Injuries Caused by Falls From Playground Equipment in the United States

Factors associated with trauma recidivism in young children

BACKGROUND

Trauma recidivism is associated with future trauma-associated morbidity and mortality. Previous evidence suggests that socioeconomic factors predict trauma recidivism in older children (10-18 years); however, risk factors in US children 10 years and younger have not been studied. We sought to determine the factors associated with trauma recidivism in young children 10 years and younger.

METHODS

We conducted a retrospective cohort study of pediatric trauma patients 10 years and younger who presented to a single American College of Surgeons-verified Level I pediatric trauma center from July 1, 2017, to June 30, 2021. All patients were evaluated for prior injury during trauma registry entry. Characteristics at the index injury were collected via chart review. Patients were geocoded to assess Social Vulnerability Index. Logistic regression examined factors associated with recidivism. Best subset selection was used to compare multivariable models and identify the most predictive and parsimonious model. Statistical significance was set at p < 0.05.

RESULTS

Of the 3,518 patients who presented in the study period, 169 (4.8%) experienced a prior injury. Seventy-six percent (n = 128) had one prior injury presentation, 18% (n = 31) had two prior presentations, and 5.9% (n = 10) had three or more. Falls were the most common mechanism in recidivists (63% vs. 52%, p = 0.009). Child physical abuse occurred in 6.5% of patients, and 0.9% experienced penetrating injury. The majority (n = 137 [83%]) were discharged home from the emergency department. There was no significant difference in the frequency of penetrating injury and child physical abuse between recidivists and nonrecidivists. Following logistic regression, the most parsimonious model demonstrated that recidivism was associated with comorbidities, age, falls, injury location, nontransfer, and racialization. No significant associations were found with Social Vulnerability Index and insurance status.

CONCLUSION

Medical comorbidities, young age, injury location, and falls were primarily associated with trauma recidivism. Support for parents of young children and those with special health care needs through injury prevention programs could reduce trauma recidivism in this population.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Impact of Outdoor Play Structures on Moderate to Vigorous Physical Activity in Children during Recess: A Comparative Study

BACKGROUND/OBJECTIVES

It is believed that outdoor play structures lead to more physical activity for kids during school recess. However, the intensity of this activity remains unknown. This study explored whether access to outdoor play structures during recess interferes with children's physical activity levels.

METHODS

Forty-one children (8-10 years old) accessed play structures during the afternoon recess but not in the morning for one entire week. To control for temperature differences, the same number of participants from another school who did not access playground structures were invited to participate. Moderate to Vigorous Physical Activity (MVPA) was determined using heart rate reserve. Heart rate was recorded using the Fitbit Inspire 2 (San Francisco, CA, USA) for at least three full school days. Wilcoxon signed-rank and Mann-Whitney U tests analyzed within- and between-group differences.

RESULTS

The findings show no difference in MVPA when accessing or not accessing outdoor play structures, both within groups [(n = 37) median (25th-75th) 16 min (7-30) vs. 14 min (5-22)] and between groups [(n = 22) 16 min (7-26)]. The weekly MVPA for all participants (n = 59) [172 min (117-282)] was the strongest variable associated with MVPA during recess [t(df) = 5.40 (38), 95% CI 0.04-0.09, p < 0.001].

CONCLUSION

accessibility to outdoor play structures does not increase MVPA during recess in children aged 8 to 10. Therefore, schools may need various options for children to play during recess, allowing them to accumulate MVPA.

Monkey Bar-Associated Pediatric Fractures: A National Epidemiologic Study of Emergency Department Visits

INTRODUCTION

Emergency department (ED) visits because of pediatric fractures are not only burdensome for patients and their families but also result in an increased healthcare expenditure. Almost half of all children experience at least one fracture by the age of 15. Many fractures occur in playgrounds, with monkey bars and other climbing apparatuses noted as frequent mechanisms of injury. Our purpose was to identify the pattern of injury and the population sustaining monkey bar-associated fractures.

METHODS

We queried the National Electronic Injury Surveillance System database for all monkey bar-associated injuries in patients aged 0 to 18 years from January 1, 2009, to December 31, 2019. We described demographic data, patient disposition from the ED, fracture pattern, and injury setting using unweighted and weighted estimates. Weighted results that more closely reflect national estimates were calculated.

RESULTS

During the study period, 30,920 (862,595 weighted) monkey bar-associated injuries presented to EDs; 16,410 (53.1%) (weighted injuries: 408,722 [47.4%]) were fracture injuries. The average age of kids sustaining fractures was 6.5 years, with most injuries (66.4%) occurring in kids between 6 and 12 years. A higher percentage of male patients presented to the ED with fractures compared with female patients (53% versus 47%). Upper extremity fractures were most common, 382,672 (94%) with forearm fractures constituting the majority (156,691 [38%]). Most children were treated and released (354,323 [87%]), with only 35,227 children (9%) being admitted for treatment. Places of recreation/sports were the most common setting of fractures (148,039 [36%]), followed by schools (159,784 [39%]). A notable association was observed between year and ethnicity and between month period and injury setting.

CONCLUSION

Monkey bar-associated injuries are a major cause of upper extremity fractures in children, with most injuries occurring in recreational areas or schools. Young elementary school children are at the highest risk of injury. ED visits because of monkey bar-associated fractures have increased over the study period, and these injuries continue to be a major cause of fractures in children. Additional measures should be installed to decrease these preventable fractures among children, with schools as a potential starting point.

What are the Characteristics of Oral Injuries Caused by Playground Equipment?

PURPOSE

Studies regarding oral injuries from playground equipment in children remain limited. This study aimed to clarify the characteristics of oral injury caused by playground equipment and identify associations with concomitant head injury.

METHODS

Children treated between 2011 and 2021 at an oral surgery clinic for oral injuries from playground equipment were retrospectively investigated. The following factors were analyzed: demographic characteristics, mechanism of injury, type of equipment causing the injury, classification of oral injury, and whether the Department of Emergency and Critical Care Medicine was consulted regarding the head injury. The data collected were statistically analyzed using the Fisher-Freeman-Halton test with significance adopted at the 5% level.

RESULTS

This study analyzed data from 82 children. Injuries were concentrated in age groups of 2 to 3 years (32.9%), 4 to 5 years (28.0%), and 6 to 7 years (25.6%). Regarding the mechanism of injury, falls were more common (89.0%) than impact/striking (11.0%). The type of equipment most frequently causing injury was slides (29.3%), followed by swings (23.2%) and iron bars (18.3%). Injuries were classified as soft tissue injury alone (56.1%) or tooth injury and/or jaw fracture (43.9%). Consultation with the Department of Emergency and Critical Care Medicine for head injury was uncommon (13.4%), and all consultations for brain injury diagnosed minor injuries.

CONCLUSION

Oral injuries caused by playground equipment were frequent between 2 and 7 years old. The most common cause was falls, with most injuries caused by slides, swings, or iron bars. Approximately half of the oral injuries were soft tissue injuries only, while the other half were associated with tooth and/or jaw injuries. Department of Emergency and Critical Care Medicine consultations for head trauma were uncommon and consistently confirmed minor injuries.

Epidemiological Characteristics of School Playground Injuries

Reports of children's play-related injuries have remained stagnant according to epidemiology studies of the past 3 decades. This article provides a unique look into the context of playground injuries within an entire school district, demonstrating the prevalence of these injuries. This study reports that playgrounds are the leading location of school injury, comprising one-third of all elementary school injuries. This study found that while head/neck injuries were the most commonly injured body region within the playground environment, the proportion of head/neck injuries decreased with age, whereas the proportion of extremity injuries increased with age. At least 1 upper extremity injury required outside medical attention for every 4 that were treated on-site, making upper extremity injuries roughly twice as likely to require outside medical attention as injuries to other body regions. The data in this study are useful for interpreting injury patterns in the context and evaluation of existing safety standards for playgrounds.

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.

Supracondylar humerus fractures in children caused by monkey bar-related injuries: a comparative study

We evaluated the functional and radiological outcomes of surgically treated supracondylar humerus fractures based on injury mechanisms, as well as the therapeutic and prognostic aspects of monkey bar-related injuries, in this study. Between December 2014 and December 2018, pediatric patients who had undergone surgical treatment for supracondylar humerus fractures were analyzed retrospectively. According to the mechanism of injury, patients were divided into two groups: monkey bar-related injuries and other injuries. Patients were evaluated functionally using the Mayo elbow performance score, while radiographically using the anterior humeral line, humero-capitellar angle, and Baumann angle. This study enrolled a total of 50 patients, 27 females and 23 males. Each patient was followed for a minimum of 24 months. There were no significant differences in age, sex or complications between the groups. The Mayo elbow performance score and fracture types were shown to be significantly associated with injury mechanisms ( P = 0.017, P < 0.001). Additionally, a significant correlation between the necessity for open reduction and the mechanism of injury was found ( P = 0.038). There were no significant differences in radiological evaluation between the groups. Supracondylar humerus fractures caused by falling from the monkey bar were more severe in children than supracondylar humerus fractures caused by other mechanisms of injury, and surgical treatment outcomes were worse for supracondylar humerus fractures caused by falling from the monkey bar.

Bone Fracture Patterns and Distributions according to Trauma Energy

Background

This study investigates the effect of injury mechanism and energy on fracture patterns and distributions. Also, it compares differences in bone fracture patterns based on injury mechanism, gender, and age.

Methods

Three thousand and sixty-six admitted patients with bone fractures were reviewed retrospectively, and the fractures were analyzed regarding age, gender, and mechanism of injury. Fractures were located in eleven bones. However, the forearm, hand, leg, and foot were considered one bone, and the fracture was then subclassified according to the anatomic position within each bone. Trauma energy was classified according to the mechanism of injury where simple falls were considered low-energy injury while falling from a height, road traffic accidents, bullet, and industrial injuries were considered high energy.

Results

Males represented most of the patients, and most injuries occurred in adults. However, the male patients were more prone to injuries than females across all age groups below fifty years, women above fifty years were more frequent, and a third of females' injuries occurred in the elderly. Simple falls represent two-thirds of the trauma mechanism, and falling from a height and road traffic accidents are the most common high-energy injuries and more prevalent in males. Scapular, clavicular, distal humerus, and shaft of long bones fractures were more prevalent in males. In contrast, females had a higher frequency of proximal humerus, proximal and distal femur, distal leg, and thoracic spine fractures. Industrial injuries are more frequent in males; thus, hand injuries are more frequent. Pathological fractures were higher in females, and spine and pelvic fractures were more associated with high-energy injuries.

Conclusions

The trauma's energy determines the bone injury's extent and nature. Knowing the trauma mechanism is essential to expect the extent of injuries and construct preventive measures accordingly.

Epidemiology of child playground equipment-related injuries in the USA: Emergency department visits, 1995-2019

AIM

To analyse the most recent trends and characteristics of playground equipment-related injuries in children.

METHODS

We used the National Electronic Injury Surveillance System database to acquire cases of playground equipment-related injuries in children ≤17 years old between 1995 and 2019. A total of 184 580 unweighted cases met our study inclusion criteria.

RESULTS

A total of 5 356 703 (95% confidence interval 4 235 530-6 477 876) emergency department visits for playground-related injuries in the USA were estimated during the study period which was equal to an average of 29.4 annual injuries per 10 000 US population ≤17 years. The mean age was 6.5 (standard error 0.049) years. School-aged (42.7%) and pre-school children (35.3%) accounted for most playground injuries. More than half of the injuries were reported in males (53.6%). Most injuries occurred with climbing apparatuses (36%), followed by swings (25.9%) and slides (20.9%). Overall number of injuries (∆ - 22.3%, P = 0.01) and incidence (∆ - 21.6%, P = 0.01) had a declining trend after 2012. However, reported concussion injuries showed an increasing trend during the study (∆ + 28.3%, P < 0.001). A marked seasonal variation in number of injuries existed with most injuries in May and September.

CONCLUSIONS

Although injuries arising from playground equipment have decreased during the past 8 years, there was an increase in number of reported concussions. The outcomes of this study suggested that further efforts should be directed towards such serious injuries.

Paediatric playground and tree-related injuries: Hospital admissions in the Midland region of New Zealand

AIM

To examine the incidence and outcomes of paediatric playground and tree-related injuries in the Midland region of New Zealand.

METHODS

A retrospective review of Midland Trauma Registry hospitalisation data between January 2012 and December 2018 was undertaken. Cases included children aged 0-14 years hospitalised for playground and tree-related injuries. Demographic and event information, injury severity and hospital-related outcomes were examined.

RESULTS

Playground and tree-related hospitalisations (n = 1941) occurred with an age-standardised rate of 144.3/100 000 (confidence interval (CI) 127.3-161.3) and increased 1.4% (CI 1.3-4.2%) annually. The highest incidence was observed in 5-9-year olds (248.8/100 000) with 0-4 and 10-14-year olds at 86.0 and 89.2/100 000, respectively. Injuries most commonly occurred at home, school or pre-school (77.1%), 93.7% were due to falls and, the upper extremity was the most frequently injured body region (69.9%), particularly due to forearm (55.6%) and upper arm (34.7%) fractures. Tree-related incidents comprised 11.6% of all injuries and explained 57.1% of injuries classified as major severity. Fifty-eight percent of children were hospitalised for 1 day and 97.0% for less than 5 days. Estimated hospital costs were NZ$1.2 million annually with a median of NZ$3898 per incident. Injuries classified as minor severity accounted for 86.5% of the total estimated cost.

CONCLUSION

Children aged 5-9 years' experience high rates of costly hospitalisation for playground and tree-related injuries. Targeted injury prevention initiatives, particularly in the home and school environments, are imperative to reduce the incidence and burden of playground and tree-related injuries to affected children, their families and hospital resources.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Playground Equipment-related Genital Injuries in Children: An Analysis of United States Emergency Departments Visits, 2010-2019

OBJECTIVE

To evaluate the demographics, epidemiology, and common mechanisms associated with playground equipment-related genital injuries in children.

METHODS

We examined the National Electronic Injury Surveillance System database to obtain playground-related genital injuries sustained in children ≤17 years from 2010 to 2019. Demographics of the patients and injury characteristics were analyzed using sample weights to produce national estimates.

RESULTS

During the study period, an estimated 27,738 (95% confidence interval 18,602-36,874) emergency department visits with an average annual incidence of 3.8 (95% confidence interval 2.5-5) per 100,000 United States population ≤17 years were reported. The mean age was 6.6 (standard error 0.152) years with most injuries occurring in pre-school children (48.1%) and females (81.1%). Over ½ of genital injuries (55.2%) were associated with climbing apparatus. This was followed by slides (10.7%), swings (9%), and seesaws (4.8%). Most genital injuries occurred at public (41.4%) and school settings (36.3%). Straddling and/or falling was the most common mechanism leading to genital injuries (84.4%). The incidence of injuries remained constant during the 10-year study period (change = + 2.6%; r² = 0.121, P = .326). Monthly variations in the number of injuries existed with peak injuries in April-May, and September-October.

CONCLUSION

Despite current safety standards, genital injuries arising from playground equipment have remained stable since 2010. By defining common devices, mechanisms, and conditions associated with genital injuries, this study may help guide efforts aimed at the prevention of such injuries in various locations.

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.

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.