Equestrian injuries: A five-year review

The Journal

of Emergency

Pergamon

Mcdicinc,

Vol12, No 2, pp 143-145,1994 @ 1994 Ebevicr scicnc~ Ltd F’ri-rk~in the USA. Au rights rcacrvcd 0736-4679/94$6.00 + .oo

CODYlidlt

073647!J(93)3ooo4-2

Original Contributions

EQUESTRIAN INJURIES: A FIVE-YEAR REVIEW Gregory D. Hobbs, MD, Donald M. Yealy, MD, and Julie Rivas, RN Department of Emergency Medicine, Scott & Whiie Clinic and Memorial Hospital, Scott, Sherwood and Brindley Foundation, Texas A&M University Health Science Center, College of Medicine, Temple, Texas Reprint Address: Gregory D. Hobbs, MD, FACEP, Scott &White Memorial Hospital, 2401 South 31st Street, Temple, TX 76506

of the inherentdangersassociatedwith this activity. The incidenceof equestrian-related injuries hasbeen reportedby the Centersfor DiseaseControl to be 18.7 per 100,000(3). Prior studies,most of which are from Europe, have analyzedinjury patternsof riders involved in organized riding clubs or only thosepatientsrequiringhospitaladmission(2-6). We desiredto define the demographicsand injury pattern of all patientspresentingwith equestrian-related injuries in a population in which most riders are involved in nonorganizedleisureriding or work activities.

0 Abtract-A retrospective chart review was conducted to define the demographk and injury patterns of patients presenting to the emergency department (ED). The setting is a rural/smaU arban tertiary care center with approximately 40,000 visits per year. All patients presenting to the ED from Jamaary l!XM through December 1990 with ~~IWSHBII-relatedinjuries were enrolled in the study. Mea-t8 idtad 4b =, mddam of Iqlprg,4arv or 4au&s dbgaosed, admidon to the hospital, morbidity, and mortal&y. A total of 142 patients met the iadusion criteria. The m@rity of 41&s occurred when the patient fell from a horse. There were also a large number of injariea assodated with hadUng the horse. Most injurk3 were minor, hut 1Wo reqdred hospital admission. There were no deaths. In condasion, eqoestrhn activities are associated with a risk of serioas 4ury to both riders and handlers of horses. E&cation of both the public and primary care physkians should focus on injary prevention. Cl Keyworth-equestrian related 4aries

4uries;

horse

MATERIALS

Temple, Texas, is located in a predominatelyrural portion of centralTexaswith a wide variety of equestrian activitiesoccurringyearround. Scott andWhite Memorial Hospital/Texas A&M University Health ScienceCenter servesas the primary trauma center for the region. The emergencydepartmenthas an annualvolume of approximately40,000visits. The medical recordsof all patients presentingto Scott and White EmergencyDepartmentwith an injury relatedto riding or handlinga horseduring the periodof January1986throughDecember1990were reviewed.The following variableswererecordedand analyzed:age,sex,type of injury, mechanismof injury, admissionto the hospital, morbidity, and mortality. An injury scoremeasuringthe long-term dis-

411ries;sports-

INTRODUCTION

At least 30 million peopleride horsesin the United Statesannually,and one half of theseride on a regular basis(1,2).Not only is horsebackriding becoming an increasinglypopular recreationalactivity, but in some areasof the country horsesare usedin farm and ranch work. Despitethe interestin participating in equestrianactivities, a low level of awarenessremains on the part of both the public and physicians 28 tember 1992;FINAL ACCEPTED:292 arch 1993

&3CEIVBD:

SUBMISSION

AND METHODS

RECEIVED:

143

15March 1993;

t

ability resulting from the injury was also recorded (Table 1). Datawereanalyzedby descriptivemethods only. RESULTS

A total of 142patientsmet the inclusioncriteria. The mean patient agewas27 years(range2 to 74 years). Fifty-three percentof the patientswerefemales.The mechanismsof injury were patient fall frOM horse (63%), horsekicked patient (17Vo),horsefell on patient (7Oro), horsesteppedon patient(a%), and other (7010). Ten patients(7Vo)not only werethrown from the horse,but they alsohad the animal fall on them. This group tended to suffer more seriousinjuries (Table2). Injuries included 41 fractures(9 rib, 9 upper extremity, 7 lower extremity, 7 spine,5 skull, 2 facial, 2 clavicle),20headinjuries, 5 blunt abdominalinjuries, 5 pneumothoraces,11lacerations,and 65 minor soft tissue injuries. Thirty-four patients had more than oneinjury. Twenty-two patients(15%) requiredhospital admission. Severemorbidity, requiring prolongedhospitalization or resultingin total disability, occurred in four patients(2.60/o).Twenty-threepatients(16%) had injuries requiringhospitalizationand postinjury physicaltherapy.Twenty-twopatients(15%) had injuries requiring an extendedrecoverytime but no residual problems. Ninety-five patients (65%) had minor injuries with uncomplicatedfull recovery. DISCUSSION

The majority (63%) of the patientsin our serieswere injured whentheyfell from a horse.This is consistent with prior reports showing45% to 75% of injuries occurringin this manner(1,2,4).All upperextremity fracturesoccurredwhenthe patientfell from a horse, Table 1. Injury by Mechanism Injury

Fall

Kick

Crush

Other

Total

: 3 4 5

66 16 12 x

15 ii 8

a5

t 0 A

95 23 23 2 2

1 = Rapid, full recovery; work; closed head injury hospitalization; extended days with residual deficits;

3 :,

2 = extended recovery time off with loss of consciousness; 3 = therapy; 4 = hospitalization; >7 5 = total disability.

Table 2. Dlstrlbutlon

of InJurlw by Mechsnlsm

Injury

Fall

Kick

Skull fractures Closed head injury Facial fractures Spinal fractures Chest trauma Abdomen trauma Upper extremity fractures Lower extremity fractures Lacerations Soft tissueinjury

2 13 0

1 :

f 4

Crush

Other

1 : 0

Total (%) 4 20 3 7

(2) (12) (2) (4) 12 (7) 7 (4)

: 2

: 1 1 1

: 0

11

0

1

0

12 (7)

t 55

2 3 14

2 1 6

0 3 4

a (5) 13 (a) 79 (9

as did all but one spinal fracture. One patient who fell suffered a C-l fracture with respiratory arrest andpermanentquadriplegia,and anotherhad an unstable burst fracture of T-10 requiring Harrington rod placementfor stabilization. Three patientswith abdominalinjuries from falls werehospitalized,but none required surgical intervention. All blunt abdominal injuries were evaluatedwith computedtomography(CT scan). A significantpercentageof injuries occurredwhile handling horseswithin a confined area. The most seriousmechanismof injury associatedwith handling horsesis beingkicked. Many kicks occurto the head, face,or chest,resultingin severeinjuries (4-6).There were four closedhead injuries, three pneumothoraces,threefacial fractures,onecervicalspinefracture, and nineblunt chestor abdominalinjuries. Two childrenwho werekicked in the abdomenwerehospitalized. Both had negativeabdominalCT scans,andno surgerywasrequired.The onecervicalspinefracture wasstableand wastreatedwith a rigid collar. Lower extremity fracturesweremore likely to be associated with the horsefalling or steppingon the patient. Two patients werebitten by a horse,one on the neck and the other on the arm. Horse bites occur commonly, with the true incidencebeing very difficult to obtain becausemost peoplebitten by horses do not seekmedicalcare.Horsebites tend to consist of severecontusionswith no breakin the skin (7). If lacerationsdo occur, prophylacticantibiotics should be considered.In addition to staphylococcusand streptococcusinfections, horse bites may involve Bacteroides spp., Clostridium tetani, and rabies.The most recentCDC report on casesof rabiesin domestic animals showed63 casesof rabid horsesin the United States,with 20 of these casesoccurring in Texas(8). Thesebites should be treatedin the same manneras other animal biteswith copiousirrigation and appropriatedebridement.Tetanus prophylaxis

Equestrian Injuries

145

should be administeredaccordingto current guidelinesfor contaminatedwounds. A total of 20 patients (12%) had head injuries, including4 skull fractures.Sixteenpatientssustained head injuries from falls, while four patients were kicked in the head.None of our patientswerewearing protectiveheadgearwhen injured. The majority of theseinjuries might have been preventedor reduced in severity if the rider had been wearing a properlydesignedand securedhelmet.Numerousauthors have emphasizedthe importance of proper headgearin reducingthe incidenceand severity of equestrian-related headinjuries (1,5,6,9,10).In a report of lethal equestrianinjuries in Sweden,Ingemarson and associates(5) found that 72% were secondary to headinjuries. The utility of some currently available headgearhas also been questioned.Muwangaand Dove (9) report on 17 patientsrequiring admissionfor headinjuries. The hat was dislodged

in six (35%) of the cases.Threepatients(17%) sustained skull fractures despitethe helmet remaining in place. Helmetsthat meet the requirementsof the American Society for Testing and Materials (10) should provide excellentprotection when appropriately secured.Many organized riding associations now require all members to wear headgearwhich meetsthesestandards. CONCLUSION Equestrian injuries are most commonly associated with falls from the horse.While the majority of the injuries are minor, a significant percentageare serious. Education of both the public and primary care physicians should focus on prevention of injuries basedon thesetypical injury patterns.This should includethe useof properheadprotection.

REFERENCES 1. Bixby-Hammett DM. Accidents in equestrian sports. Am Fam Physician. 1987;36(3):209-14. 2. Barone CW, Rodgers BM. Pediatric equestrian injuries: a 14 year review. J Trauma. 1989;29(2):245-7. 3. From the Centers for Disease Control. Injuries associated with horseback riding-United States, 1989 and 1988. JAMA. 1990; 264(1):18-19. 4. Edixhoven P, Sii SC, Dandy DJ. Horse injuries, injury. Br J Accident Sum. 1981:12(4):279-82. 5. Ingemarson H; Grew&in ‘S, Thoren L. Lethal horse-riding injuries. J Trauma. 1989;29(1):25-30. 6. Bixby-Hammett D, Brooks WH. Common injuries in horseback riding: A review. Sports Med. 1990,9(1):36-47.

7. Marrie TJ, Bent JM, RT, West AB. ART, Roberts TMF, Haldane EV. Extensive gas in tissues of the forearm after horsebite. South Med J. 1979;72:1473. 8. Pacer RE, Fishbein DB, Baer GM, Jenkins SR, Smith JS. Rabies in the US and Canada, 1983. Morb Mortal Wkly Rep 1985;34:155. 9. Muwanga LC, Dove AF. Head protection for horse riders: a cause for concern. Arch Emerg Med. 1985;2(2):85-7. 10. Specification for Headgear Used in Horse Sports and Horseback Riding. Standard No. F1163-88. American Society for Testing and Materials, 1916 Race St., Philadelphia, PA, 19103.