Surface-specific fall injury rates on Utah school playgrounds

Assessment of the environmental risk factors associated with traumatic dental injuries among WHO index-aged children and adolescents

BACKGROUND

Traumatic dental injuries (TDIs) are becoming a worldwide phenomenon owing to their variable prevalence, and their etiology is considered multifactorial and complex in interactions among various risk factors. These are preventable if risk factors are analyzed and interpreted in all possible scientific manners. The objective of this study was to assess the various environmental risk factors (places of occurrence of TDI) among World Health Organization (WHO) index-aged children and adolescents (12 and 15 years).

MATERIAL AND METHODS

This was the epidemiological cross-sectional study conducted in Aligarh City, Uttar Pradesh, India, in the year 2018, with a sample size of 1000. Multistage random sampling technique was employed. Study data were collected by doing dental examination and structured interview with self-prepared pro forma in ten randomly selected sampling sites (schools) from different regions of the city. Subsequently, data were entered in an Excel sheet and then analyzed with the Chi-square test using the Statistical Package for the Social Sciences (SPSS) software.

RESULTS

Overall, school (63; 46.7%) was found to be the most prevalent environmental risk factor for TDI followed by home (37; 27.4%), roadside (10; 7.4%), and playground (9; 6.7%). Fifteen (11.1%) affected individuals were not able to recall the place of the TDI incident, while 0.7% (1) had TDI occurrence in other places. Among 12-year index-aged children, home (15; 34.1%) was the most common place of TDI in rural regions, while school (27; 67.5%) was the most frequent place of TDI in urban regions. Among 15-year index-aged adolescents, school (19; 59.4%) was found to be the most common place in rural regions, whereas school (9; 47.4%) was the most frequent place of TDI in urban regions.

CONCLUSION

Environmental factors, especially school premises, infrastructure, and playing facilities, need to be upgraded and built with an emphasis on a safer environment for children. Teachers, parents, and school children should be educated and made aware of the preventive measures for dental injuries in schools and homes. Appropriate safety gears should be mandatory to use among children and adolescents during outdoor sports and recreational activities.

Fall characteristics among elderly populations in urban and rural areas in Korea

Falling is one of the leading causes of injury among elderly populations. As the population over 65 years old increases, medical costs due to falling will also increase. Urban and rural areas have different fall characteristics, and research into these differences is lacking.A survey was conducted on 2012 people over 60 years old between September 1, 2015, to October 12, 2015. Guro-gu (Seoul), Yeongdeungpo-gu (Seoul), and Jung-gu (Daegu) were classified as urban areas and included 1205 of the study participants. Dalseong-gun (Daegu) and Yangpyeong-gun (Gyeonggi-do) were categorized as rural areas and included 807 participants. The survey included questions about fall history, cause, season and time of recent falls, and external conditions associated with recent falls, like floor or ground materials and shoe types.Rural respondents were older than urban respondents (P < .001) but did not differ significantly in gender proportion (P = .082). Fall history over the past year was not different between the 2 regions (P = .693), but lifetime fall history was greater among rural respondents (P < .001). Only 5.1% of all respondents had undergone fall-prevention education. A slippery floor was the most common cause of falls in both regions, but there was a significant difference in pattern of fall causes (P < .001). Falls were more frequent in the summer, spring, and the afternoon in urban areas, and in the summer, autumn, and the morning in rural areas. Cement and asphalt were the most common ground materials at the time of falls in both regions, but rural respondents had higher fall rates when walking on soil and when wearing slippers.A fall-prevention program that reflects the characteristics and differences of falls in urban and rural areas should be developed and used to effectively prevent falling among elderly people.

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.

THE STANDARD OF PLAYGROUNDS AND SAFETY MEASURES IN PREVENTION OF TRAUMATIC DENTAL INJURIES IN NIGERIAN PRIMARY SCHOOLS

BACKGROUND

Playgrounds provide a recreational refuge for children and play a role in the development of their cognitive, psychosocial, and physical coordination skills. Unfortunately, it may also be a source of traumatic dental injuries (TDI).

AIM

To assess the standards of playgrounds in primary schools in Southern Nigeria.

SETTING

Selected public and private primary schools in Lagos (Southwest), Enugu (Southeast) and Rivers (Southsouth) states of Nigeria.

MATERIALS & METHODS

Multi-stage sampling was used to select 180 schools (30 private and 30 public schools in each state) spread across the 3 study states of Lagos, Enugu and Rivers of Nigeria. A structured questionnaire which was interview administered was used to obtain information from the head teachers of 180 selected schools in Southern geo-political zones of Nigeria. The presence or absence of playgrounds & play equipment; quality of playgrounds and equipment; and supervision of the pupils during play were assessed. Statistical comparison of public and private schools, as well as comparison between the three geopolitical zones was by chi square statistics and one way ANOVA respectively.

RESULTS

Playgrounds were present in 147(81.7%) schools; 83 (56.5%) and 64 (43.5%) were public and private schools respectively. Ninety three (51.7%) schools had teachers or minders at the play grounds during recreation. Most of the public schools had no minders. Majority (69.7%) of the playgrounds surfaces were bare earth. Ninety three (55.4%) schools had play equipment with about 7.5% of them padded. The maintenance of the play equipment was not regular in 54.3% of the schools. The impact absorbing surfaces under the play equipment were majorly (66.6%) pits filled with sand in the three zones while rubber matting was found only in 7.7% of schools which were exclusively in the Southwestern zone of the country.

CONCLUSION

Most of the schools had playgrounds but inadequate consideration was given to safety measures in terms of playground size, surfaces, equipment type, height and supervisions by teachers. We therefore recommended that playgrounds should be standardized in Nigerian primary schools and more awareness about the occurrence and prevention of TDI during recreation should be created in schools.

School environment and school injuries

Background: Although injuries at school are an important issue in public health, environmental factors in schools and school yards have seldom been the focus of school injury research. The goal of our investigation was to examine the effect of environmental factors on school injuries.

Methods: Nine comprehensive Finnish schools registered school injuries over a period of two school years. Injuries were classified as being associated with environmental factors, suspected environmental factors, and others. The consensus between two independent classifiers was 81%.

Results: A total of 722 injuries were classified. In 11.6% of these injuries, the physical environment factor was evident, and in 28.1% of the injuries, physical environment was suspected of being a contributory risk factor. Thus the physical environment of the school was a contributing factor in over a third (39.7%) of injuries occurring in the school, on the school yard or during the journey to, or from school. In this study, conducted in Finland, ice on the ground was mentioned most frequently as an environmental risk factor.

Conclusion: In Finland, the Nordic weather conditions are not taken into account in the school yard and playground plans as they ought to from the safety point of view. An initiative has been launched on a mandatory wintertime master plan for every school yard.

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.

Temporal variation in pediatric supracondylar humerus fractures requiring surgical intervention

BACKGROUND

Pediatric supracondylar humerus fractures commonly require surgical intervention and hospital admission, which is costly and consumes significant health care resources. There are few data regarding temporal characteristics (month, day and hour of injury) of this particular pediatric fracture. We wished to investigate the month, day of the week, and time of occurrence of these fractures to guide appropriate use of health care resources and prevention strategies.

METHODS

This study was a retrospective review of clinical records and radiographs of 353 children with operative supracondylar humerus fractures in a temperate climate region over 6 years. Date and time of injury and demographic data (gender, age, laterality) were extracted. Variation in month, weekday, and time of injury was analyzed using circular analysis, cosinor analysis, probability distributions and topographical distribution.

RESULTS

There was a statistically significant increase in the number of fractures during the summer with a peak in early July. When analyzing by month and day of the week, a peak was seen Thursday-Saturday during May-July and middle of the week September-October. Weekdays demonstrated a higher proportion of fractures occurring in the morning and at school. The injuries occurred in the am in 37 and the pm in 241; detailed data were known in 227 with 37 between 0000 and 1159, 51 between 1200 and 1559, and 139 between 1600 and 2359 h. The peak time of injury was 1800 h.

CONCLUSIONS

The increase in supracondylar humerus fractures in the spring through autumn in temperate regions indicates that education campaigns reinforcing fall prevention and landing surfaces should be done in the early spring. The hourly data support the need for dedicated early morning operating rooms to care for these fractures.

LEVEL OF EVIDENCE

Prevalence study, retrospective cohort, Level II .

Temporal variation in childhood injury from common recreational activities

BACKGROUND/PURPOSE

To investigate the month and day of the week of injury in common childhood activities using the National Electronic Injury Surveillance System database.

METHODS

All emergency department visits 2002–2006 from bicycles/tricycles, scooters, playground equipment, swimming/water activities, skiing/snowboarding, trampolines, and skating were analysed. The NEISS weighted and stratified data set was analysed using SUDAAN software. Weekday and month of injury, gender, race, anatomical location of the injury, geographical location of injury, and disposition were tabulated. Simple variation by month or weekday was analysed using cosinor analysis; combined variation for both month and weekday was analysed by topographical analysis.

RESULTS

There were an estimated 4.61 million emergency department visits for injuries from these activities in children in the United States. The average age was 9.5 years; there were 1.65 million girls (35.9%) and 2.97 boys (64.1%). Cosinor analysis demonstrated significant single peaks for month of injury for snow activities (January 27), trampolines (June 10), scooters (June 24), cycling (July 6), and water (July 12) activities. Double cosinor peaks were noted for skating (April 13 and September 12) and playground (April 22 and September 21) activities. Cosinor analyses demonstrated that the peak week days of injury were Monday for trampoline and snow activities, Saturday/Sunday for skating activities, Sunday for cycling, and Wednesday for playground equipment. There was no peak injury day for scooter or water activities. Topographical representation of paediatric injuries demonstrated that injuries from slides most frequently occurred April–May on Wednesdays and Saturdays, and those on swings April–May all days except Tuesday. Monkeybar injuries were bimodal, with the spring peak on Wednesday–Thursday in April/May and the fall peak Tuesday–Friday in September. Rollerblade injuries occurred Saturday–Sunday from March/April; rollerskates on Saturday–Sunday in January–April, and skateboards Saturday–Monday in August–October and Sundays in April.

CONCLUSIONS

These findings can be used to further guide childhood injury prevention programmes/campaigns and especially track improvements after targeted prevention programmes. Public parks and schools should check/correct the status of playground landing surfaces just before the bimodal peaks. Education campaigns reinforcing the need for bicycle helmets could be concentrated immediately before the increase in cycling activity – March on weekends and April/May for weekdays.

Composite playground safety measure to correlate the rate of supracondylar humerus fractures with safety: an ecologic study

BACKGROUND

More than 200,000 children are injured at playgrounds in the United States each year. Our goal was to introduce a composite measure of playground safety and use this instrument to correlate the incidence of supracondylar humerus fractures with playground safety in an ecologic study design.

METHODS

We used a novel "overall-safety rating," defined as a composite of 3 previously validated instruments (National Program for Playground Safety School score, surface depth compliance, and the use zone compliance) to measure the overall safety of all playgrounds within a region. The regions were rated from most to least safe based on average playground safety as measured by this new method. The incidence of supracondylar fractures was calculated using Hasbro Children's Hospital Emergency Department data and state of Rhode Island Census data from 1998 to 2006. The incidence was then correlated with playground safety as defined by our composite measure.

RESULTS

Compared with the neighborhood deemed the safest, the least safe district had 4.7 times greater odds of supracondylar humerus fracture. Overall composite safety score of the district was linearly correlated with the injury rate observed in the population at risk (R=0.98; P=0.04).

CONCLUSIONS

Using our novel composite playground safety score, we found that the incidence of supracondylar humerus fractures was increased in districts with playgrounds with lower scores, suggesting that improvements in playground infrastructure may potentially reduce the incidence of supracondylar humerus fractures, and other injuries, in children.

LEVEL OF EVIDENCE

Level IV.

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

BACKGROUND

The risk of playground injuries, especially fractures, is prevalent in children, and can result in emergency room treatment and hospital admissions. Fall height and surface area are major determinants of playground fall injury risk. The primary objective was to determine if there was a difference in playground upper extremity fracture rates in school playgrounds with wood fibre surfacing versus granite sand surfacing. Secondary objectives were to determine if there were differences in overall playground injury rates or in head injury rates in school playgrounds with wood fibre surfacing compared to school playgrounds with granite sand surfacing.

METHODS AND FINDINGS

The cluster randomized trial comprised 37 elementary schools in the Toronto District School Board in Toronto, Canada with a total of 15,074 students. Each school received qualified funding for installation of new playground equipment and surfacing. The risk of arm fracture from playground falls onto granitic sand versus onto engineered wood fibre surfaces was compared, with an outcome measure of estimated arm fracture rate per 100,000 student-months. Schools were randomly assigned by computer generated list to receive either a granitic sand or an engineered wood fibre playground surface (Fibar), and were not blinded. Schools were visited to ascertain details of the playground and surface actually installed and to observe the exposure to play and to periodically monitor the depth of the surfacing material. Injury data, including details of circumstance and diagnosis, were collected at each school by a prospective surveillance system with confirmation of injury details through a validated telephone interview with parents and also through collection (with consent) of medical reports regarding treated injuries. All schools were recruited together at the beginning of the trial, which is now closed after 2.5 years of injury data collection. Compliant schools included 12 schools randomized to Fibar that installed Fibar and seven schools randomized to sand that installed sand. Noncompliant schools were added to the analysis to complete a cohort type analysis by treatment received (two schools that were randomized to Fibar but installed sand and seven schools that were randomized to sand but installed Fibar). Among compliant schools, an arm fracture rate of 1.9 (95% confidence interval [CI] 0.04-6.9) per 100,000 student-months was observed for falls into sand, compared with an arm fracture rate of 9.4 (95% CI 3.7-21.4) for falls onto Fibar surfaces (p< or =0.04905). Among all schools, the arm fracture rate was 4.5 (95% CI 0.26-15.9) per 100,000 student-months for falls into sand compared with 12.9 (95% CI 5.1-30.1) for falls onto Fibar surfaces. No serious head injuries and no fatalities were observed in either group.

CONCLUSIONS

Granitic sand playground surfaces reduce the risk of arm fractures from playground falls when compared with engineered wood fibre surfaces. Upgrading playground surfacing standards to reflect this information will prevent arm fractures.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN02647424.

Pediatric tree house-related injuries treated in emergency departments in the United States: 1990-2006

OBJECTIVES

The objective was to describe the epidemiology of tree house-related injuries in the United States among children and adolescents.

METHODS

The authors conducted a retrospective analysis using data from the National Electronic Injury Surveillance System for patients < or =19 years who were treated in an emergency department (ED) for a tree house-related injury from 1990 through 2006.

RESULTS

An estimated 47,351 patients < or =19 years of age were treated in EDs for tree house-related injuries over the 17-year study period. Fractures were the most common diagnosis (36.6%), and the upper extremities were the most commonly injured body part (38.8%). The odds of sustaining a head injury were increased for children aged <5 years. Falls were the most common injury mechanism (78.6%) and increased the odds of sustaining a fracture. Falls or jumps from a height > or =10 feet occurred in 29.3% of cases for which height of the fall/jump was recorded. Boys had significantly higher odds of falling or jumping from a height of > or =10 ft than girls, and children 10 to 19 years old also had significantly higher odds of falling or jumping from a height of > or =10 feet, compared to those 9 years old and younger. The odds of hospitalization were tripled if the patient fell or jumped from > or =10 feet and nearly tripled if the patient sustained a fracture.

CONCLUSIONS

This study examined tree house-related injuries on a national level. Tree house safety deserves special attention because of the potential for serious injury or death due to falls from great heights, as well as the absence of national or regional safety standards. The authors provide safety and prevention recommendations based on the successful standards developed for playground equipment.

The demographics of playground equipment injuries in children

BACKGROUND/PURPOSE

There have been many different studies of injuries owing to playground equipment but none that have looked in detail using large nationwide databases. It was the purpose of this study to investigate injuries owing to playground equipment using the National Electronic Injury Surveillance System (NEISS) database and further understand their demographics.

METHODS

Detailed NEISS injury data from 2002 through 2004 for slides, monkey bars, and swings were analyzed. Appropriate statistical analyses were performed; because of the many analyses on this large data set, P < .01 was considered statistically significant.

RESULTS

There were 22728 emergency department visits owing to playground equipment injuries recorded by NEISS between 2002 and 2004; 83.9% were owing to monkey bars, swings, and slides, and the 5 most common diagnoses were fractures (39.3%), contusions/abrasions (20.6%), lacerations (16.6%), strains/sprains (9.9%), and traumatic brain injuries (TBI) (8.5%). There were 9487 boys (54.3%) and 7995 girls (45.7%). The average age was 6.5 +/- 3.0 years. The injuries occurred at school in 38.9%; at a recreation/sporting facility, in 35.5%; and at home, in 25.6%. Most were treated and released (94.4%). Amerindian children were 2 times more likely than blacks to be admitted; compared to contusions, fractures were 9.8 times, and TBIs, 4.7 times more likely to be admitted. Injuries on monkey bars were 1.2 times more likely to be admitted than those on swings or slides. Fractures were 1.9 times more likely to occur on a monkey bar compared with swings or slides. Traumatic brain injuries were 1.4 times more likely to occur on a swing compared to slides or monkey bars.

CONCLUSION

Swings at school are the most common mechanism of injury for TBIs, and the seasonal data would suggest that increased supervision of children using swings during school hours might reduce the occurrence of TBIs. Monkey bars are the most common cause of fracture, and fracture is the most common cause of admission. Prevention strategies to reduce the number of fractures should be directed at monkey bar equipment and landing surfaces. The trend in playground equipment injury also indicates that monkey bars are problematic because the number of injuries per year per capita owing to monkey bars is stable, whereas those from swings and slides is decreasing.

Poor neighborhoods: safe playgrounds

Although unstructured physical play is helpful to child development and physical activity is important to obesity prevention, up-to-date information about playgrounds and playground hazards in urban areas is limited. Local data are needed to identify problems and target interventions. The aim of this study was to describe the hazards in playgrounds located in low-income (median dollars 28,728-38,915) and very low-income (median dollars 18,266-18,955) Chicago neighborhoods. Using a standardized on-site survey (National Program for Playground Safety), two investigators reviewed seventy-eight public playgrounds for hazards related to playground design, safe surfaces, supervision, and equipment design and maintenance. The design of 56 playgrounds (72%) posed no hazards. One playground lacked protection from motor vehicles, and 21 had minor flaws. One playground had an asphalt surface; all others had protective surfaces, usually wood chips. The chips were too thin in many places, and in 15 playgrounds (19%), at least one concrete footing was exposed. Trash was a common surface hazard (68%). Although most equipment was safe (swings of soft materials and appropriate platform barriers), many pieces needed repairs. Equipment maintenance hazards included gaps (44%) and missing (38%) or broken parts (35%). In 13 of 39 playgrounds (33%) where children were observed playing, one or more were unsupervised. Playgrounds in very low-income neighborhoods more often had trash in the fall zone and exposed footings (P<.01 for each); there were no differences between low and very low-income neighborhoods in playground design or equipment maintenance. We conclude that playgrounds in low-income Chicago neighborhoods are of good design and have appropriate surfaces. Needed improvements include attention to wood chip depth, the removal of trash from the fall zone, and equipment repairs. Greater adult supervision is warranted.

The Stamp-in-Safety Program: A Behavioral Intervention to Reduce Behaviors that Can Lead to Unintentional Playground Injury in a Preschool Setting

OBJECTIVE

To introduce and evaluate the Stamp-in-Safety program, a behavioral intervention designed to increase the quality of supervision by teachers on preschool playgrounds and to reduce the risk of unintentional child playground injury.

METHODS

A quasi-experimental time series design was used, with observational techniques, to evaluate behavior on the playground before, during, and after the intervention as well as during a 6-month post-intervention assessment.

RESULTS

Both applied behavior analysis techniques and inferential statistics suggest that the Stamp-in-Safety program resulted in behavioral changes likely to reduce the risk of child injury on the playgrounds of childcare centers.

CONCLUSION

Results indicate promise for the Stamp-in-Safety program as a low-cost, easily implemented intervention to reduce pediatric playground injury risk at childcare centers. Suggestions for future research are offered.

Motor ability: protective or risk for school injuries?

The study aims were to assess the independent contribution of motor ability to the incidence of school injuries. The study included 2057 pupils in grades 3-6 of primary schools in a city in the north of Israel. A surveillance system gathered information about injuries that occurred on school premises or during school related activities and required medical treatment or caused limitation of usual activities. Children provided information on sensation seeking, self-appraisal of health, academic performance, physical activity, and dominant hand; anthropometric measurements and motor ability tests were performed. The incidence of injury events was 4% (95% CI=3.2-5.0). Injuries increased with increased balance and agility, but there were no differences according to reaction time. No other study variables were associated with the incidence of injuries. Our findings of an increase in the incidence of injuries with better motor ability may express differences in exposure to risk situations between children with better and poorer motor abilities.

Injury and frequency of use of playground equipment in public schools and parks in Brisbane, Australia

OBJECTIVE

The purpose of this study was to determine the frequency of use of play equipment in public schools and parks in Brisbane, Australia, and to estimate an annual rate of injury per use of equipment, overall and for particular types of equipment.

METHODS

Injury data on all children injured from playground equipment and seeking medical attention at the emergency department of either of the two children's hospitals in the City of Brisbane were obtained for the years 1996 and 1997. Children were observed at play on five different pieces of play equipment in a random sample of 16 parks and 16 schools in the City of Brisbane. Children injured in the 16 parks and schools were counted, and rates of injury and use were calculated.

RESULTS

The ranked order for equipment use in the 16 schools was climbing equipment (3762 uses), horizontal ladders (2309 uses), and slides (856 uses). Each horizontal ladder was used 2.6 times more often than each piece of climbing equipment. Each horizontal ladder was used 7.8 times more than each piece of climbing equipment in the sample of public parks. Slides were used 4.6 times more than climbing equipment in parks and 1.2 times more in public schools. The annual injury rate for the 16 schools and 16 parks under observation was 0.59/100 000 and 0.26/100 000 uses of equipment, respectively.

CONCLUSIONS

This study shows that annual number of injuries per standardized number of uses could be used to determine the relative risk of particular pieces of playground equipment. The low overall rate of injuries/100 000 uses of equipment in this study suggests that the benefit of further reduction of injury in this community may be marginal and outweigh the economic costs in addition to reducing challenging play opportunities.

Playground injury prevention

Playground safety recently has received increasing attention from parents and municipalities. Orthopaedic surgeons treat a large number of the more than 350,000 injuries per year sustained on the play areas of this country's school, home, and community play areas. A parent brings a child to the playground for fun, healthy exercise, and imaginative play. Unfortunately, most parents may not be aware of recommended injury prevention methods. Data from the Consumer Product Safety Commission and other epidemiologic studies document frequency, identify at-risk activities and equipment, give direction for additional research, and guide regulations. It is appropriate for the medical community to lead in this safety effort and to contribute to additional research and advocacy efforts.

Evaluation of the Utah student injury reporting system

The Utah Student Injury Reporting System (SIRS), implemented in 1984 to monitor injuries to students in grades K-12 in Utah schools, has served as a model for surveillance systems created by other states and some European countries. This paper evaluates the Utah experience in developing and administering the SIRS. The evaluation identifies usefulness of the system, discusses the sensitivity of the system in detecting school injuries, estimates the system's costs, and provides suggestions to other states and districts interested in building a cost-effective and efficient surveillance instrument.

Playground injuries in children: a review and Pennsylvania Trauma Center experience

ISSUES AND PURPOSE

To describe patient demographics, injury characteristics, and circumstances of playground injuries in children admitted to Pennsylvania trauma centers and to identify injury prevention strategies.

DESIGN AND METHODS

Retrospective, descriptive study of 234 children ages 1 to 18 years sustaining playground-related injuries and whose hospital data were entered into the Pennsylvania Trauma Outcome Study.

RESULTS

Most of the injuries occurred between April and September (77%), and noon to 6 P.M. (69%). Falls from playground equipment constituted the highest proportion of incidents (73%). Of 421 injuries (M = 1.8/patient), most were upper extremity (n = 117) and head (n = 110) injuries.

PRACTICE IMPLICATIONS

Nurses can advocate for playground safety by teaching children to play safely and recommending age-appropriate equipment and protective surfacing.

Multiple attribute entropy classification of school-age injuries

The data exploration task in epidemiology of school children injuries is aimed at defining specific risk groups that can be further analyzed for definition of prevention measures. These groups are selected by means of entropy classification of relevant data collected in the Koprivnica district, Croatia. The necessary pruning procedure for the entropy classification tree is proposed for: (a) entropy increase for uniformly populated classes, and (b) entropy decrease for the case of zeros in a class. The second reason for pruning is emphasized for multiple (> 3) attribute descriptions of injury events because the number of classes increases exponentially with the number of attributes. Four possible prevention groups have been found by entropy classification: (1) dislocation, sprain and strain injuries, mostly on legs of both age groups of boys (7-10 years, 11-14 years) in/around the house activities; (2) arm fractures of all boys in/around the house activities; (3) open wounds mostly of the head, in younger boys at school, and open wounds in younger boys in road traffic; and (4) contusions mostly on arms, of older girls at school and contusions in older boys in road traffic accidents. These groups comprise 57.2% of all considered cases.

An intervention to reduce playground equipment hazards

OBJECTIVES

A community intervention trial was carried out to evaluate the relative effectiveness of two methods of reducing playground hazards in schools. The study hypotheses were: (1) a health promotion programme addressing barriers to implementing the New Zealand Playground Safety Standard will reduce playground hazards and (2) the intervention programme will be more successful than providing information alone.

METHODS

Twenty four schools in Wellington, New Zealand were randomly allocated into two groups of 12 and their playgrounds audited for hazards. After the audit, the intervention group received a health promotion programme consisting of information about the hazards, an engineer's report, regular contact and encouragement to act on the report, and assistance in obtaining funding. The control group only received information about hazards in their playground.

RESULTS

After 19 months, there was a significant fall in hazards in the intervention schools compared with the control schools (Mann-Whitney U test, p = 0.027). No intervention schools had increased hazards and eight out of 12 had reduced them by at least three. In contrast, only two of the control schools had reduced their hazards by this amount, with three others increasing their hazards in that time.

CONCLUSIONS

It is concluded that working intensively with schools to overcome barriers to upgrading playground equipment can lead to a reduction in hazards, and that this form of intensive intervention is more effective than providing information alone.

Monkeybar injuries: complications of play

BACKGROUND

Playground equipment resulted in >200 000 injuries from 1990 to 1994, according to the Consumer Product Safety Commission; 88% were attributable to climbers (monkeybars/jungle gyms [MB/JGs]), swings, and slides. Equipment-specific injury requiring emergency department (ED) evaluation has not been reported previously.

OBJECTIVE

To describe the spectrum of significant MB/JG-related injuries.

METHODS

A 2-year retrospective chart review was performed using the computerized charting system at a large urban Children's Hospital/Regional Pediatric Trauma Center with 50 000 ED visits per year. A telephone survey also was conducted after the chart review to obtain additional information concerning the injury location, the surface type below the equipment, and the presence of adult supervision.

RESULTS

A total of 204 patients were identified. Mean age was 6.2 years (range, 20 months to 12 years); 114 (56%) were male. A seasonal variation was noted with June to August accounting for 43% of visits. Injuries included fractures in 124 (61%), contusions in 20 (10%), neck and back strains in 17 (8%), lacerations in 16 (8%), closed head injuries in 10 (5%), abdominal trauma in 5 (3%), genitourinary injuries in 5 (3%), and miscellaneous injuries in the remainder. Among fractures, 90% were fractures of the upper extremity; 48 (40%) were supracondylar fractures. One child sustained a C7 compression fracture. Abdominal injuries included 1 child who sustained a splenic laceration. All genitourinary injuries (2 vaginal hematomas, 1 vaginal contusion, 1 penile laceration, and 1 urethral injury) were from straddle-type injuries. Fifty-one (25%) patients were admitted to the hospital. Of these, 47 (92%) required an operative procedure (orthopedic reduction or vaginal examination under anesthesia). Analysis of the telephone data revealed that the surface did not influence the injury type. Of the 79 fractures, 30 occurred on "soft surfaces." Injury type was associated significantly with chronologic age. Younger children (1 to 4 years of age) sustained more long-bone fractures than did older children. The presence of adult (at least 18 years of age) supervision, did not influence the occurrence of fractures.

CONCLUSIONS

These data suggest that 1) a significant proportion (25%) of MB/JG-related injuries that are evaluated in the ED require hospitalization; 2) most of the injuries resulting in admission will require operative intervention (92%); 3) the surface below the equipment has no influence on the type or severity of the injury; 4) younger children are more likely to sustain long-bone fractures than are older children; and 5) adult supervision does not influence the injury pattern. These data identify the need for additional investigation of means of making MB/JGs safer for child use.

School-injury determinants and characteristics: developing an investigation instrument from a literature review

The school constitutes an environment of public-health concern since it is the location of occurrence of a major proportion of injuries sustained by children. This paper reviews a total of 42 empirical studies dealing with the determinants and characteristics of injuries to school pupils. On the basis of the review, a proposal is made for a specialized instrument (SIIR) dedicated to the analysis and registration of injuries and incidents at school. It addresses the 'who?', 'where?', and 'what?' questions usually posed in traditional instruments for injury surveillance but places far greater emphasis on the 'how?' and 'why?' questions of injury. SIIR enables the injury phenomenon to be subjected to greater scrutiny, and is designed to support preventive work at school level. For one school-year, it is also being employed for the creation of a data register for research and development purposes.

Surface stiffness affects impact force during a fall on the outstretched hand

Falls on the outstretched hand are among the most common causes of traumatic bone fracture. However, little is known regarding the biomechanical factors that affect the risk for injury during these events. In the present study, we explored how upper-extremity impact forces during forward falls are affected by modification of surface stiffness, an intervention applicable to high-risk environments such as nursing homes, playgrounds, and gymnasiums. Results from both experimental and linear biomechanical models suggest that during a fall onto an infinitely stiff surface, hand contact force is governed by a high-frequency transient (having an associated peak force Fmax1), followed by a low-frequency oscillation (having an associated lower magnitude peak force Fmax2). Practical decreases in surface stiffness attenuate Fmax1 but not Fmax2 or the magnitude of force transmitted to the shoulder. Model simulations reveal that this arises from the compliant surface's ability to decrease the velocity across the wrist damping elements at the moment of impact (which governs Fmax1) but inability to substantially reduce the peak deflection of the shoulder spring (which governs Fmax2). Comparison between model predictions and previous data on fracture force suggests that feasible compliant surface designs may prevent wrist injuries during falls from standing height or lower, because Fmax1 will be attenuated and Fmax2 will remain below injurious levels. However, such surfaces cannot prevent Fmax2 from exceeding injurious levels during falls from greater heights and therefore likely provide little protection against upper-extremity injuries in these cases.

Council playgrounds in New South Wales: compliance with safety guidelines

Despite initiatives to improve the safety of play environments, playground-related injuries continue to be a major public health problem. Efforts to address playground safety in New South Wales were consolidated during 1994 through the Kidsafe Playground Safety Project. In stage 1 of the project (described here), 240 council playgrounds were assessed to determine the extent to which playground equipment complied with safety guidelines. On-site inspection of the selected playgrounds provided data on 862 separate pieces of playground equipment. Of the 723 pieces requiring undersurfacing, less than half (45.4 per cent) had the recommended type of undersurfacing while only 42 of those pieces had undersurfacing to the recommended depth. However, when the fall height of equipment was considered in addition to the undersurfacing guidelines, only 13 (1.8 per cent) of the 723 pieces of equipment simultaneously satisfied all of the safety guidelines. Regrettably, none of the 240 council playgrounds assessed complied fully with the key safety guidelines. The results underscore the need for a collaborative effort on the part of local government, Kidsafe and health promotion and regional public health units to ensure that council playgrounds in New South Wales comply with recommended safety guidelines.

A descriptive analysis of children's playground injuries in the United States 1990-4

OBJECTIVES

To review playground injury statistics over a five year period in order to develop an awareness of how and where children in the United States are being injured.

METHODS

All data are based on the United States Consumer Product Safety Commission's National Electronic Injury Surveillance System (NEISS) for playground related injuries during 1990-4. The surveillance data includes injuries recorded in more than 90 hospital emergency departments located throughout the United States.

RESULTS

Each year there are roughly 211,000 preschool or elementary school-children in the United States who receive emergency department care for injuries associated with playground equipment. On average, 17 of these cases result in death. 70% of all injuries occur on public playgrounds, with nearly one third classified as severe. Swings, climbers, and slides are the pieces of playground equipment associated with 88% of all NEISS reported injuries. Falls to the surface are responsible for 70%.

CONCLUSIONS

NEISS playground injury statistics contribute to our understanding of playground injuries. By identifying where and how children are injured, suggestions can be made in an attempt to make playgrounds safer.

A nursing intervention to ensure a safe playground environment

Unintentional injuries sustained on school playgrounds are a continual problem not only for children but also for the school nurses who are concerned with their safety. A group of school nurses organized by the local health department's pediatric nurse practitioner responded proactively to this problem by enlisting both school officials and students to accept joint responsibility for a safe play environment. The school nurses assisted the staff in providing a safe play environment and encouraged the students to behave in a safe and acceptable manner on the playground. The nurses developed (a) a Playground Safety Assessment Guide for the school staff to establish and maintain a safe play environment, (b) an in-service session for playground monitors to learn how to supervise children at recess, and (c) a student-oriented program for the children to improve behavior on the playground based on a program conceived by Utah State University (Daug & Fukui, 1988). School nurses and pediatric nurse practitioners can use this program as a model for other schools to improve the physical play environment and behavior of the children at recess.

Height and surfacing as risk factors for injury in falls from playground equipment: a case-control study

OBJECTIVES

Despite the widespread promotion of safety standards no epidemiological studies have adequately evaluated their effectiveness in preventing injury in falls from playground equipment. This study evaluated the effectiveness of the height and surfacing requirements of the New Zealand standard for playgrounds and playground equipment.

SETTING

Early childhood education centres and schools in two major cities in the South Island of New Zealand.

METHODS

Data were collected on 300 children aged 14 years or less who had fallen from playground equipment. Of these, 110 (cases) had sustained injury and received medical attention, while 190 (controls) had not sustained injury requiring medical attention.

RESULTS

Logistic regression models fitted to the data indicated that the risk of injury being sustained in a fall was increased if the equipment failed to comply with the maximum fall height (odds ratio (OR) = 3.0; 95% confidence interval (CI) 0.7 to 13.1), surfacing (OR = 2.3; 95% CI 1.0 to 5.0), or safe fall height (OR = 2.1; 95% CI 1.1 to 4.0) requirements. Falls from heights in excess of 1.5 metres increased the risk of injury 4.1 times that of falls from 1.5 metres or less and it was estimated that a 45% reduction in children attending emergency departments could be achieved if the maximum fall height was lowered to 1.5 metres.

CONCLUSIONS

Although the height and surfacing requirements of the New Zealand standard are effective in preventing injury in falls from playground equipment, consideration should be given to lowering the maximum permissible fall height to 1.5 metres.