and prevention strategies.

METHODS

This study was a retrospective review of clinical records and radiographs of 353 children with operative supracondylar humerus fractures in a temperate climate region over 6 years. Date and time of injury and demographic data (gender, age, laterality) were extracted. Variation in month, weekday, and time of injury was analyzed using circular analysis, cosinor analysis, probability distributions and topographical distribution.

RESULTS

There was a statistically significant increase in the number of fractures during the summer with a peak in early July. When analyzing by month and day of the week, a peak was seen Thursday-Saturday during May-July and middle of the week September-October. Weekdays demonstrated a higher proportion of fractures occurring in the morning and at school. The injuries occurred in the am in 37 and the pm in 241; detailed data were known in 227 with 37 between 0000 and 1159, 51 between 1200 and 1559, and 139 between 1600 and 2359 h. The peak time of injury was 1800 h.

CONCLUSIONS

The increase in supracondylar humerus fractures in the spring through autumn in temperate regions indicates that education campaigns reinforcing fall prevention and landing surfaces should be done in the early spring. The hourly data support the need for dedicated early morning operating rooms to care for these fractures.

LEVEL OF EVIDENCE

Prevalence study, retrospective cohort, Level II .

Football helmet drop tests on different fields using an instrumented Hybrid III head

An instrumented Hybrid III head was placed in a Schutt ION 4D football helmet and dropped on different turfs to study field types and temperature on head responses. The head was dropped 0.91 and 1.83 m giving impacts of 4.2 and 6.0 m/s on nine different football fields (natural, Astroplay, Fieldturf, or Gameday turfs) at turf temperatures of -2.7 to 23.9 °C. Six repeat tests were conducted for each surface at 0.3 m (1') intervals. The Hybrid III was instrumented with triaxial accelerometers to determine head responses for the different playing surfaces. For the 0.91-m drops, peak head acceleration varied from 63.3 to 117.1 g and HIC(15) from 195 to 478 with the different playing surfaces. The lowest response was with Astroplay, followed by the engineered natural turf. Gameday and Fieldturf involved higher responses. The differences between surfaces decreased in the 1.83 m tests. The cold weather testing involved higher accelerations, HIC(15) and delta V for each surface. The helmet drop test used in this study provides a simple and convenient means of evaluating the compliance and energy absorption of football playing surfaces. The type and temperature of the playing surface influence head responses.

Temporal variation in childhood injury from common recreational activities

BACKGROUND/PURPOSE

To investigate the month and day of the week of injury in common childhood activities using the National Electronic Injury Surveillance System database.

METHODS

All emergency department visits 2002–2006 from bicycles/tricycles, scooters, playground equipment, swimming/water activities, skiing/snowboarding, trampolines, and skating were analysed. The NEISS weighted and stratified data set was analysed using SUDAAN software. Weekday and month of injury, gender, race, anatomical location of the injury, geographical location of injury, and disposition were tabulated. Simple variation by month or weekday was analysed using cosinor analysis; combined variation for both month and weekday was analysed by topographical analysis.

RESULTS

There were an estimated 4.61 million emergency department visits for injuries from these activities in children in the United States. The average age was 9.5 years; there were 1.65 million girls (35.9%) and 2.97 boys (64.1%). Cosinor analysis demonstrated significant single peaks for month of injury for snow activities (January 27), trampolines (June 10), scooters (June 24), cycling (July 6), and water (July 12) activities. Double cosinor peaks were noted for skating (April 13 and September 12) and playground (April 22 and September 21) activities. Cosinor analyses demonstrated that the peak week days of injury were Monday for trampoline and snow activities, Saturday/Sunday for skating activities, Sunday for cycling, and Wednesday for playground equipment. There was no peak injury day for scooter or water activities. Topographical representation of paediatric injuries demonstrated that injuries from slides most frequently occurred April–May on Wednesdays and Saturdays, and those on swings April–May all days except Tuesday. Monkeybar injuries were bimodal, with the spring peak on Wednesday–Thursday in April/May and the fall peak Tuesday–Friday in September. Rollerblade injuries occurred Saturday–Sunday from March/April; rollerskates on Saturday–Sunday in January–April, and skateboards Saturday–Monday in August–October and Sundays in April.

CONCLUSIONS

These findings can be used to further guide childhood injury prevention programmes/campaigns and especially track improvements after targeted prevention programmes. Public parks and schools should check/correct the status of playground landing surfaces just before the bimodal peaks. Education campaigns reinforcing the need for bicycle helmets could be concentrated immediately before the increase in cycling activity – March on weekends and April/May for weekdays.

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.

Supervision of young children with fall injuries

BACKGROUND

Specific information about the supervision of young children with injuries related to falls is limited. In this study, we describe the supervision and physical environment of falls resulting in medical care in the emergency department.

METHODS

We enrolled a convenience sample of 108 children younger than 7 years with fall injuries.

RESULTS

The average age was 3 years, and 56% were male. Seventy-six (70%) were a fall from a height including 16 that involved stairs. Among caretakers in a nongroup setting (n = 95), most (61%) were supervising more than one child. The attention to the child was holding or playing with the child (13%), observing (45%), usually constantly, or listening for the child (19%); 9% reported no supervision at the time of the fall. Thirty-two percent stated they were touching or within reach of the child. Of falls indoors (n = 56), the supervisor was in the same room as the child for more than half of cases. There was no association between the number of children supervised and fall type (height vs. same level). When compared with those with same level falls, children with falls from a height were more often supervised with listening or no supervision (vs. observation, holding, or playing with the child) χ², p = 0.004.

CONCLUSIONS

Many children were supervised at the time of their fall. Most caretakers had visual contact, and up to a third were touching or within reach of the child. The strategies used in these apparently low-risk situations were insufficient to prevent the falls we report.

Composite playground safety measure to correlate the rate of supracondylar humerus fractures with safety: an ecologic study

BACKGROUND

More than 200,000 children are injured at playgrounds in the United States each year. Our goal was to introduce a composite measure of playground safety and use this instrument to correlate the incidence of supracondylar humerus fractures with playground safety in an ecologic study design.

METHODS

We used a novel "overall-safety rating," defined as a composite of 3 previously validated instruments (National Program for Playground Safety School score, surface depth compliance, and the use zone compliance) to measure the overall safety of all playgrounds within a region. The regions were rated from most to least safe based on average playground safety as measured by this new method. The incidence of supracondylar fractures was calculated using Hasbro Children's Hospital Emergency Department data and state of Rhode Island Census data from 1998 to 2006. The incidence was then correlated with playground safety as defined by our composite measure.

RESULTS

Compared with the neighborhood deemed the safest, the least safe district had 4.7 times greater odds of supracondylar humerus fracture. Overall composite safety score of the district was linearly correlated with the injury rate observed in the population at risk (R=0.98; P=0.04).

CONCLUSIONS

Using our novel composite playground safety score, we found that the incidence of supracondylar humerus fractures was increased in districts with playgrounds with lower scores, suggesting that improvements in playground infrastructure may potentially reduce the incidence of supracondylar humerus fractures, and other injuries, in children.

LEVEL OF EVIDENCE

Level IV.

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.

Advances in the prevention of children's injuries: an examination of four common outdoor activities

PURPOSE OF REVIEW

Injuries remain the leading cause of death for children. Experts in paediatrics and child health have a current interest in promoting children's healthy active living. This review highlights findings from recent literature regarding the prevention of injuries from four common outdoor activities: bicycling, snowboarding and skiing, walking and playground activity.

RECENT FINDINGS

There is sound evidence for the effectiveness of bicycle helmets, the promotion of bicycle helmets at a community level and through physician counselling, and legislation; for the effectiveness of helmets for skiing and snowboarding; for the effectiveness of implementing playground safety standards; and for the effectiveness of modifications to the pedestrian physical environment.

SUMMARY

The science of injury prevention has advanced considerably. The highest level of evidence, including systematic reviews, is now available regarding the effectiveness of protective measures, engineering approaches to the environment and legislation. Healthcare providers caring for children play a leading role in injury prevention through child and family counselling, advocacy and research.

An Investigation of School Playground Safety Practices as Reported by School Nurses

The purpose of this study was to investigate school playground safety practices. The study used a purposeful sample of school nurses who attended a playground safety workshop at the 2006 National Association of School Nurses annual conference. Seventy-five questionnaires were distributed, and 64 useable questionnaires were returned. The responses indicated that little attention is being given to providing safe playground environments in schools as measured by best practices of supervision, age-appropriate design, fall surfacing, and equipment maintenance. Participants pointed to the need for better supervision and supervision training, careful selection of age-appropriate equipment, maintaining adequate fall surfaces under the equipment, and ensuring that equipment is properly maintained and repaired. The study also revealed that school nurses believe they could play a role in playground injury prevention through the collection and analysis of injury data, communication to administrators about the need for comprehensive planning of the play environment, and becoming active members of playground safety committees.

Relationships of job hazards, lack of knowledge, alcohol use, health status and risk taking behavior to work injury of coal miners: a case-control study in India

Objective is to assess the relationships of job hazards, individual characteristics, and risk taking behavior to occupational injuries of coal miners. This case-control study compared 245 male underground coal miners with injury during the previous two-year period with 330 matched controls without injury during the previous five years. Data were collected via face-to-face interview and analyzed using the conditional logistic model. Handling material, poor environmental/working conditions, and geological/strata control- related hazards were the main risk factors: adjusted ORs 5.15 (95% CI 2.42-10.9), 2.40 (95% CI 1.29-4.47), and 2.25 (95% CI 1.24-4.07) respectively. Their roles were higher among the face-workers than among the non-face-workers. No formal education, alcohol consumption, disease, big-family, and risk-taking behavior were associated with injuries (2.36</=ORs</=10.35), and the findings were similar for both face and non-face workers. Prevention should focus on handling material, poor environmental condition, especially addressing workers with no formal education, alcohol consumption, disease, big family size, and risk-taking behavior.

The demographics of playground equipment injuries in children

BACKGROUND/PURPOSE

There have been many different studies of injuries owing to playground equipment but none that have looked in detail using large nationwide databases. It was the purpose of this study to investigate injuries owing to playground equipment using the National Electronic Injury Surveillance System (NEISS) database and further understand their demographics.

METHODS

Detailed NEISS injury data from 2002 through 2004 for slides, monkey bars, and swings were analyzed. Appropriate statistical analyses were performed; because of the many analyses on this large data set, P < .01 was considered statistically significant.

RESULTS

There were 22728 emergency department visits owing to playground equipment injuries recorded by NEISS between 2002 and 2004; 83.9% were owing to monkey bars, swings, and slides, and the 5 most common diagnoses were fractures (39.3%), contusions/abrasions (20.6%), lacerations (16.6%), strains/sprains (9.9%), and traumatic brain injuries (TBI) (8.5%). There were 9487 boys (54.3%) and 7995 girls (45.7%). The average age was 6.5 +/- 3.0 years. The injuries occurred at school in 38.9%; at a recreation/sporting facility, in 35.5%; and at home, in 25.6%. Most were treated and released (94.4%). Amerindian children were 2 times more likely than blacks to be admitted; compared to contusions, fractures were 9.8 times, and TBIs, 4.7 times more likely to be admitted. Injuries on monkey bars were 1.2 times more likely to be admitted than those on swings or slides. Fractures were 1.9 times more likely to occur on a monkey bar compared with swings or slides. Traumatic brain injuries were 1.4 times more likely to occur on a swing compared to slides or monkey bars.

CONCLUSION

Swings at school are the most common mechanism of injury for TBIs, and the seasonal data would suggest that increased supervision of children using swings during school hours might reduce the occurrence of TBIs. Monkey bars are the most common cause of fracture, and fracture is the most common cause of admission. Prevention strategies to reduce the number of fractures should be directed at monkey bar equipment and landing surfaces. The trend in playground equipment injury also indicates that monkey bars are problematic because the number of injuries per year per capita owing to monkey bars is stable, whereas those from swings and slides is decreasing.

Risk factors for unintentional injuries due to falls in children aged 0-6 years: a systematic review

OBJECTIVE

To identify risk factors for unintentional injuries due to falls in children aged 0-6 years.

DESIGN

A systematic review of the literature.

METHODS

Electronic databases from 1966 to March 2005 were comprehensively searched to identify empirical research that evaluated risk factors for unintentional injuries due to falls in children aged 0-6 years and included a comparison group.

RESULTS

14 studies met the inclusion criteria. Studies varied by the type of fall injury that was considered (ie, bunk bed, stairway, playground or infant walker) and with respect to the quality of evidence. In general, major risk factors for the incidence or severity of injuries due to falls in children included age of the child, sex, height of the fall, type of surface, mechanism (dropped, stairway or using a walker), setting (day care v home care) and socioeconomic status.

CONCLUSION

Despite a high burden, few controlled studies have examined the risk and protective factors for injuries due to falls in children aged 0-6 years. The only study to examine falls from a population health perspective suggests that age, sex and poverty are independent risk factors for injuries due to falls in children.