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Childhood injuries
Horse-related injuries in children
Andrew J A Holland, Gerard T Roy, Valapha Goh, Frank I Ross, John P
Keneally and Daniel T Cass
MJA 2001; 175: 609-612
Abstract -
Methods -
Results -
Discussion -
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Objectives: To identify the frequency, spectrum and
outcome of horse-related injuries in children.
Design and setting: Retrospective case series of
horse-related injuries in children admitted to the Children's
Hospital at Westmead (CHW) from January 1988 to December 1999, the
John Hunter Children's Hospital (JHCH) from January 1991 to December
1997 and deaths reported to the New South Wales Paediatric Trauma
Death (NPTD) Registry from January 1988 to December 1999.
Main outcome measures: Circumstances of injury;
helmet use; adult supervision; type and number of injuries
identified.
Results: 232 children were admitted with
horse-related trauma, 97 to the CHW over 12 years and 135 to JHCH over
seven years, with one death at each hospital. There were six deaths
reported to the NPTD Registry over 12 years. The median age was 11 years
(range, 1-17). Girls accounted for 65% of those injured and 75% of
children were injured while riding. Falls caused the injury in 76.3%
of cases. Head and upper-limb trauma accounted for 216 of the injuries
(73%). Five out of six children with severe head injuries died. In the
CHW group, helmet use was documented in only 24 riders (38%) and adult
supervision in 22 (22.9%).
Conclusions: Horse-related trauma accounts for a
considerable number of deaths and injuries in children in NSW. The use
of a Standards-approved helmet for riding or horse-related
activities might have decreased the severity of head injuries.
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In 1788, six horses — four mares and two stallions — arrived with the
First Fleet at Botany Bay, New South Wales. The first paediatric
equestrian death was reported in 1830.1 Both the equine and human
populations in Australia have grown enormously since then, but there
have been few reviews of horse-related trauma in this
country.2-4 This is surprising given
Australia's considerable rural population and the popularity of
horse riding as a sporting and leisure activity.
Trauma is the most common cause of both morbidity and mortality in
children, and motor vehicle injuries are the most frequent cause of
such trauma. Although horse-related injuries in children are not as
common, the potential for serious injury or death in a young child is
high. An adult horse may weigh over 500 kg, gallop at speeds of up to 65
km/h and kick with a force 1.8 times its weight.5 The physical differences
between horses and children predispose towards severe injury and are
compounded by the potential for unpredictable behaviour in both
species.
We reviewed the records of children admitted with horse-related
injuries to two paediatric tertiary referral centres — one in Sydney
receiving children predominantly from an urban and outer urban
environment (the Children's Hospital at Westmead [CHW]), and the
other in a more rural environment in the Hunter Valley (the John Hunter
Children's Hospital [JHCH]). These two hospitals receive most NSW
children admitted with horse-related injuries (except those from
southern NSW, who may be admitted to Sydney Children's Hospital).
These data were supplemented with cases reported to the New South
Wales Paediatric Trauma Death (NPTD) Registry. We wished to
establish the extent and spectrum of horse-related trauma in
children to determine the most effective approach to injury
prevention.
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We performed a retrospective review of children aged under 18 years
admitted to the CHW and JHCH, or reported to the NPTD Registry, with
horse-related injuries. Data were collected on age, location of
injury, whether the child was riding or not riding at the time of the
injury, the mechanism of injury, the injuries and surgical
intervention required, complications and final outcome. For
children admitted to CHW and reported to the NPTD Registry, data were
also collected on documented adult supervision and helmet use. In
children who died, the cause of death was identified from the coronial
postmortem report.
CHW admissions: Data were collected from January
1988 to December 1999. Patients were identified retrospectively
from the Paediatric Trauma Database compiled by the trauma research
nurse at Westmead and the Royal Alexandra Hospital for Children
hospitals (subsequently the CHW). In addition, a retrospective
medical record search was made for children discharged with
"animal-related injury external cause" code categories.
JHCH admissions: Data were collected from January
1991 to December 1997. Patients were identified through a
retrospective medical record search for children discharged with
"animal-related injury external cause" code categories and a search
of the John Hunter Hospital trauma database.
NPTD Registry: This records all deaths resulting
from trauma in children under 16 years of age in NSW that are reported to
the coroner. Data were available from January 1988 to December 1999.
The police statement and coroner's report, together with the
postmortem findings, were reviewed for children who had died after
horse-related trauma.
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Results |
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Horse-related injuries and deaths identified | |
The Box summarises our data on the 236 children who sustained injuries
between January 1988 and December 1999.
Girls accounted for 65% of those injured and 75% of children who were
injured while riding a horse. Falls, or a fall followed by a further
injury, was the mechanism in 76% of cases. There was no trend over time
for a change in the frequency or type of injury at either hospital, or
helmet use at CHW.
CHW: There were 97 children with horse-related
injuries, representing 6% of children admitted with all play and
sporting injuries and 35% of animal-related trauma over the 12-year
period. Thirty-four patients (35%) were transferred from a
peripheral hospital. One child, a non-riding two-year-old boy, died
in hospital. Of those children injured while riding, 24 (38%) were
wearing a helmet, 21 (33%) were not, and for 18 (29%) there was no
documentation.
The location of the injury event was identified in 41 cases: a farm in
26, private land in seven, a riding school or competition in five, and a
public highway in three. In 22, adult supervision was recorded; there
was no adult supervision in 31, and this was not documented in 44.
None of the children not riding were wearing a helmet at the time of the
injury, even when involved in activities requiring close proximity
to the horse. In four cases the children's feet were caught in the
stirrup when the horse bolted and they were dragged along the ground.
JHCH: There were 135 children admitted with
horse-related injuries, accounting for 8% of children admitted with
play and sporting injuries and 48% of animal-related trauma over the
seven-year period. One child, a 13-year-old girl, died in hospital.
NPTD Registry: There were six deaths from
horse-related injuries (including the two mentioned above),
representing 8% of the 78 play-related and sporting-related deaths
recorded over the 12 years. There was only one other animal-related
death reported to the registry. Five of these children were injured on
a farm and one during a competition. An adult was present in three
cases. Only two of the four children injured while riding were wearing
helmets; one of these helmets was seen to fall off before the child
struck the ground.
In summary, there were significantly more children injured while
riding (81% v 66%;  2 = 6.741; P = 0.009),
and more children injured through falls from a horse as opposed to
being kicked or trampled (75% v 52%; 2 = 17.3; P = 0.001), in
the JHCH group compared with the CHW group. Further, there was no
difference between the age of the children who survived and those who
died, but boys accounted for 50% of fatalities, compared with 34% of
admissions.
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Spectrum of injuries | |
The Box (b) compares the injuries identified. Head and upper-limb
trauma accounted for 124 and 92 of the injuries, respectively,
representing a combined total of 73%. Significantly more patients
had head trauma (58% v 34%; 2 = 16.66; P = 0.001)
and torso trauma (25% v 10%; 2 = 8.588; P = 0.003) in
the CHW group; limb trauma (31% v 54%; 2 = 12.20; P = 0.001)
was more frequent in the JHCH group.
Major head injury was the cause of death in five of the six children who
died, none of whom were wearing a helmet when their heads struck the
ground.
Of those children admitted to CHW who survived a head injury, 17 were
wearing a helmet, 25 were not and there was no documentation for 10.
Although there was no significant difference between the initial
severity of head injury between children in these groups, no patient
who was wearing a helmet at the time of injury, compared with five
children who were not wearing helmets, had a long-term neurological
deficit.
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Treatment and outcome | |
One hundred and fifty patients required 174 procedures under general
anaesthesia (mostly either limb fracture reduction and fixation or
debridement and suturing of a laceration) and three patients had four
procedures under local anaesthesia. There were significant adverse
outcomes in 23 survivors (10%), eight of which involved a
neurological deficit.
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The risk of injury while horse riding has been estimated as between 1
per 320 to 1 per 1000 hours of riding.4,6 The variation in reported
population-based risk of horse-related trauma of between 18.7
injuries per 100 000 to 9.5 injuries per 1000 population per year
illustrates the difficulties of accurate data collection and
variable inclusion of non-riding injuries.7 Interestingly, the overall
risk of injury from horse-related activity has been determined to be
greater than that of car racing or riding a motorcycle, and the rate of
hospitalisation from falls from a horse equivalent to that from
playing rugby.8-10
Our data indicate that horse-related trauma is a significant problem
for children in Australia, particularly those living in rural
environments. This probably reflects greater exposure to horses in
rural areas, together with greater numbers of riders and riding hours
compared with children living in an urban environment.11-14 The true
scale of the problem is likely to be even greater than our data suggest,
as children with minor injuries may not require admission to a
paediatric hospital, and we may not have identified all
patients.4
Girls accounted for 65% of horse-related injuries in children in this
study and three-quarters of those injured while riding, but only 50%
of fatalities. This overall female preponderance, a contrast to the
situation for most traumatic injuries, is likely to represent the
greater participation of girls in horse-related
activities.4,6,13,15-17 The equal sex
ratio for fatal horse-related injuries in this review resulted from
the number of male preschool non-riders injured while in close
proximity to a horse. Sex differences in exploratory behaviour
patterns would explain this finding.18
Although the risk of injury in children involved in horse-related
activities is high, of perhaps more importance is the severity of such
injuries and their potential long-term consequences.2,13,15,16,19 In
addition to the six deaths over 12 years in NSW, 230 children had
sufficiently severe injuries to require hospital admission. While a
kick from a horse may cause a lower-limb fracture or soft-tissue
injury in an adult, in a child it may result in a compound skull
fracture, thoracic trauma or perforated hollow viscus.2,12
Our findings indicate that the social and economic cost of
horse-related trauma in children is considerable: a death every two
years in NSW, over 200 children admitted with an average length of stay
of three days, and 10% of survivors having complications.4 These negative
outcomes must be balanced with the positive health aspects of a
sporting activity that involves interaction with a companion
animal.
The challenge is therefore to improve the safety of horse riding. Our
data suggest that some fatalities and injuries might be avoided, or
their severity reduced, through a combination of increased adult
supervision of preschool age children and the use of appropriate
safety measures such as a Standards-approved helmet.6,18,20,21
Although the use of Standards-approved helmets is encouraged by both
the Pony Club Association of NSW and the Equestrian Federation of
Australia (EFA), it is not a legal requirement as it is for pedal and
motor cyclists. Further, their use in place of a top hat or traditional
riding helmet may even be disallowed when competing at the higher
levels (national, international, Olympic, etc) of dressage
competition (E Canapini, National Coaching Manager, EFA, personal
communication).
Compliance with helmet use in this study, although not fully
documented, appeared to be poor and reflects published
findings.2-4 While the number of
patients in our study for whom there were complete data was small,
children wearing helmets when riding appeared less likely to suffer
long-term neurological sequelae compared with those who were not. We
therefore propose that consideration be given to making the use of a
Standards-approved helmet for horse riding mandatory. Although it
would not be practical to enforce helmet use in rural areas,
compulsory use in all styles of competition, in riding schools, and on
public highways might have a follow-on effect on farms and in children
who become occupational riders as adults.22
We see no reason why children and adults engaged in horse-related
activities should not receive the benefits of helmet use that have
been shown in cyclists, and which they currently enjoy by
law.23
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Dr P Subramaniam provided assistance with the collection of data from
the John Hunter Children's Hospital. Mr A J A Holland was supported by a
Surgeon Scientist Scholarship from the Royal Australasian College
of Surgeons. Associate Professor J Peat provided assistance with
statistical analysis.
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None declared.
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References |
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Williams F, Ashby K. Horse-related injuries. Edition No. 23.
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Cripps, RA. Horse-related injury in Australia. Edition No. 24.
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Kriss TC, Kriss VM. Equine-related neurosurgical trauma: a
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Bixby-Hammett DM. Pediatric equestrian injuries. Pediatrics
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Nicholls JP. Safety of horseriding. BMJ 1990; 301: 496.
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Chapman MAS, Oni J. Motor racing accidents at Brands Hatch, 1988/9.
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Buckley SM, Chalmers DJ, Langley JD. Injuries due to falls from
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Christey GL, Nelson DE, Rivara FP, et al. Horseback riding
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Thompson JM, von Hollen B. Causes of horse-related injuries in a
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Barone GW, Rodgers BM. Pediatric equestrian injuries: a 14-year
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Nelson DE, Bixby-Hammett D. Equestrian injuries in children and
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Campbell-Hewson GL, Robinson SM, Egleston CV. Equestrian
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Lam LT, Ross FI, Cass DT. Children at play: the death and injury
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Ingemarson H, Grevsten S, Thoren L. Lethal horse-riding
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Finch C. Sports injury prevention. In: Ozanne-Smith J, Williams
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Rivara FP. Fatal and non-fatal farm injuries to children and
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Condie C, Rivara FP, Bergman AB. Strategies of a successful
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(Received 2 Jan, accepted 16 Aug, 2001)
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The Children's Hospital at Westmead, Royal Alexandra Hospital for
Children, The University of Sydney, NSW.
Andrew J A Holland, FRCS, FRACS, Senior Research Fellow, and
Clinical Lecturer, Department of Academic Surgery;
Valapha
Goh, RN, Trauma Research Nurse;
Frank I Ross,
BAppSc(Nurs), MPH, Clinical Nurse Consultant;
Daniel T
Cass, PhD, FRACS, William Dunlop Professor of Paediatric
Surgery;
John P Keneally, MB BS, FANZCA, Head, and Clinical
Senior Lecturer, Department of Anaesthesia.
The John Hunter Children's Hospital, Newcastle, NSW.
Gerard T Roy, FRCS, FRACS, Paediatric Surgeon.
Reprints: Mr Andrew J A Holland, Department of Academic Surgery, The
Children's Hospital at Westmead, Royal Alexandra Hospital for
Children, Locked Bag 4001, Westmead, NSW 2145.
AndrewH3ATchw.edu.au
©MJA 2001
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