Lawnmower Injuries in the United States: 1996 to 2004

The global burden of traumatic amputation in 204 countries and territories

Background

Traumatic amputation leads to disability and imposes a heavy health burden. This study aims to explore the current status and temporal trends of the global burden of traumatic amputation according to sex, age, amputation site, cause, and reginal level of social development.

Methods

The data were extracted from the Global Burden of Diseases (GBD) Study 2019. Prevalence, incidence, years lived with disability (YLDs) and corresponding age-standardized rate were compared. Estimated annual percentage change (EAPC) was applied to reflect trends in age-standardized rates over a specific period. Spearman rank test and curve fitting methods were used to analyze the relationship between disease burden and Socio-Demographic Index (SDI).

Results

Globally, the incidence and prevalence number of traumatic amputation increased from 11.37 million and 370.25 million in 1990, to 13.23 million and 552.45 million in 2019, with a raise of 16.4 and 49.2%, respectively. But the age-standardized incidence rate (ASIR) (EAPC = -0.56; 95%CI, -0.72 to -0.41) and age-standardize prevalence rate (ASPR) (EAPC = -0.63; 95%CI, -0.74 to -0.52) declined during this period. The YLDs count also increased by 39.2% globally (from 5.28 million to 7.35 million), while the age-standardize YLDs rate (ASYR) decreased by an average of 1.00% per year (95% CI, -1.10 to -0.90) from 1990 to 2019. The incidence, prevalence, and YLDs rate of traumatic amputation continue to increase with age. Traumatic amputations were most common in the fingers, while unilateral lower limb amputation caused the greatest burden of disability. ASIR and SDI were positively correlated (ρ = 0.442, p < 0.001), while ASYR and SDI were not significantly correlated (ρ = -0.030, p = 0.669), and EAPC in ASYR and SDI were negatively correlated (ρ = -0.275, p < 0.001). Exposure to mechanical forces and falls were the leading causes of traumatic amputation.

Conclusion

Despite the declining trends in ASIR, ASPR, and ASYR, the incidence, prevalence, and YLDs counts of traumatic amputation have increased significantly worldwide, especially in the older adults population. With the population aging, targeted health policies are needed to address the increasing global burden of traumatic amputations in the future.

[Case studies in expert review of electrical injury]

Electrical injury is quite rare in forensic practice, and situational examinations for this type of injury are even rarer. A case of an electrical injury is presented where the circumstances of the death and the conditions of injury were not obvious. As part of the commissioned examination, a repeated review of the accident scene and an examination of the alleged injuring object were conducted, which facilitated reconstruction of conditions and circumstances of the electric injury.

A 'Final Destination injury': Penetrating trauma of the neck and a pneumomediastinum by a metal part shot from a lawnmower

Introduction

Outside of war regions, penetrating neck injury is rare. Penetrating neck injury due to a lawnmower has never been described, despite the annual 74.000 injuries caused by lawnmowers in the United States. In this report, the case of a 65-year old women, admitted after a penetrating neck injury due to a metal piece shot from a lawnmower, is described.

Report

A 65-year old women, with no relevant medical history, presented at the Emergency Department after she was hit in the neck by an iron projectile shot from a professional lawnmower. On site, the projectile, a metal part from the lawnmower blade, was removed by her husband. CT scan showed a pneumomediastinum, without signs of vascular injury. Surgical exploration was immediately performed in the operation room (OR). No vascular or esophageal injuries werefound, only lacerated neck muscles. Perioperatively, the ENT surgeon performed an endoscopy, which showed a small injury of the hypopharynx. Postoperatively, the patient was prophylactically treated with antibiotics for 7 days. Patient was discharged in good clinical condition after 7 days, without complications.

Conclusion

In this report we present a case with a sharp traumatic injury of the neck, caused by a metal projectile shot from a lawnmower. The laceration of the pharynx was explored in the OR by the ENT- and vascular surgeon. The pneumomediastinum was treated with prophylactic antibiotics. Currently the patient is doing fine without any complications of the injury. Traumatic injury of the neck requires direct direct surgical exploration, however, when patients present hemodynamically stable, a neck CTA will add to the diagnosis (e.g. a pneumomediastium).

Penetrating pulmonary injury due to a thrown rusty nail while using a lawn mower: a case report

Accidents while using lawn mowers are often reported, but chest injuries are rare. We report a case of a penetrating pulmonary injury due to a rusty nail thrown by a lawn mower. A 63-year-old man injured his left precordium by a thrown object while using a lawn mower; he thereafter visited a nearby hospital. A computed tomography image showed a left-sided pneumothorax and a penetrating pulmonary injury of the left upper lobe due to a foreign body. Pneumothorax was treated with thoracic drainage and resolved. He was transferred to our hospital on the second day after the injury, and video-assisted thoracoscopic surgery was performed to remove the foreign body. Surgical findings showed a penetrating wound in the left upper lobe and leakage of pus from its margin. The foreign body was a rusty nail. The penetrating wound was treated by partial pulmonary resection to control the infection. Histopathological findings revealed the formation of a lung abscess. Penetrating pulmonary injuries do not require surgical treatment for most patients. However, residual foreign bodies can cause lung abscesses. The removal of foreign bodies depends on the type of injury as well as the type and location of the foreign body. Theoretically, the foreign body should be removed and the penetrating pulmonary injury should be treated, if possible, to control infection.

Lawnmower Injuries in Children: A National 13-Year Study of Urban Versus Rural Injuries

INTRODUCTION

Although the American Academy of Orthopaedic Surgery, American Academy of Pediatrics, and Pediatric Orthopedic Society of North America have established lawnmower safety guidelines, a notable number of injuries continue to occur. We sought to elaborate on the epidemiology of lawnmower injuries in the pediatric age group and compare urban versus rural injuries.

METHODS

The Pediatric Health Information System database was queried for patients of 1 to 18 years of age from 2005 to 2017 who presented with a lawnmower injury. Results were computed using bivariate tests and multinomial regressions.

RESULTS

A total of 1,302 lawnmower injuries were identified (mean age 7.7 ± 5.1 years, range 1 to 18 years; 78.9% males). Incidence rates by region, adjusted for regional case volume, were 2.16 injuries per 100,000 cases in the South, 2.70 injuries per 100,000 cases in the Midwest, 1.34 injuries per 100,000 cases in the Northeast, and 0.56 injuries per 100,000 cases in the Western United States. After stratifying and adjusting for total case volume by locale (urban/rural), it was found that urban areas had an incidence rate of 1.47 injuries per 100,000 cases, whereas rural areas had a rate of 7.26 injuries per 100,000 cases. Rural areas had higher rates of infection and higher percentages of patients requiring inpatient stay. The surgical complication rate in rural areas was 5.5% as compared to 2.6% in urban areas. Based on urban/rural status, a significant difference was observed with the age group, length of stay, income, surgical complication, and presence of infection at the bivariate level with P < 0.05. Rural areas had an overall amputation rate of 15.5% compared with 9.6% in urban areas, with rural patients being 1.7 times more likely to undergo an amputation (P < 0.05).

CONCLUSION

The findings of this study show that numerous geographic and locale disparities exist in pediatric lawnmower injuries and reveal the need for improved safety awareness, especially in at-risk rural populations.

Pediatric Lawnmower Injuries and Strategies for Prevention: A Systematic Review

BACKGROUND

Lawnmower injuries remain a preventable cause of serious morbidity and even mortality in children. We aimed to characterize lawnmower injuries in children and to describe reported mechanisms through a review of the literature to better understand these injuries and their prevention.

METHODS

The Embase and MEDLINE databases were queried for studies pertaining to pediatric lawnmower injuries, along with manual searching of references of included studies and Google Scholar searches. Reviews and case reports were excluded. Studies relating to lawnmower injuries were broadly included to ensure capture of the relevant studies. Studies with both adult and pediatric data were included if pediatric data were granular and available for separate analysis.

RESULTS

Thirteen studies met inclusion criteria: 8 single-center series and 5 national database studies. Age of injury was bimodal with peak frequencies at ages 3 and 16 years. National studies estimated a mean of 11.2 injuries per 100,000 children, with 5% to 8% of patients hospitalized. Analysis of both single-center series and national database studies revealed 3 major mechanisms of injury: blade injuries, projectile injuries, and burn injuries. Blade injuries resulted in higher morbidity, with a greater need for operative management, amputation, and longer length of hospitalization. Similarly, rider mowers posed a greater injury risk than push mowers.

CONCLUSIONS

This systematic review of lawnmower injuries in children identified patterns and mechanisms of injuries across the literature that may serve to educate parents, policy-makers, and health-care providers as well as provide data to develop and improve prevention strategies.

Patients admitted for treatment of traumatic finger amputations: Characteristics, causes, and prevention

BACKGROUND

The aim of this study was to analyze the epidemiology of patients admitted with finger amputations in the U.S., as well as to evaluate and propose prevention strategies.

METHODS

The National Electronic Injury Surveillance System was queried to obtain data on patients that presented to, and were admitted from US emergency departments for treatment of traumatic finger amputations during the period of 2002-2016. The Haddon Matrix, a framework that can be used to analyze the host, agent, and environmental factors of an injury relative to its timing, was then used to evaluate possible contributing factors of amputation events, and thereby explore plausible prevention interventions.

RESULTS

From 2002 to 2016, approximately 348,719 people were admitted from the ED for traumatic amputations. The majority were Caucasian and were male. The mean age was 42.3 years old. This was significantly older than those who were not admitted. The top five products responsible for amputations in admitted patients were power saws (40.9% of cases), doors (10.3%), lawn mowers (7.4%), snow blowers (4.3%), and bicycles (2.4%). This list included a higher proportion of powered tools than those with finger amputations who were discharged from the ED with a finger amputation.

CONCLUSION

Patients admitted with finger amputations from the ED were older, more likely to be male, and more likely to be victims of powered tools than those that were discharged. Table saws are responsible for a high proportion of the finger amputations that result in hospital admissions. The Haddon Matrix helps us identify factors (host, agent, physical environment, and social environment) to be addressed in prevention strategies. Such approaches might include championing education campaigns, policy measures, and equipment safety features. The effectiveness of such strategies warrants further investigation.

Characteristics of accidental injuries from power tools treated at two emergency departments in Queensland

OBJECTIVE

Injuries are a major burden on the Australian healthcare system. Power tool usage is a common cause of accidental injury. A better understanding of the trends of power tool injuries will inform prevention strategies and potentially mitigate costs.

METHODS

The ED databases from two level 1 hospitals were reviewed for presentations between 2005 and 2015 resulting from accidental injury with power tools. A subgroup of patients presenting to one hospital between 2016 and 2017 were interviewed about the activities and circumstances that led to their injuries, and followed up 3 months later to assess outcomes.

RESULTS

A total of 4057 cases of accidental injury from power tool use were identified. Power saws and grinders contributed to 54% of injuries. Most injuries were located on an upper limb (48%) or the head and neck (30%). Over half (54%) of all head injuries were associated with metal and wood fragments to the eye from grinders, drills and saws. Hospital admission rates were highest for patients aged >60 years. Injuries to females were <5% of all presentations, but 40% of those caused by lawnmowers. Among the 200 patients interviewed, lapses in concentration during use, and modification and inappropriate use of a power tool were the main contributors to injury. Recovery periods >3 months were common.

CONCLUSIONS

Accidental injuries from power tool use have a considerable impact on ED resources and can affect the long-term quality of life of those injured. Effective education about safe usage and protection may prevent many injuries.

Pediatric Lawn-Mower Injuries Presenting at a Level-I Trauma Center, 1995 to 2015: A Danger to Our Youngest Children

BACKGROUND

Unintentional injuries are the leading cause of morbidity and mortality among children 0 to 18 years of age in the U.S. An estimated 9,400 to 17,000 pediatric lawn-mower injuries occur each year. The aims of this study were to better define the epidemiology of lawn-mower injuries and to identify predictors of severe lawn-mower injuries to optimize public education and injury prevention.

METHODS

All patients 0 to 18 years of age who presented to Children's Mercy Hospital (CMH), Kansas City, Missouri, during the period of 1995 to 2015 after sustaining a lawn-mower injury were identified using International Classification of Diseases, 9th Revision (ICD-9) codes. Demographic information and data regarding primary outcome measures (death, amputation, need for prosthesis, Injury Severity Score [ISS]) and secondary outcome measures were collected. Bivariate and multivariate analyses were used to identify risk factors for severe lawn-mower injuries.

RESULTS

One hundred and fifty-seven patients were identified, with a bimodal age distribution peaking at 4 and 15 years of age. Seventy-five percent of the subjects were male. Sixty-six percent of the patients were admitted to the hospital, with a mean length of stay of 6 days. An average of 3 operations were performed. Nineteen percent of the patients lived in a nonmetro/rural location. Lower-extremity injuries were most prevalent, affecting 84% of the patients. Forty percent of the patients experienced at least 1 traumatic amputation. Thirteen percent of the patients required a prosthesis after the injury. The average ISS was 8. Significant predictors of a higher ISS included an age of 0 to 9 years, a riding lawn mower, a grandparent operator, and a nonmetro/rural location. Younger children were more likely to be injured from a riding lawn mower, be the passenger of the mower or a bystander, be injured with a grandparent operator, and live in a nonmetro/rural location. Younger children also had a higher ISS and amputation rate, longer LOS, and more surgical procedures.

CONCLUSIONS

Education to protect younger patients should target parent, grandparent, and older sibling operators. Education for the older, teenage group should include safe mowing techniques. Efforts should also target nonmetro/rural populations and grandparents, specifically highlighting the severe dangers of riding lawn mowers when young children are passengers or bystanders.

LEVEL OF EVIDENCE

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

Establishment of an in vivo turkey model for the study of flexor tendon repair

Flexor tendon injuries are common and pose a clinical challenge for functional restoration. The purpose of our study was to assess the adequacy of the turkey as a large animal model for flexor tendon injuries in vivo. Twenty-four male turkeys underwent surgical flexor tendon cut and repair. Turkeys were allocated to five groups postoperatively: (1) foot casted in extension and sacrificed after 3 weeks; (2) foot casted in extension and sacrificed after 6 weeks; (3) foot casted in flexion and sacrificed after 3 weeks; (4) foot casted in flexion and sacrificed after 6 weeks; and (5) foot casted in flexion for 6 weeks and then free roaming allowed for an additional 3 weeks before sacrifice. After sacrifice, digits were collected and analyzed for adhesion formation, healing at the macrolevel and histologically, and biomechanical properties-including friction, work of flexion, stiffness, and strength of repair. All turkeys survived anesthesia and surgery. Tendon rupture occurred in all extension casts and in 11% of those casted in flexion. Friction and work of flexion were significantly higher in the repaired digit than the control digit. There was a correlation between duration of immobilization and repair strength. Histologically, the tendon healed with tenocytes migrating into the gap and producing collagen fibers. We have, for the first time, studied flexor tendon injury and repair using turkeys in terms of anesthesia, surgical procedures, postoperative care, and animal husbandry. The findings regarding functional and histological results from this novel avian model were comparable to the most commonly used mammal model. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2497-2505, 2018.

Incidence, Distribution, and Cost of Lawn-Mower Injuries in the United States, 2006-2013

OBJECTIVES

Characterization of the epidemiology and cost of lawn-mower injuries is potentially useful to inform injury prevention and health policy efforts. We examined the incidence, distribution, types and severity, and emergency department (ED) and hospitalization charges of lawn-mower injuries among all age groups across the United States.

METHODS

This retrospective, cross-sectional study used nationally representative, population-based (all-payer) data from the US Nationwide Emergency Department Sample for lawn-mower-related ED visits and hospitalizations from January 1, 2006, through December 31, 2013. Lawn-mower injuries were identified by using International Classification of Diseases, Ninth Revision, Clinical Modification code E920 (accidents caused by a powered lawn mower). We analyzed data on demographic characteristics, age, geographic distribution, type of injury, injury severity, and hospital charges.

RESULTS

We calculated a weighted estimate of 51 151 lawn-mower injuries during the 8-year study period. The most common types of injuries were lacerations (n = 23 907, 46.7%), fractures (n = 11 433, 22.4%), and amputations (n = 11 013, 21.5%). The most common injury locations were wrist or hand (n = 33 477, 65.4%) and foot or toe (n = 10 122, 19.8%). Mean ED charges were $2482 per patient, and mean inpatient charges were $36 987 per patient. The most common procedures performed were wound irrigation or debridement (n = 1436, 29.9%) and amputation (n = 1230, 25.6%).

CONCLUSIONS

Lawn-mower injuries occurred at a constant rate during the study period. Changes to nationwide industry safety standards are needed to reduce the frequency and severity of these preventable injuries.

Occult lawn mower projectile injury presenting with hemoptysis

We present the case of a 72-year-old man with hemoptysis after a thoracic projectile injury, which occurred while mowing the lawn. Chest radiograph followed by a computed tomography angiogram revealed a metallic foreign body in the right middle lobe of the lung. The patient underwent a right anterolateral thoracotomy where the object was successfully retrieved. The patient had an uneventful postoperative recovery.

Pediatric Lower Extremity Lawn Mower Injuries and Reconstruction: Retrospective 10-Year Review at a Level 1 Trauma Center

INTRODUCTION

From 2004 to 2013, there were 9341 lawn mower injuries in children under 20 years old. The incidence of lawn mower injuries in children has not decreased since 1990 despite implementation of various different prevention strategies. In this report, the authors review the results of pediatric lawn mower-related lower-extremity injuries treated at a tertiary care referral center as well as review the overall literature.

METHODS

A retrospective review was performed at a level 1 trauma center over a 10-year period (2005-2015). Patients younger than 18 years who presented to the emergency room with lower extremity lawn mower injuries were included.

RESULTS

Of the 27 patients with lower-extremity lawn mower injuries during this period, the mean age at injury was 5.5 years and Injury Severity Score was 7.2. Most (85%) patients were boys and the predominant type of mower causing injury was a riding lawn mower (96%). Injury occurred in patients who were bystanders in 78%, passengers in 11%, and operators in 11%. Mean length of stay was 12.2 days, and mean time to reconstruction was 7.9 days. Mean number of surgical procedures per patient was 4.1. Amputations occurred in 15 (56%) cases with the most common level of amputation being distal to the metatarsophalangeal joint (67%). Reconstructive procedures ranged from direct closure (41%) to free tissue transfer (7%). Major complications included infection (7%), wound dehiscence (11%), and delayed wound healing (15%). Mean follow up was 23.6 months and 100% of the patients were ambulatory after injury. The subgroup of patients with the most severe injuries, highest number of amputations, and need for overall surgical procedures were patients aged 2 to 5 years. A review of the literature also showed consistent findings.

CONCLUSIONS

This study demonstrates the danger and morbidity that lawn mowers present to the pediatric population, particularly children aged 2 to 5 years. Every rung of the so-called reconstructive ladder is used in caring for these children. Increased public awareness is insufficient to decrease the incidence of these injuries. These products should have additional warning labels and meet updated changes to the design of lawn mowers to prevent these mutilating injuries successfully.

Turkey model for flexor tendon research: in vitro comparison of human, canine, turkey, and chicken tendons

BACKGROUND

Flexor tendon injuries are one of the most common hand injuries and remain clinically challenging for functional restoration. Canine and chicken have been the most commonly used animal models for flexor tendon-related research but possess several disadvantages. The purpose of this study was to explore a potential turkey model for flexor tendon research.

METHODS

The third digit from human cadaveric hands, canine forepaws, turkey foot, and chicken foot were used for this study. Six digits in each of four species were studied in detail, comparing anatomy of the flexor apparatus, joint range of motioņ tendon excursion, tendon cross-sectional area, work of flexion, gliding resistance at the level of the A2 pulley, modulus of elasticity, suture retention strength, and histology across species.

RESULTS

Anatomically, the third digit in the four species displayed structural similarities; however, the tendon cross-sectional area of the turkey and human were similar and larger than canine and chicken. Furthermore, the turkey digit resembles the human's finger with the lack of webbing between digits, similar vascularization, tendon excursion, work of flexion, gliding resistance, mechanical properties, and suture holding strength. More importantly, human and turkey tendons were most similar in histological appearance.

CONCLUSIONS

Turkey flexor tendons have many properties that are comparable to human flexor tendons which would provide a clinically relevant, economical, nonhuman companion large animal model for flexor tendon research.

Children treated for lawn mower-related injuries in US emergency departments, 1990-2014

OBJECTIVE

Investigate the epidemiology of lawn mower-related injuries to children in the US.

METHODS

A retrospective analysis was conducted of children younger than 18years of age treated in US emergency departments for a lawn mower-related injury from 1990 through 2014 using data from the National Electronic Injury Surveillance System.

RESULTS

An estimated 212,258 children <18years of age received emergency treatment for lawn mower-related injuries from 1990 through 2014, equaling an average annual rate of 11.9 injuries per 100,000 US children. The annual injury rate decreased by 59.9% during the 25-year study period. The leading diagnosis was a laceration (38.5%) and the most common body region injured was the hand/finger (30.7%). Struck by (21.2%), cut by (19.9%), and contact with a hot surface (14.1%) were the leading mechanisms of injury. Patients <5years old were more likely (RR 7.01; 95% CI: 5.69-8.64) to be injured from contact with a hot surface than older patients. A projectile was associated with 49.8% of all injuries among patients injured as bystanders. Patients injured as passengers or bystanders were more likely (RR 3.77; 95% CI: 2.74-5.19) to be admitted to the hospital than lawnmower operators.

CONCLUSIONS

Lawn mower-related injuries continue to be a cause of serious morbidity among children. Although the annual injury rate decreased significantly over the study period, the number of injuries is still substantial, indicating the need for additional prevention efforts. In addition to educational approaches, opportunities exist for improvements in mower design and lawn mower safety standards.

Surface Modification with Chemically Modified Synovial Fluid for Flexor Tendon Reconstruction in a Canine Model in Vivo

BACKGROUND

Functional restoration is the major concern after flexor tendon reconstruction in the hand. The purpose of the present study was to investigate the effects of modifying the surface of extrasynovial tendon autografts with carbodiimide-derivatized synovial fluid with gelatin (cd-SF-G) on functional outcomes of flexor tendon reconstruction using a canine model.

METHODS

The second and fifth flexor digitorum profundus tendons from eleven dogs were transected and repaired in zone II. The dogs then had six weeks of free activity leading to tendon rupture and scar formation (the repair-failure phase). In the reconstruction phase, two autologous peroneus longus tendons from each dog were harvested; one tendon was coated with cd-SF-G and the other, with saline solution, as a control. A non-weight-bearing rehabilitation protocol was followed for six weeks after reconstruction. The digits were then harvested and evaluations of function, adhesion status, gliding resistance, attachment strength, cell viability, and histology were performed.

RESULTS

The tendons coated with cd-SF-G demonstrated significantly lower values (mean and standard deviation) compared with the saline-solution group for work of flexion (0.63 ± 0.24 versus 1.34 ± 0.42 N-mm/deg), adhesion score (3.5 ± 1.6 versus 6.1 ± 1.3), proximal adhesion breaking force (8.6 ± 3.2 versus 20.2 ± 10.2 N), and gliding resistance (0.26 ± 0.08 versus 0.46 ± 0.22 N) (p < 0.05). There was no significant difference between the cd-SF-G and saline-solution groups (p > 0.05) in distal attachment-site strength (56.9 ± 28.4 versus 77.2 ± 36.2 N), stiffness (19 ± 7.5 versus 24.5 ± 14.5 N/mm), and compressive modulus from indentation testing (4.37 ± 1.26 versus 3.98 ± 1.24 N/mm). Histological analysis showed that tendons coated with cd-SF-G had smoother surfaces and demonstrated tendon-to-bone and tendon-to-tendon incorporation. No significant difference in viable cell count between the two groups was observed on tendon culture.

CONCLUSIONS

Modification of the flexor tendon surface with cd-SF-G significantly improved digital function and reduced adhesion formation without affecting graft healing and stiffness.

CLINICAL RELEVANCE

This study used native synovial fluid as a basic lubricating reagent to treat a tendon graft in vivo, a novel avenue for improving clinical outcomes of flexor tendon reconstruction. This methodology may also apply to other surgical procedures where postoperative adhesions impair function.

Lawn mower injuries to the lower extremity: a 10-year retrospective review

INTRODUCTION

Lawn mower injuries occur frequently in the United States and oftentimes result in extensive trauma to the lower extremities. These injuries can be quite devastating and cause there to be loss of function and amputation. The purpose of this study was to determine if there are specific factors that would help determine the best treatment protocol, patient outcomes, and prognosis after lawn mower injury to the foot and ankle.

MATERIAL AND METHODS

A retrospective review of medical records was performed on all patients treated at a university level 1 trauma center from 2000 to 2010. Only subjects 18 years or older who sustained an injury below the level of the knee were included for review.

RESULTS

Seventy-three patients were included in this review. The results revealed that patients who developed a complication were significantly older than the group of patients without complications (P = .03). Digits were found to be injured most often but the odds of developing a complication were much higher if these injuries involved the plantar foot, dorsal foot, or ankle. Interestingly, patients on prolonged antibiotic therapy had a significantly higher risk of developing complications. The presence of comorbidities significantly increased the risk of complication (P = .008); the greatest risk factors were cardiovascular disease (P = .001) and diabetes (P = .06).

DISCUSSION

The authors present the largest cohort of lawn mower injuries in the medical literature, which demonstrates that factors such as age, location of injury, and the presence of comorbidities influence the outcome and increase the risk of injury to the foot and ankle. These results may be useful in determining the best treatment plan possible for patients with these severe injuries.

LEVELS OF EVIDENCE

Therapeutic, Level IV, Retrospective case series.

The spectrum of open fractures of the foot in adults

BACKGROUND

Open foot fractures are rare, and few surgeons see the whole spectrum of these injuries. There has been no previous study of the epidemiology and severity of open foot fractures.

METHODS

A 23-year study of the epidemiology of open fractures was undertaken in a hospital with a catchment area of about 530 000 adults. The results were used to calculate the incidences of open foot fractures and to study their epidemiology and severity.

RESULTS

In 23 years, 348 open foot fractures were treated. Analysis showed 3 levels of severity with the least severe fractures being isolated open forefoot fractures, which occurred in 69% of the patients. Patients with multiple forefoot fractures had a higher Injury Severity Score (ISS), prevalence of Gustilo type III fractures, and amputation rate. The most severely injured patients presented with open hindfoot and midfoot fractures. They had an average ISS of 12, and 65.9% had Gustilo type III fractures. In patients with open hindfoot fractures, the amputation rate was 17.1%. This rose to 30% in patients with open midfoot fractures. Open foot fractures tended to occur in younger patients, and only 13% were in patients aged at least 65 years.

CONCLUSIONS

Open foot fractures are uncommon. There were 3 levels of injury. Level 1 injuries were isolated fractures of the forefoot. Level 2 injuries were multiple forefoot fractures, and level 3 injuries were open fractures of the midfoot and hindfoot. These were severe injuries with a high amputation rate. They should be treated in level 1 trauma centers.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

The epidemiology of lawn trimmer injuries in the United States: 2000-2009

INTRODUCTION

Yard maintenance equipment is potentially dangerous, and some of the more frequency used equipment (e.g., lawn mowers) has been extensively studied. However, the extent of lawn trimmers as a source of injury has not previously been explored.

METHODS

Data from the Consumer Product Safety Commission's National Electronic Injury Surveillance System were used to estimate the number of patients treated in U.S. emergency departments for lawn trimmer-related injuries. Injury rates were calculated according to age, sex, and race, and characteristics of the injury event were determined.

RESULTS

An estimated 81,907 injuries involving a lawn trimmer occurred from 2000-2009. The incidence generally increased over time. Men, people aged 40-49, and Caucasians were the groups most likely to be injured. The most commonly injured body part was the head, specifically the eye, accounting for 42.5% of the injuries. Contusions and abrasions were the most common type of injury to the head, but lacerations were the most common injury to the extremities, and strains/sprains were the most common injury to the trunk.

DISCUSSION

Although previous research on lawn trimmers has focused exclusively on injuries to the eyes, the results of the current study show that such injuries are one component of the problem. Because most of the injuries were due to foreign objects, it is important that the use of adequate safety gear be emphasized when operating lawn trimmers.

IMPACT ON INDUSTRY

Results suggest that lawn trimmer design changes and better safety education for trimmer use can reduce the rate of injury and reverse the current trend.

Pediatric lower extremity mower injuries

Lawn mower injuries in children represent an unfortunate common problem to the plastic reconstructive surgeon. There are approximately 68,000 per year reported in the United States. Compounding this problem is the fact that a standard treatment algorithm does not exist. This study follows a series of 7 pediatric patients treated for lower extremity mower injuries by a single plastic surgeon. The extent of soft tissue injury varied. All patients were treated with negative pressure wound therapy as a bridge to definitive closure. Of the 7 patients, 4 required skin grafts, 1 required primary closure, 1 underwent a lower extremity amputation secondary to wounds, and 1 was repaired using a cross-leg flap. Function limitations were minimal for all of our patients after reconstruction. Our basic treatment algorithm is presented with initial debridement followed by the simplest method possible for wound closure using negative pressure wound therapy, if necessary.

Improvement of flexor tendon reconstruction with carbodiimide-derivatized hyaluronic acid and gelatin-modified intrasynovial allografts: study of a primary repair failure model

BACKGROUND

Tendon grafts play an important role in flexor tendon reconstruction. This study was an investigation of the effects of surface modification of allograft intrasynovial tendons with carbodiimide-derivatized hyaluronic acid and gelatin in an in vivo canine model. To mimic the actual clinical situation, a novel and clinically relevant model of a failed primary flexor tendon repair was used to evaluate the flexor tendon grafts.

METHODS

Twenty-eight flexor digitorum profundus tendons from the second and fifth digits of fourteen dogs were lacerated and repaired in zone II in a first-surgery phase. The dogs were allowed free active motion postoperatively. In a second phase, six weeks later, the tendons were reconstructed with use of a flexor digitorum profundus allograft. In each dog, one graft was treated with carbodiimide-derivatized hyaluronic acid and gelatin (the CHG group) and the other was treated with saline solution, as a control. The dogs were restricted from free active motion, but daily therapy was performed beginning on postoperative day 5 and continued until six weeks after the operation, when the animals were killed. The outcomes were evaluated on the basis of digit work of flexion, gliding resistance, healing at the distal attachment, graft cell viability, histological findings, and findings on scanning electron microscopy.

RESULTS

In the first phase, all twenty-eight repaired tendons ruptured, with scar and adhesion formation in the repair site. Six weeks after allograft reconstruction, the mean work of flexion was 0.37 and 0.94 N-mm/degree in the CHG group and the saline-solution control group, respectively; these values were significantly different (p < 0.05). The gliding resistance in the CHG group was also significantly less than that in the saline-solution control group (0.18 versus 0.28 N) (p < 0.05), but no difference between groups was observed with regard to the distal tendon-bone pullout strength. Histological analysis showed that tenocytes in the host tendon proliferated and migrated toward the acellular allograft.

CONCLUSIONS

This primary repair failure model was reproducible and reliable, with a uniform failure pattern, and provides an appropriate and clinically relevant animal model with which to study flexor tendon reconstruction. The surface modification of allografts with carbodiimide-derivatized hyaluronic acid and gelatin improved digital function and tendon gliding ability.

Injuries associated with the use of riding mowers in the United States, 2002-2007

CONTEXT

To examine injuries among patients treated in an emergency department (ED) related to the use of a riding lawn mower.

DESIGN AND SETTING

Data were obtained from the National Electronic Injury Surveillance System for the years 2002-2007. National estimates of ED visits for injuries associated with the use of a riding lawn mower were analyzed. Narrative text entries were categorized to provide a detailed record of the circumstances precipitating the injury. Average annual rates were calculated and logistic regression analyses were employed to determine risk estimates for patient disposition and demographic characteristics related to ED visits for injuries associated with riding mowers.

RESULTS

From 2002 through 2007, there were an estimated 66,341 ED visits for injuries related to the use of riding lawnmowers in the U.S., with an average annual rate of 6.0 ED visits per 100,000 males, and 1.6 ED visits per 100,000 females. Older adults had higher rates of ED visits for injuries (7.2/100,000) than younger age groups. The most common injuries involved contusions (24%); sprains/strains (22%) and fractures (17%). The majority of patients (90%) were treated and released the same day. Results of logistic regression analyses revealed that older adults were more likely to be hospitalized when compared to younger age groups; and incidents involving rollovers [OR=5.45 (95% CI=3.22-9.23)] and being run over [6.01 (95% CI 3.23-11.17)] were more likely to result in hospitalization when compared to all other circumstances of injury.

CONCLUSIONS

Riding mowers present injury patterns and circumstances that are different than those reported for push mowers. Circumstances related to injuries and age groups affected were varied, making prevention of riding mower injuries challenging. APPLICATION/IMPACT: Findings support the need to increase awareness and/or change the design of riding mowers with respect to risk of rollover injuries.

Infections following lawnmower and farm machinery-related injuries in children

AIMS

Because of the paucity of previous data, we report the organisms causing infection in children with injuries from lawnmowers and farm machinery.

METHODS

Retrospective study of children admitted to the Children's Hospital at Westmead for lawnmower and farm machinery-related injuries from 1998 to 2007.

RESULTS

Twenty-four patients were admitted for lawnmower-related injuries. They had a bimodal age distribution, with peaks at 2-4 years and 14 years. Twenty-one (87.5%) were boys. Positive wound cultures were obtained in 16.7% and included Gram-positive and Gram-negative organisms. Eight patients were admitted for farm machinery-related injuries. Two patients (25%) returned positive wound cultures with multiple organisms including bacteria, fungi and mycobacteria and were diagnosed with osteomyelitis caused by Stenotrophomonas maltophilia and Scedosporium prolificans, respectively.

CONCLUSION

The rate of infection in our small series of children with lawnmower and farm machinery-related injuries was comparable to previous reports. We found a wide range of causative organisms, often inherently antibiotic resistant, and we add a case of invasive fungal infection to previous case reports. Because of the wide range of organisms, empirical antibiotic therapy is difficult and our data emphasise the need for cultures to direct ongoing therapy.

Lawn mower-related projectile injury

Lawn mower injuries are a potentially devastating, yet preventable cause of morbidity and mortality in the pediatric population. The sequelae to these injuries can become even worse if the initial presentation goes unsuspected by medical staff, leading to a delay in treatment. The authors report the case of a lawn mower-related penetrating missile injury, where the extent of injury was not appreciated by the patient until signs and symptoms of a soft-tissue infection developed, prompting the patient to seek medical attention the next day.