Paediatric horse-related trauma

CNS and Thorax Injury and Associated Risks Factors in Equestrian Sports

CONTEXT

Equestrian sports continue to gain popularity in the United States and are associated with a high injury rate, especially involving the central nervous system and thorax. Due to this high rate of injury and the potential for long-term consequences associated with participation, an understanding of the unique risks of this sport is needed.

OBJECTIVE

To describe severe injury in equestrian sports and review the role that protective gear plays in injury mitigation.

DATA SOURCES

The PubMed Database was searched using the search terms "equestrian" and "horse" combined with "spinal cord injury," "head injury," "traumatic brain injury," "experience levels," and "demographics."

STUDY SELECTION

A total of 53 papers were selected based on their relevance of epidemiology, risk factors, and management of injuries sustained during equestrian activities. Case studies, randomized controlled trials, prospective studies, and retrospective studies were all included for further review.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

None.

RESULTS

Injuries to the thorax, including fractures, pneumothoraces, internal organ contusions, and crush injuries, have been cited in multiple national and international trauma registries as the most prevalent injury location in equestrians; however, head and neck injuries, high cervical spine fractures, and closed head injuries are reported to be associated with the highest rates of mortality. Helmets provide protection against skull fracture and traumatic brain injury. Vests were not associated with diminished rates of spinal cord injuries; however, they may provide protection to the thorax. Riding experience also plays a role in reducing the prevalence of injury.

CONCLUSION

Equestrian-related activities are associated with a high risk of injury despite protective measures. Protective gear can mitigate some injury risk but does not protect against spinal injury. Continued investigation into improving protective equipment, rider education, and preventative strategies to mitigate this risk is needed.

Horse-riding hazards: an observational cohort study mapping equestrian related injuries at a Scandinavian trauma centre

INTRODUCTION

Horse-riding is practiced on a regular basis by 500,000 people in Sweden. It is reputed to be one of the most dangerous sports. On average, there were 1756 acute injuries and three fatalities each year between 1997 and 2014 in Sweden related to horses. The primary aim of this study was to outline the injury spectrum related to equestrian activities cared for at a large Swedish trauma centre. The secondary aim was to identify trends in clinical outcomes and to investigate the association between age and such outcomes.

MATERIAL AND METHODS

The electronic medical records system at Karolinska University Hospital was queried for patients cared for due to equestrian related trauma between July 2010 and July 2020. Complementary data were gathered using the hospital's Trauma Registry. No exclusion criteria were applied. Descriptive statistics were used to outline the injury spectrum. Age was split into four categories which were compared using the Kruskal-Wallis H test or the Chi-squared test. Logistic regression was used to analyse correlations between age and outcomes.

RESULTS

A total of 3036 patients were included with 3325 injuries identified as equestrian related. The hospital admission rate was 24.9%. The cohort had one death. Regression analysis showed significant associations between decreasing risk of upper extremity injury (p < 0.001), increasing risk of vertebral fractures (p = 0.001) and increasing risk of thoracic injury (p < 0.001) with increasing age.

CONCLUSIONS

Equestrian activities are not without risks. The morbidity is high, and injuries are taken seriously by the medical profession, reflected by the high admission rate. There are age-related variations in the injury spectrum. Older age appears to predispose to vertebral fractures and thoracic injuries. Other factors than age appear more important in determining the need for surgery or admission to ICU.

Horse and Cattle-Related Trauma: A Retrospective Review of Injuries and Management in a Regional Queensland Hospital

BACKGROUND

Horse and cattle-related trauma is a common presentation to regional hospitals in Australia. We review local incidence and patterns of injuries relating to horse and cattle trauma over a three-year period at the Toowoomba Base Hospital within the Darling Downs region in Queensland, an area rich in cattle farming and equestrian recreation.

METHODS

We conducted a single-centre retrospective cohort study. The inclusion criteria were all patients presenting with injuries following cattle or horse-related incidents between January 2018 and April 2021. Primary outcomes were the mechanism of trauma, confirmed injuries, and the need for admission, operative intervention, or inter-hospital transfer.

RESULTS

A total of 1002 individuals (55% female; mean age 34 years; median Injury Severity Score (ISS) 2) were identified during the study period. Presentations relating to horses (81%) were more frequent than cattle (19%). The most common mechanism of injury was "falling" for horse incidents (68%) and "trampling" for cattle incidents (40%). Horse incidents often resulted in soft tissue injury (55%), upper limb fracture (19%), or lower limb fracture (9%). Cattle incidents often resulted in soft tissue injury (57%), upper limb fracture (15%), and rib fracture (15%). Overall, 14% required admission, 13% required operative intervention, and 1% required inter-hospital transfer.

CONCLUSIONS

This local series demonstrates a high volume of cattle and horse-related trauma in our region. Whilst most patients are managed locally without operative intervention, the high frequency of injuries observed necessitates further development of preventative measures and safety advocacy.

Incidence of concussions and helmet use in equestrians

OBJECTIVES

Equestrians have a high risk of concussions per hospital records. However, most concussions occur in private settings where concussions are not tracked. We determined concussion incidence by self-report, expressed per 1000 h of exposure, and determined helmet usage and concussion knowledge.

DESIGN

Descriptive epidemiological study.

METHODS

Equestrians were recruited using a snowball method of sampling in which enrolled participants recruited more equestrians. Participants completed a survey of equestrian experience and history of concussion, symptoms and provided estimates of hours spent in various equestrian activities. From these data, incidences of concussions were calculated. In addition, they answered questions regarding helmet usage and willingness to take risks when concussed.

RESULTS

210 participants (203 women) reported 27 ± 14 years of equine experience and 728 concussions, 3.47 ± 5.34 per person (0-55). Incidence while riding was 0.19/1000 h which was greater than the incidence while driving (0.02/1000 h) or handling horses (0.03/1000 h). Riders were helmeted at the time of injury 85% of the time. While concussion knowledge was high, most reported willingness to risk permanent injury by continuing to work with horses while injured.

CONCLUSIONS

To our knowledge this is the first study to document incidence of concussions in equestrians: incidence is higher while riding than during football or rugby training. Helmets were far more commonly worn at the time of concussion than reported in hospital data, suggesting that helmets effectively reduce concussions severe enough to warrant urgent medical care.

Patterns of injury following equine trauma: a non-trauma centre experience

INTRODUCTION

Horse riding carries risk of injury which can result in fatality. The majority of published literature describes major trauma centre experience. We aimed to characterise injury patterns following equine trauma at a Scottish district general hospital.

METHODS

A retrospective review of admissions following equine trauma was undertaken from 2014 to 2019. Mechanism and nature of injuries were noted. Patient management and outcomes were recorded and analysed to determine correlation.

RESULTS

Of the 162 patients identified, 121 (74.7 per cent) were female. The commonest mechanism and injury sustained were falling from a horse (86.4 per cent) and head injury (17.9 per cent) respectively. Forty-four (27.2 per cent) had multiple injuries identified. Being crushed or kicked resulted in more abdominal visceral injuries (22.7 vs 0.7 per cent, p = <0.05) and ITU admissions (18.2 vs 6.4 per cent, p = 0.06) when compared with falling from alone. Eight (4.9 per cent) required transfer to a major trauma centre and 30-day mortality was 0.6 per cent.

CONCLUSION

Although variable, injuries following equine trauma can be life threatening. Increased awareness and development of safety legislation is needed. In addition, research could be directed at assessing functional outcomes given the large number of orthopaedic injuries.

Radial neck fractures in children secondary to horse-riding accidents: a comparative study

INTRODUCTION

In the pediatric population, fractures of the radial neck account for approximately 1% of all fractures and can have substantial consequences. Given the growing popularity of horse riding and the high-energy traumas that this can entail, we sought to assess prognosis for radial neck fracture sustained in horse riding.

HYPOTHESIS

Radial neck fracture sustained in horse riding is more severe and more frequently associated with other ipsilateral osteoarticular lesions which worsen prognosis.

MATERIAL AND METHOD

We performed a multicenter retrospective comparative study in a continuous series of 39 patients. The inclusion criteria consisted of radius neck fracture in children under the age of 15 years. Endpoints comprised associated lesions at time of trauma, and ranges of elbow motion in pronation/supination and flexion/extension at last follow-up.

RESULTS

Compared to other etiologies, radial neck fractures following horse-riding accidents were more frequently associated with other ipsilateral osteoarticular lesions (p=0.0002), and more often required open reduction (p=0.0409) and postoperative rehabilitation (p=0.041). However, there were no significant differences in any ranges of motion at last follow-up (p>0.05).

CONCLUSION

Radial neck fractures following horse-riding accidents in children were more severe than those caused by other mechanisms. Awareness campaigns in riding clubs and development of specific protective equipment should be considered to reduce occurrence.

LEVEL OF EVIDENCE

Therapeutic III - Retrospective comparative study.

Head and Spinal Injuries in Equestrian Sports: Update on Epidemiology, Clinical Outcomes, and Injury Prevention

Equestrian sports represent a variety of activities involving a horse and rider. Due to the unpredictable nature of horses, their height, and potential high speeds involved, equestrian athletes are at risk of head and spinal injuries. This review describes the epidemiology, injury mechanisms, and risk factors for equestrian sports-related head and spinal injuries. Traumatic brain injuries, including concussions, are more common than spinal injuries. Both injury types are most commonly related to a rider fall from a horse. Spinal injuries are less common but are associated with potentially significant neurological morbidity when spinal cord injury occurs. An improved understanding of preventable injury mechanisms, increased certified helmet use, improved helmet technologies, and educational outreach may help to address the risk of head and spinal injuries in equestrian sports.

Do riders who wear an air jacket in equestrian eventing have reduced injury risk in falls? A retrospective data analysis

OBJECTIVES

To investigate the association between air jacket usage and rider injury severity in equestrian eventing competition falls world-wide.

DESIGN

Retrospective data analysis.

METHODS

An analysis was conducted on Fédération Equestre Internationale data for 1819 riders who fell wearing an air jacket and 1486 riders who fell while not wearing an air jacket from 2015 to 2017. Injury data were categorised as either 'no/slight injury' or 'serious/fatal injury'. A chi-square test determined whether an association was present between injury severity category and air jacket usage and binary logistic regression determined the effect size of this association.

RESULTS

As a result of falls, 3203 riders sustained no/slight injuries and 102 sustained serious/fatal injuries. While 55.0% of riders who fell were wearing an air jacket, they represented 67.6% of the serious/fatal injury outcomes. Air jacket usage was significantly associated with serious/fatal injuries in falls (X² = 6.76; p = 0.009). Riders wearing an air jacket had 1.7 times (95%CI 1.14-2.64) increased odds of sustaining a serious or fatal injury in a fall compared to riders not wearing an air jacket.

CONCLUSIONS

Riders wearing an air jacket were over represented in the percentage of serious or fatal injuries in falls compared to riders who only wore a standard body protector. Further research is needed to understand the reason(s) for this finding. It is recommended that additional data on injury outcomes, rider characteristics and the biomechanics of falls be examined in future analyses, and that air jacket and body protector characteristics be further investigated.

Injury Patterns of Equine-Related Trauma

Introduction:

Equestrian sports are popular in the United Kingdom (UK), with approximately 2.7 million people of all ages participating in equine-related sports in 2015. These sports are not without risk; the position of the mounted rider puts them at risk of injuries sustained by fall from a height, compounded by movement at speed. The aim of this study was to characterise demographics and injury patterns of equine-related trauma presentations at a major trauma centre in the UK.

Methods:

From a trauma admissions database and electronic search of radiology requests including keywords “equine”, “equestrian”, “horse”, and “pony” with cross-referencing from ICD-10 coding, 144 patients were identified to have presented to an adult major trauma centre with equine-related injuries from falls while mounted over a 3-year period.

Results:

Females accounted for 86% of patients (n = 123). The most common presenting age group was age 20-29, but most injuries occurred with patients of ages 50-59. Spinal injuries accounted for 41% (n = 69) of all injuries and occurred in a similar proportion in all age groups. Upper limb injuries accounted for 100% of injuries in those aged 0-9. 39% (n = 56) of patients required operative management for their injuries.

Conclusion:

We have been able to identify which body zones of injury are more at-risk in equine-related sports following falls from mounted riders, and recognize how certain injury patterns may be more prevalent in particular age groups. Spinal injuries have been demonstrated to be a new leading zone of injury, possibly due to stricter legislation from government and industry leading to the relative reduction of head injuries. Reducing the number and severity of these injuries will not only improve patient outcomes but reduce the burden on the healthcare system.

Horse-related incidents and factors for predicting injuries to the head

Objectives

Head injuries are the leading cause of death in horse-related injury events and, even since the introduction of helmets, represent a sizeable proportion of all horse-related injuries. Falls from horseback and kicks to the head are the most frequent type of incident causing head injuries, but it is unknown whether these incidents are predictors of head injury. This study aimed to investigate head injuries and the association between incident type and head injury.

Method

Retrospective review of 7815 horse-related injury events was conducted. Data were gathered from hospitals, local healthcare centres and public dental services in Skaraborg, Sweden. Binary logistic regression was used to analyse the association between the incident type and occurrence of head injury while controlling for risk factors.

Results

Approximately 20% of riders sustained a head injury, mostly soft tissue injuries (56.3%) and concussions (33.4%). A fall from or with the horse was the primary cause of head injury (63.9%). Those who fell from a carriage or other height or who were injured through contact with the horse had no difference in the likelihood of head injury when compared with those that fell from or with the horse. However, those who sustained an injury without any horse contact had lower odd of head injury (OR: 0.640, p<0.00005, 95% CI 0.497 to 0.734). Additionally, the older the rider, the lower the odds of head injury (OR=0.989, p<0.00005, 95% CI 0.985 to 0.993).

Conclusion

Improved protection for those suffering falls from horseback as well as those who are kicked in the head should be investigated.

Hospital-treated injuries from horse riding in Victoria, Australia: time to refocus on injury prevention?

BACKGROUND

The most recent report on hospital-treated horse-riding injuries in Victoria was published 20 years ago. Since then, injury countermeasures and new technology have aimed to make horse riding safer for participants. This study provides an update of horse-riding injuries that required hospital treatment in Victoria and examines changes in injury patterns compared with the earlier study.

METHODS

Horse-riding injuries that required hospital treatment (hospital admission (HA) or emergency department (ED) presentations) were extracted from routinely collected data from public and private hospitals in Victoria from 2002-2003 to 2015-2016. Injury incidence rates per 100 000 Victorian population per financial year and age-stratified and sex-stratified injury incidence rates are presented. Poisson regression was used to examine trends in injury rates over the study period.

RESULTS

ED presentation and HA rates were 31.1 and 6.6 per 100 000 person-years, increasing by 28.8% and 47.6% from 2002 to 2016, respectively. Female riders (47.3 ED and 10.1 HA per 100 000 person-years) and those aged between 10 and 14 years (87.8 ED and 15.7 HA per 100 000 person-years) had the highest incidence rates. Fractures (ED 29.4%; HA 56.5%) and head injuries (ED 15.4%; HA 18.9%) were the most common injuries. HA had a mean stay of 2.6±4.1 days, and the mean cost per HA was $A5096±8345.

CONCLUSION

Horse-riding injuries have remained similar in their pattern (eg, types of injuries) since last reported in Victoria. HA and ED incidence rates have increased over the last 14 years. Refocusing on injury prevention countermeasures is recommended along with a clear plan for implementation and evaluation of their effectiveness in reducing injury.