Epidemiology of non-submersion injuries in aquatic sporting and recreational activities

Aquatic Feasibility of Limbs Application of Tourniquets (AFLAT) during a Lifeguard Water Rescue: A Simulation Pilot Study

INTRODUCTION

Control of massive hemorrhage (MH) is a life-saving intervention. The use of tourniquets has been studied in prehospital and battlefield settings but not in aquatic environments.

OBJECTIVE

The aim of this research is to assess the control of MH in an aquatic environment by analyzing the usability of two tourniquet models with different adjustment mechanisms: windlass rod versus ratchet.

METHODOLOGY

A pilot simulation study was conducted using a randomized crossover design to assess the control of MH resulting from an upper extremity arterial perforation in an aquatic setting. A sample of 24 trained lifeguards performed two randomized tests: one using a windlass-based Combat Application Tourniquet 7 Gen (T-CAT) and the other using a ratchet-based OMNA Marine Tourniquet (T-OMNA) specifically designed for aquatic use on a training arm for hemorrhage control. The tests were conducted after swimming an approximate distance of 100 meters and the tourniquets were applied while in the water. The following parameters were recorded: time of rescue (rescue phases and tourniquet application), perceived fatigue, and technical actions related to tourniquet skills.

RESULTS

With the T-OMNA, 46% of the lifeguards successfully stopped the MH compared to 21% with the T-CAT (P = .015). The approach swim time was 135 seconds with the T-OMNA and 131 seconds with the T-CAT (P = .42). The total time (swim time plus tourniquet placement) was 174 seconds with the T-OMNA and 177 seconds with the T-CAT (P = .55). The adjustment time (from securing the Velcro to completing the manipulation of the windlass or ratchet) for the T-OMNA was faster than with the T-CAT (six seconds versus 19 seconds; P < .001; effect size [ES] = 0.83). The perceived fatigue was high, with a score of seven out of ten in both tests (P = .46).

CONCLUSIONS

Lifeguards in this study demonstrated the ability to use both tourniquets during aquatic rescues under conditions of fatigue. The tourniquet with the ratcheting-fixation system controlled hemorrhage in less time than the windlass rod-based tourniquet, although achieving complete bleeding control had a low success rate.

Pediatric Diving-Related Injuries in Swimming Pools Presenting to US Emergency Departments: 2008-2020

OBJECTIVES

Recreational swimming/diving is among the most common physical activities in US children and a significant cause of morbidity across the United States. This study updates the national epidemiology of diving-related injuries.

METHODS

The Consumer Product Safety Commission's National Electronic Injury Surveillance System database was queried for patients aged 0 to 19 from 2008 to 2020 who presented to any of the 100 National Electronic Injury Surveillance System-participating emergency departments for a diving-related injury. Dive characteristics such as dive height, dive skill, dive direction, and dive sequence were determined from case narratives.

RESULTS

A total of 1202 cases were identified for analysis corresponding to a total national estimate of 37,387 diving related injuries during the period from 2008 to 2020 and a national incidence of 3.6 injuries per 100,000 population. Males accounted for 64% of injuries. The average yearly incidences of injury in the 10 to 14 and 15 to 19 age groups were identical at 5.8 per 100,000. Contact with the diving board or platform was the most common cause of injury (34%). Diving backwards or attempting a flip or handstand dive were associated with increased odds of sustaining an injury resulting from contact with the diving board or platform (odds ratio, 16.0 and 6.9, respectively). In 2020, the incidence of diving-related injury fell to 1.6 per 100,000 population.

CONCLUSIONS

Diving injuries are common in children and adolescents, especially in boys aged 10 to 19. There was a significant reduction in diving-related injury corresponding with the COVID-19 pandemic.

Isolated Femoral Shaft Fracture in Wakeboarding and Review of the Literature

Introduction

Wakeboarding is an extreme sport that has shown increasing popularity in recent years, with an estimated 2.9 million participants in 2017. Due to this trend, injuries related to this sport are likely to become more common. Isolated femoral shaft are rare; however, they occur much more frequently in youth as a result of high velocity events, such as dashboard-related injuries. Few studies have addressed injuries related to wakeboarding, and of those that have, most have reported on muscle injuries, ligament ruptures, and sprains. Due to the dearth in literature, we want to present two cases of isolated noncontact femoral shaft fractures that resulted from wakeboarding. Case Presentation. Two 28-year-old, otherwise healthy, wakeboarders-patient A, male, and patient B, female-presented to our Department of Orthopaedics and Sports Medicine with isolated femoral shaft fractures. Both were admitted due to wakeboard-related noncontact injuries, where patient A fell while performing a sit-down start during cable wakeboarding and patient B after attempting a wake-jump. Both patients were being pulled by motorboats at roughly 40 km/h. After clinical examination and radiography, left spiral (AO classification: 32-A1.2) (patient A) and right-sided bending, wedge (AO classification 32-B2.2) (patient B) isolated femoral shaft fractures were diagnosed. No concomitant injuries were reported. For treatment, long reamed locked nails were applied, while the patients were under spinal anaesthesia. Physiotherapy was prescribed postoperatively. Patient A returned to wakeboarding 155 days after the surgery, and patient B returned after approximately half a year.

Conclusion

This case series shows that even in noncontact sports such as wakeboarding, high-energy forces applied to the femur can cause isolated femoral shaft fractures. Despite multiple reports in various sports of stress fractures of the femur, there are few publications of direct trauma.

Trauma on the high seas: an overview of recreational water use injuries

Recreational water use (RWU) injuries span from superficial lacerations to even death. Given the global popularity of RWU, radiologists should be aware of the common mechanisms and key imaging findings related to injuries in this setting. The goal of this article is to depict common RWU injuries and their emergent radiographic findings, which may have both important surgical and management implications. We present a broad review with case illustrations of these injuries seen at our level 1 trauma center showing the breadth of injury that can occur, general mechanisms and sample imaging findings.

Aquatic Orthopaedic Injuries

Extremity injuries sustained in aquatic environments require unique considerations compared with injuries sustained on land. Knowledge of these considerations is becoming more important as aquatic recreational activities increase in popularity. Aquatic injuries may occur through mechanical contact with a variety of different objects or surfaces, such as a recreational device or watercraft part, or may occur through contact with marine animals. Marine animal injuries can be further categorized into bites, stings, or blunt contact, as well as venomous or nonvenomous, distinctions that should be used to guide clinical management. Numerous instances of retained foreign bodies after marine animal stings exist, which can result in infection and prolonged envenomization; thus, radiographic examination should be routinely performed in aquatic sting injuries to prevent these harmful sequelae. Any aquatic injury resulting in an open wound has an increased risk for infection, and prophylactic antibiotics must be given with consideration for the unique microbiologic flora of the aquatic environment.

Risk factors associated with life jacket wear among adult canoeists and kayakers in the United States, 1999-2017

Drowning is the most common cause of death in recreational boating. Life jackets prevent drowning, yet adult wear rates remain relatively low on most types of boats. Canoes and kayaks are among the least used boat types, yet maintain the third and first highest annual boating-related drowning rates in 2012, respectively. This 1999-2017 study collected data from 124 study sites across the US. Life jacket wear was calculated for 13 dichotomized risky and non-risky variables, using Chi-square tests. A count variable based on number of risks was created, and Cochran-Armitage trend tests examined linearity in life jacket use. Three illustrative variables for each boat type were represented in tree diagrams. Kayakers had higher wear rates than canoeists among all variables observed. For both boats, the majority of risky conditions had higher life jacket wear rates than their non-risky alternatives. As the number of risks increased, life jacket wear rate increased. Boaters seemingly conduct a mental assessment of risk to determine whether to wear a life jacket.

Pediatric and adolescent injury in aquatic adventure sports

Drowning is a leading cause of death in children. Each year there are thousands of injuries in children, some fatal, associated with aquatic adventure sports. Personal water craft rapidly accelerate children to high velocities, as does being towed behind boats on skis or tubes, whereupon children have no control of their speed or direction. Canoeing and white-water kayaking particularly stress the upper limbs and shoulder dislocations are a primary concern. Surfing and kite-surfing generate more injuries to the head and face than other parts of the body and, in scuba diving, children most frequently injure their ears due to the acute pressure changes experienced. Aquatic injuries cost more in children than in adults and residual functional deficits may last a lifetime. There is a pressing need for research into the prevalence and incidence of aquatic injuries in children, so the effectiveness of preventive interventions can be determined.

Wet and wounded: Pediatric facial trauma from swimming and diving

OBJECTIVES

Swimming has been reported as the most common recreational activity among American youths, while diving remains a popular youth activity as well. We characterize the most common facial injuries occurring during these activities and evaluate facial fracture mechanisms and demographic trends, as this information may be helpful in preventative counseling as well as diagnosis.

METHODS

The National Electronic Injury Surveillance System was assessed for swimming- and diving-related facial injuries in children from 2007 to 2016. Estimates of national injury incidence were recorded, and patient diagnoses, demographics, and injury mechanisms were evaluated.

RESULTS

In the 10-year period assessed, 789 NEISS entries extrapolated to an estimated 27,709 patients nationwide were analyzed. The yearly incidence fluctuated but steadily rose from 2013 to 2016. Males comprised a majority of injuries (58%), and laceration was the most common diagnosis (65%), followed by abrasion/contusion (22%) and fracture (9%). Facial fractures were most likely to involve the nasal bones (87%). Swimming injuries were more numerous overall (74%), but a greater proportion of diving injuries resulted in fracture (12% vs. 7%). Teenagers were also more likely to suffer fractures than were younger children involved in the same activities.

CONCLUSION

Most analyses of swimming and diving injuries have focused on spinal and orthopedic trauma. Nevertheless, the nature of headfirst diving and swim strokes suggest facial trauma is an underappreciated concern for clinicians. These findings reinforce the need for safer swimming and diving practices and serve as a useful resource for physicians managing pediatric facial injuries.

Water-Related Vaginal Injury: A Case Report and Review of the Literature

BACKGROUND

Vaginal injury can result from entry of water into the vagina under high pressure. Previously reported cases describe water-jet vaginal injuries in women participating in water-related activities, including: water skiing, personal watercraft use, waterslides, water hose and fountains, with and without foreign body in situ.

CASE

We describe the case of a severe vaginal laceration and hemorrhage in a 44-year-old female from a high-pressure water-jet generated during a water-ski fall requiring operative repair. Timely management resulted in excellent patient outcome.

CONCLUSION

A literature review demonstrated that, although uncommon, watersport-related gynaecologic injuries can be life-threatening, and women who regularly engage in watersports can be counselled regarding potential preventative measures. Physicians encountering patients with these injuries should rule out intraperitoneal injury and consider benefits of antibiotics.

Emergency department visits coded for swimming pool diving injuries

Despite legislative efforts to enhance safety in public swimming pools, diving injuries are still common. This study investigated the characteristics of emergency departments (EDs) visits for diving accidents. This study utilized 2006-2014 data from the Nationwide Emergency Department Sample and examined visits for accidents due to diving or jumping into water (swimming pool). Data were stratified by age categories. Over 83,000 ED visits were found and the majority of visits were by males. Significantly more patients were in the 15-24 age category. The majority of patients were discharged and were covered by private insurance. Total charges for the six-year period approached $620 million. Spinal cord injuries were more common in those over age 25, whereas intracranial injuries occurred more frequently in younger patients. This study provides a profile of patients presenting to US EDs for diving-related injuries.

Epidemiology of Aquatic and Recreational Water Sport Injuries: A Case-Control Analysis

The purposes of the current investigation are to evaluate the epidemiology of water sport injuries at a coastal tertiary trauma center and to determine the association of these activities with spinal column injury and to determine whether aquatic trauma injuries differ significantly from those that occur terrestrially. A retrospective review of a consecutive series of 105 patients with aquatic-based mechanisms of injury admitted to a Level II trauma center over a 3-year period, as well as a matched control cohort with terrestrial-based mechanisms of injury, was conducted. Patients were treated at a Level II trauma center from January 1, 2008, to December 31, 2010. All patients received a full trauma work-up on arrival. Patients were identified retrospectively from a prospectively collected database (N=5298). Eligible patients were identified from billing/coding data as having mechanisms of injury related to an aquatic setting. Patients were evaluated using standard trauma protocols. Spinal column and cord injury occurrence and differences between groups were reviewed. Personal watercrafts accounted for the majority of injuries (n=39). Cervical (33.3%), closed-head (25.7%), and thoracolumbar (21.9%) injuries accounted for the majority of injury types. The cervical spinal column and the spinal cord were at an increased risk of injury in the aquatic injury cohort (P<.0001). The current data show the high incidence of spinal column and cord injuries in this patient population relative to controls. Practitioners who care for trauma patients near an aquatic environment should be aware of the high prevalence of these injuries, with proper spinal cord preservation protocols in place to optimize outcome.

A rare case of a scuba diver's death due to propeller injuries of a desalination pump

Water skiing, boat racing, skin and scuba diving, as well as pleasure boat cruising are becoming increasingly popular hobbies. As a result, the incidence of injuries secondary to motor propellers is becoming more frequent. Injuries by propellers, amputation, death by drowning, and bleeding are rare reported events in forensic literature. The most common circumstances surrounding boat-propeller-related injuries are concerned with getting into or out of the boat, personal watercraft use or water skiing, and falling or being thrown from the boat. A case of a scuba diver's death that occurred during an illegal scuba fishing trip around a desalination plant is presented. A complete autopsy and histological study of all organs and surfaces of dismembered cadaveric sections, performed in order to determine the phases of death, are reported. An underwater scene investigation was conducted by an engineering team studying the mouth of the pump and the dynamic characteristic of rotating propeller blades.

Injuries, ill-health and fatalities in white water rafting and white water paddling

White water (WW) activities such as paddling (canoeing and kayaking) and rafting are popular sports for recreational and professional participants. An increase in participation has been seen worldwide. However, these activities come with a risk of injury and even death if not conducted safely. A review was conducted to identify the types of injuries and ill-health that occur as a result of these activities. Injury and fatality rates were assessed to establish the risk attributed to these activities. Web of Science, PubMed, Ergonomics Abstracts and PsycINFO databases were searched and a total of 16 published articles were identified and reviewed. The shoulders and back were the most vulnerable sites for injury in WW paddling. Injuries to the face and lower limbs were most common in WW rafters. However, injury rates are low and estimates are discussed. Due to different methods used across the studies, the reported injury rates are not comparable. This review identified three illnesses incurred through WW activities. There may be more but these are not currently reported in the literature. A relative paucity of studies regarding injuries and fatalities in WW activities was identified. Directions for future research are suggested and discussed.

Wet and wild: results from a pilot study assessing injuries among recreational water users in Western Australia

To identify, describe and compare injuries among three water sport activities: kite surfing (KS), personal watercraft (PWC) and towed water sports (TWS). The study was a cross sectional, online survey. The setting was on Perth, Western Australia's popular beaches and riverbanks. Main outcome measures were number of injuries and level of severity; level of exposure and protection measures. Overall, 43% reported at least one injury in the past 12 months, a rate of 22.3 injuries per 100 h. Kite surfers were more likely to report an injury than PWC or TWS. One-half of injuries occurred while on the water. Most injuries were caused by landing awkwardly (56%) and/or trying new tricks (41%). Despite 90% of respondents having used at least one personal protective equipment (PPE) item, half (49%) reported always using a personal floatation device. This study provided information on KS, PWC and TWS injuries as well as a range of safety behaviours. It is recommended that these results form the basis of further research to reduce injury rates and encourage the use of PPE items.

Lesões desportivas na natação

O estudo objetivou analisar a ocorrência de lesões em nadadores, associando-as a fatores de risco específicos da modalidade e do atleta. Fizeram parte desse estudo 215 atletas, de ambos os sexos, participantes dos principais campeonatos promovidos pela Federação Aquática Paulista. Os dados foram obtidos por meio de Inquérito de Morbidade Referida, constituído por perguntas relacionadas ao atleta, modalidade e referentes ao tipo, mecanismo e local da lesão. A análise entre variáveis antropométricas e presença de lesão foi realizada pelo teste t de Student ou pelo teste não paramétrico de Mann Whitney. Para relação entre as especificidades e o tipo, mecanismo e local da lesão, utilizou-se o teste de Goodman. Resultados significantes foram obtidos entre os atletas lesionados com mais idade e anos de treinamento. Segundo o mecanismo da lesão, o volume dos treinos é a principal causa de ocorrências de lesões e as tendinopatias são as lesões mais comuns. O ombro é o local mais acometido pelas diferentes especialidades, com exceção dos nadadores de peito que referiram a virilha. Conclui-se a partir dos achados que a exposição dos nadadores a prática esportiva associada ao volume de treinamento estão relacionadas com as frequentes lesões nestes atletas.

Diving-related injuries in children <20 years old treated in emergency departments in the United States: 1990-2006

OBJECTIVE

The purpose of this work was to comprehensively examine diving-related injuries in the United States among children and adolescents <20 years of age.

METHODS

We conducted a retrospective analysis of diving-related injury data from the National Electronic Injury Surveillance System, including patients aged <20 years old who were seen in an emergency department for a diving-related injury from 1990 through 2006.

RESULTS

An estimated 111341 patients aged <or=19 years were treated in emergency departments for diving-related injuries over the 17-year period of the study. The average annual injury rate was 8.4 injuries per 100000 US residents <20 years old. Patients aged 10 to 14 years composed the largest group (36.3%) of injured divers. Injuries to the head and/or neck (38.2%) and face (21.7%) were the most common, with the most frequent diagnoses being lacerations (33.9%) and soft tissue injuries (24.3%). Collision with a diving board and/or platform was the leading cause of injuries (43.9%). Children <10 years old had increased odds of sustaining a laceration, children <5 years old had increased odds of injury to the face, and 10- to 19-year-olds had increased odds of sustaining a fracture or an injury to the extremities. The odds of injury caused by contact with the diving board dramatically increased if the child was performing a flip and/or handstand or a backward dive.

CONCLUSIONS

To our knowledge, this is the first study to examine recreational and competitive diving-related injuries among children and adolescents using a nationally representative sample. These results can help inform pediatricians, parents, coaches, and trainers regarding injuries seen during recreational and competitive diving and can help guide future prevention efforts.

Carp versus cranium: a fishy story

Issues of drowning or near drowning in aquatic sporting have received considerable attention in the literature; however, there is not a lot of attention to nonsubmersion injuries such as water tubing. Water tubing is similar to water skiing but with much less control by the rider, leaving the rider at the mercy of the driver or any obstacle in their path. This report describes unusual events surrounding the injury of a 5-year-old boy enjoying water fun with his father on his boat. The importance of adequate safety precautions during aquatic recreational activities will also be highlighted.

Risk Factors for Water Sports???Related Cervical Spine Injuries

BACKGROUND

To examine risk factors associated with water sports-related cervical spine injuries (WSCSI).

METHODS

A retrospective analysis of all patients admitted for WSCSI from 1993 to 1997 was performed. The severity of cervical spine injury was assessed by review of medical records and imaging studies. Mechanisms of injury and activities at the time of injury were noted to determine risk factors for cervical spine injuries caused by wave forced impacts (WFI) from activities such as bodysurfing and body boarding. These risks were compared with injuries incurred by shallow water dives (SWD).

RESULTS

One hundred patients were analyzed (mean age, 36 years old); 89% were male, 62% were nonresidents of Hawaii, and 75% had a large build. Patients without radiographic evidence of fractures, subluxations, and/or dislocations (n = 26) were significantly older (48 versus 32 years old, p < 0.0001) with a higher rate of pre-existing cervical spine abnormalities (65% versus 15%, p < 0.0001) compared with the remainder of patients (n = 74). Seventy-seven percent of WFI involved nonresidents. The mean age of WFI patients was significantly older than patients involved in SWD (42 versus 25 years). Ninety-six percent of wave-related accidents occurred at moderately to severely rated shorebreak beaches.

CONCLUSIONS

Wave forced impacts of the head with the ocean bottom typically occurred at moderate to severe shorebreaks, and involved inexperienced, large-build males in their 40s. Spinal stenosis and degenerative spondylosis may increase the risk of cervical spine injury associated with WFI due to the increased risk of neck hyperextension and hyperflexion impacts inherent to this activity.

Characteristics of water skiing-related and wakeboarding-related injuries treated in emergency departments in the United States, 2001-2003

BACKGROUND

Water skiing and wakeboarding are popular sports with high potential for injury due to rapid boat acceleration, lack of protective gear, and waterway obstacles. However, trends in water skiing- and wakeboarding-related injuries in the United States have not been described using national data.

HYPOTHESIS

The number of injuries, injury diagnoses, and body regions injured vary by sport.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

Data regarding water skiing- and wakeboarding-related injuries presenting to 98 hospital emergency departments in the United States between January 1, 2001, and December 31, 2003, were extracted from the National Electronic Injury Surveillance System. Data included demographics, injury diagnosis, and body region injured.

RESULTS

Data were collected for 517 individuals with water skiing-related injuries and 95 individuals with wakeboarding-related injuries. These injuries represent an estimated 23 460 water skiing- and 4810 wakeboarding-related injuries treated in US emergency departments in 2001 to 2003. Head injuries represented the largest percentage of injuries for wakeboarders (28.8% of all injuries) and the smallest percentage for water skiers (4.3%) (P < .01; relative risk [95% confidence interval], 6.73 [3.89-11.66]). Analysis of injury diagnosis was consistent as wakeboarders had significantly more traumatic brain injuries (12.5% of all injuries) than did water skiers (2.4%) (P < .05; relative risk [95% confidence interval], 5.27 [2.21-12.60]). Strains or sprains were the leading injury diagnoses for water skiing (36.3% of all injuries), and the majority (55.7%) were to the lower extremity. Lacerations were the most common diagnoses for wakeboarders (31.1% of all injuries), and the majority (59.6%) were to the face.

CONCLUSION

The analyses of water skiing- and wakeboarding-related injuries treated in US emergency departments in 2001 to 2003 highlight the differences in injury patterns for these 2 sports. The substantial number of head and facial injuries among wakeboarders underscores the need for research on the potential role of helmets or other protective gear to reduce these common injuries.

The relationship of blood alcohol concentration to impairment severity in spinal cord injury

OBJECTIVE

To investigate the relationship between blood alcohol concentration (BAC) and severity of neurological impairment.

DESIGN

Retrospective cross-sectional study.

PARTICIPANTS

Subjects with traumatic spinal cord injury (SCI; N = 119) with dates of injury between 1991 and 2000 who received their acute treatment at a midwestern Model SCI Care System and for whom information regarding BAC was available.

MAIN OUTCOME MEASURE

severity of neurological impairment. Data were analyzed using chi2 tests and analysis of variance (ANOVA).

RESULTS

A significant association was observed between impairment severity and BAC.

CONCLUSIONS

The study suggests that alcohol consumption is associated with severity of SCI. A more rigorous study controlling for trauma attributes is necessary to confirm these results and appraise whether alcohol has a potentiating effect on impairment. If borne out, the study's findings may lead to alterations in emergency room procedures and to changes in public health and education efforts resulting from a reframing of the issue of safe consumption of alcohol.

Review of the role of alcohol in drowning associated with recreational aquatic activity

OBJECTIVE AND DESIGN

To assess the role of alcohol in drowning associated with recreational aquatic activity by reviewing the English language literature published up to October 2003.

RESULTS

Alcohol is widely used in association with recreational aquatic activity in the United States, but there is minimal information regarding the extent of use elsewhere. A priori and anecdotal evidence suggests that alcohol is an important risk factor for drowning associated with recreational aquatic activity. Specific studies provide good evidence supporting this, but the extent of increased risk associated with alcohol use, and the attributable risk due to alcohol use, is not well characterised. Drowning appears to be the overwhelming cause of death associated with recreational aquatic activity with alcohol detected in the blood in 30%-70% of persons who drown while involved in this activity. The few relevant studies on degree of increased risk suggest persons with a blood alcohol level of 0.10 g/100 ml have about 10 times the risk of death associated with recreational boating compared with persons who have not been drinking, but that even small amounts of alcohol can increase this risk. The population attributable risk seems to be in the range of about 10%-30%.

CONCLUSIONS

Alcohol consumption significantly increases the likelihood of immersions resulting in drowning during aquatic activities. However, more information is required if appropriate prevention activities are to be planned, initiated, and evaluated. This includes better information on alcohol use, and attitudes to alcohol use, in association with recreational aquatic activity, and the nature and extent of increased risk associated with alcohol use. Evaluation of interventions is also needed.