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

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.

A Pilot Randomized Trial Evaluating the Cool 2 Be Safe Junior Playground Safety Program for Preschool Children

OBJECTIVE

Unintentional injury is the leading cause of death to children worldwide, and playgrounds pose a significant risk of injury. Those aged 5 and 6 years are particularly vulnerable to playground injuries. Previous interventions have typically targeted environmental modifications or increased supervision to reduce playground injuries; however, minimal research has focused on implementing behavioral interventions that seek to change children's safety knowledge and risk-taking behaviors on the playground. The current randomized trial addressed these gaps in the literature and sought to increase preschool children's hazard awareness skills and knowledge of unsafe playground behaviors and decrease their intentions to engage in risk-taking behaviors on the playground.

METHOD

A total of 77 children aged 5 and 6 years were tested at a laboratory on a university campus, using a parallel group design, with 38 randomized to the playground intervention group and 39 randomly assigned to a control group. The intervention was manualized and delivered to small groups of children (3-5) over several sessions.

RESULTS

Statistical analyses revealed significant group differences. Intervention experience led to significant increases in hazard awareness skills and knowledge of unsafe playground behaviors, and significant decreases in children's risk-taking behavioral intentions, whereas those in the control group showed no significant changes in these scores. Attention scores for those in the intervention group highlighted that the program content was successful in maintaining children's attention and engagement, and memory scores indicated excellent retention of lesson content.

CONCLUSION

The program shows promise in addressing the issue of unintentional playground injuries in young children.

Playing it safe: The relationship between parent attitudes to risk and injury, and children's adventurous play and physical activity

BACKGROUND

Children naturally seek risk in play and adventurous play outdoors confers many benefits, including the potential to increase moderate-to-vigorous physical activity (MVPA). This study aimed to investigate the relationship between parent attitudes to risk and injury, and their elementary school-aged child's daily adventurous play and MVPA.

METHODS

A panel sample of 645 Australian parents/guardians completed an online survey consisting of several validated measures of risk and injury attitudes, and physical activity and play behaviour. Data were analysed via descriptive statistics, univariate and multivariable regressions using Stata 17. A series of exploratory univariate logistic regressions were conducted, followed by a series of multivariable logistic regressions fitted to test the association between parent risk and injury attitudes and (i) children's MVPA, (ii) active play and (iii) adventurous play, while adjusting for socio-demographic factors.

RESULTS

Most adult participants (81%) were female. The mean age of the child participants (53% male) was 8.6 years (SD = 2.4). On average, parents were positive about children's engagement with risk, however, 78% of parents had low tolerance of risk when presented with specific play scenarios, and attitudes towards injuries varied, with mothers more concerned than fathers. After adjusting for confounders, children with parents who were tolerant of risk in play were more likely to meet the MVPA guideline of ≥60 min daily (OR 2.86, CI: 1.41, 5.82, p < 0.004) and spend more time playing adventurously (OR 3.03, CI: 1.82, 5.06, p < 0.001). Positive associations for MVPA and adventurous play were observed across all models examining parent attitudes to risk and injury. Younger children engaged in more play and physical activity, however, more positive parent attitudes appeared to moderate the age-related influences.

CONCLUSIONS

We found a divergence between the outcomes parents desire for their children through engagement with risk and the play activities they are comfortable with in practice. Parent attitudes to risk and injury are potentially modifiable factors that may increase children's affordances for adventurous play and physical activity. Interventions that provide parents with practical approaches to address injury concerns and support children's risk-taking in play outdoors are recommended.

Preventing Unintentional Injuries in School-Aged Children: A Systematic Review

BACKGROUND AND OBJECTIVES

Unintentional injuries constitute the leading causes of death and long-term disabilities among children aged 5 to 15 years. We aimed to systematically review published literature on interventions designed to prevent unintentional injuries among school-aged children.

METHODS

We searched MEDLINE, PubMed, Embase, Cochrane Central Register of Controlled Trials, CINAHL, and PsycINFO and screened the reference lists of included studies and relevant reviews. We included randomized controlled trials, controlled before-and-after studies, and interrupted time series studies. The focus of included studies was on primary prevention measures. Two reviewers collected data on type of study design, setting, population, intervention, types of injuries, outcomes assessed, and statistical results.

RESULTS

Of 30 179 identified studies, 117 were included in this review. Most of these studies were conducted in high-income countries and addressed traffic-related injuries. Evidence from included studies reveals that multicomponent educational interventions may be effective in improving safety knowledge, attitudes, and behaviors in school-aged children mainly when coupled with other approaches. Laws/legislation were shown to be effective in increasing cycle helmet use and reducing traffic-related injury rates. Findings reveal the relevance of infrastructure modification in reducing falls and improving pedestrian safety among children.

CONCLUSIONS

Additional studies are needed to evaluate the impact of unintentional injury prevention interventions on injury, hospitalizations, and mortality rates and the impact of laws and legislation and infrastructure modification on preventing unintentional injuries among school-aged children.

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.

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.

Risk of Recurrent Fracture: A Population-Based Study

OBJECTIVES

To determine if children who sustain a fracture in childhood had an increased rate of fracture later in childhood or early adulthood. The a priori null hypothesis was that children who sustained a fracture would not have an increased rate of future fractures compared with children who did not sustain a fracture when controlling for important covariates.

METHODS

This is a population-based retrospective cohort study using health care databases in Ontario. Approximately 2.5 million healthy children aged 0 to 15 years living in Ontario, Canada between April 1, 2003, and March 31, 2004, were included and followed for 7 years. The exposure was occurrence of any fracture during a 1-year baseline period. The main outcome was any fractures during a 7-year follow-up period.

RESULTS

A total of 43 154 children suffered a fracture during the baseline year (17.5 fractures per 1000 child years). Children with a baseline fracture had a 60% higher rate of fracture (incidence rate ratio: 1.60; 95% confidence interval: 1.46-1.75; P < .0001) during the follow-up period after adjustment for sex, rurality, history of previous fracture, and the occurrence of other injuries (head and soft-tissue).

CONCLUSIONS

The occurrence of a fracture during childhood was associated with an increased rate of future fractures compared with children who did not suffer a fracture. Attempting to improve childhood bone health by targeting children who present to a fracture clinic with multiple fracture risk factors may be a useful strategy for secondary prevention of fractures and may have beneficial effects on long-term bone health.

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.

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.

Predisposing Effect of Elbow Alignment on the Elbow Fracture Type in Children

OBJECTIVES

Under the hypothesis that the elbow alignment, namely the carrying angle, could predispose individuals to a specific type of pediatric elbow fracture after a fall onto an outstretched arm, we investigated the relationship between radiographic carrying angle and elbow fracture type in children.

DESIGN

Retrospective case-control study.

SETTING

Level I pediatric trauma center.

PATIENTS/PARTICIPANTS

We reviewed 374 children who were diagnosed with supracondylar fracture (SCF, n = 208), lateral condylar fracture (LCF, n = 132), and radial neck fracture (RNF, n = 34).

INTERVENTION

The association between the radiographic carrying angle and the fracture type was investigated.

MAIN OUTCOME MEASUREMENTS

To adjust for bias, 2 statistical methods were used: multivariate analysis using a baseline-category logistic model and a case-matching method using propensity score analysis.

RESULTS

In the multivariate analysis, with SCF patients set as the baseline category, a more valgus-deviated elbow (increased carrying angle, P = 0.011) predisposed individuals to RNF, whereas a more varus-deviated elbow (decreased carrying angle, P < 0.001) predisposed them to LCF. In the case-matched analysis, there were also significant differences in carrying angles between RNF and case-matched SCF patients (14.3 vs. 11.4 degrees, P = 0.013) and between LCF and case-matched SCF patients (7.7 vs. 11.7 degrees, P < 0.001).

CONCLUSIONS

Elbow alignment, which may influence the transmission of traumatic force during a fall onto an outstretched elbow, could be a predisposing factor for specific types of pediatric elbow fracture. The results provide the additional information about the injury mechanisms of pediatric elbow fracture and may deepen our understanding of the fractures.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Position Statement on Active Outdoor Play

A diverse, cross-sectorial group of partners, stakeholders and researchers, collaborated to develop an evidence-informed Position Statement on active outdoor play for children aged 3–12 years. The Position Statement was created in response to practitioner, academic, legal, insurance and public debate, dialogue and disagreement on the relative benefits and harms of active (including risky) outdoor play. The Position Statement development process was informed by two systematic reviews, a critical appraisal of the current literature and existing position statements, engagement of research experts (N = 9) and cross-sectorial individuals/organizations (N = 17), and an extensive stakeholder consultation process (N = 1908). More than 95% of the stakeholders consulted strongly agreed or somewhat agreed with the Position Statement; 14/17 participating individuals/organizations endorsed it; and over 1000 additional individuals and organizations requested their name be listed as a supporter. The final Position Statement on Active Outdoor Play states: “Access to active play in nature and outdoors—with its risks— is essential for healthy child development. We recommend increasing children’s opportunities for self-directed play outdoors in all settings—at home, at school, in child care, the community and nature.” The full Position Statement provides context for the statement, evidence supporting it, and a series of recommendations to increase active outdoor play opportunities to promote healthy child development.

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

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

Pediatric elbow fractures in a major trauma center in iran

Background

Elbow fractures are one of the most common traumatic fractures in the pediatric population. Since severe complications may occur, appropriate diagnosis and treatment are imperative when dealing with this type of fracture.

Objectives

The aim of this study was to evaluate the epidemiology of elbow fracture in children admitted in Alzahra hospital, Isfahan, IR Iran over a one year period.

Patients and Methods

During a one year period, a prospective study was conducted on 300 patients under the age of 16 who had sustained elbow fractures. Data included age, gender, mechanism of trauma, type of elbow fractures, complications, and outcomes.

Results

The mean age of the patients was 8.1 ± 2.31 years old. Boys were injured 2.6 times more often than the girls. Falling was the major cause of pediatric elbow fractures (86%). Supra condylar were the most common type of fracture. There was a significant association between gender and type of injury (P < 0.01).

Conclusions

Supracondylar fracture is the most common fracture type resulting from 4 - 8 year old boys’ falls. Our findings indicate the critical nature of appropriate treatment in order to prevent severe complications.

The effect of surface and season on playground injury rates

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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