- Email: [email protected]
Equine-related injury: a retrospective analysis of outcomes over a 10-year period
The American Journal of Surgery (2008) 195, 702–704
Society of Black Academic Surgeons
Equine-related injury: a retrospective analysis of outcomes over a 10-year period Callisia N. Clarke, M.D., Betty J. Tsuei, M.D., Karyn L. Butler, M.D.* Department of Surgery, Division of Trauma/Critical Care, University of Cincinnati, 231 Albert B. Sabin Way, Cincinnati, OH 45267-0828, USA KEYWORDS: Equine-related injuries; Horse activities; Equine injuries
Abstract BACKGROUND: Morbidity and financial loss caused by equine-related injuries may be significant. The purposes of this study were to determine the patterns of equine-related injury and the impact on outcomes. METHODS: A 10-year retrospective review of equine-related injuries was performed. Age, gender, mechanism, injury severity score, Glasgow Coma Score, length of stay, surgical interventions, and mortality were assessed. RESULTS: Of 80 emergency department evaluations, 76 patients were admitted and form the basis of this study. The most frequent mechanism of injury was fall (68%), followed by crush injuries (15%), kicks (8%), and trampling (5%). Musculoskeletal injuries were most common (64%). Thirty-eight (50%) patients required surgical intervention. Thirty-seven (52%) patients were discharged home; 34% required outpatient physical therapy, and 14% required inpatient rehabilitation. The mortality rate was 7%. CONCLUSIONS: Equine-related injuries resulted in significant morbidity; most victims required outpatient or inpatient rehabilitation. The use of preventive strategies may minimize mortality and reduce the financial impact of postinjury morbidity. © 2008 Elsevier Inc. All rights reserved.
Equine-related trauma accounts for a small percentage of emergency department visits in the United States. National data from the Centers for Disease Control, from 2001 to 2003, estimated that approximately 100,000 emergency room visits each year are attributed to equine-related activities [1]. Further, the data from the Centers for Disease Control concluded that women were more likely to be injured from horse-related activities than men, and 66% of all injuries occurred while riders were attempting to mount the horse. Although the mortality rate is low (⬍10%) rela-
* Corresponding author. Tel.: ⫹1-513-558-8931; fax: ⫹1-513-558-0456. E-mail address: [email protected] Manuscript received July 11, 2007; revised manuscript November 26, 2007
0002-9610/$ - see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2007.11.007
tive to other causes of blunt trauma, morbidity can be significant as a result of the increased incidence of skeletal fractures and head injury [2]. Moreover, areas with large numbers of equine activities potentially may incur significant financial loss owing to injury-related morbidity and mortality. Internationally, a large proportion of health care dollars are expended investigating strategies to reduce equine-related injury. In one Australian study, equine-related injury was among the top 20 recreational activities resulting in emergency evaluations, and, more significantly, these injuries ranked third in recreational activity requiring hospitalization [3]. In the United States, a high injury rate has been reported in competitive horse racing. The actual incidence of injury reported, however, may not include
C.N. Clarke et al. Table 1
Equine related injury
703
Demographic data
Age, y ISS Hospital length of stay, d Gender Glasgow Coma Score
42 ⫾ 1 13 ⫾ 1 5⫾1 50% male 14 ⫾ 0.2
those jockeys evaluated and treated by medical personnel at the track [4]. Ohio is home to 8 thoroughbred race tracks throughout the state and the greater Cincinnati area is home to 6 professional racing tracks within a 100-mile radius. Although these tracks predominantly reside within Kentucky, the University of Cincinnati is the primary level I trauma center for this catchment area. Moreover, enthusiasm for horse-related activities extends outside the professional arena of thoroughbred racing. Therefore, the purposes of this study were to determine the patterns of the equinerelated injuries and their impact on patient outcomes.
Methods The study design was reviewed and approved by the University of Cincinnati Institutional Review Board. Patients with equine-related injuries were identified by the University Hospital Regional Trauma Center Trauma Registry Data Base. A retrospective review of the medical records of these patients from July 1993 to July 2004 was performed. Demographic data collected and analyzed included age, gender, injury severity score (ISS), Glasgow Coma Score, hospital length of stay, surgical interventions, mortality, and the need for rehabilitation after discharge from the hospital. Data are expressed as mean ⫾ standard error of the mean.
Figure 1 Mechanism of injury in victims of equine-related trauma. Falls were the most common mechanism of injury followed by being crushed, kicked, or trampled.
and extremity injuries (21% each). When all injuries to the musculoskeletal system were combined, they accounted for 64% of all injuries sustained; far surpassing the frequency of head trauma (Fig. 2). Of the 76 patients admitted for management of their injuries, 38 patients (50%) required surgical intervention. Orthopedic procedures were performed most frequently (19%); however, other surgical services included neurosurgery (6%), general surgery (5%), and urology/vascular procedures (8%). There was no significant difference in ISS in patients requiring surgical intervention compared with patients who did not require surgery (15.5 ⫾ 2 vs 12.3 ⫾ 1; P ⫽ .14). The mortality rate in the study group was 7% (5 patients); the mean ISS of 35 ⫾ 8 in nonsurvivors reflects the severity of associated injuries. Four patients died from severe head trauma and 1 patient died from blunt abdominal trauma with injuries to the liver and spleen. Of the 71 surviving patients, 37 (52%) were discharged home without the need for further intervention; however, 24 (34%) patients required outpatient physical therapy. The remaining 10 (14%) patients were transferred to an inpatient rehabilitation center. Their injuries included closed head injury (3 patients), musculoskeletal trauma (3 patients), spinal cord injury (3 patients), and multisystem trauma (1 patient).
Results During the 10-year study period, 80 adult patients with equine-related injuries were evaluated by the trauma service at the University of Cincinnati trauma center. Four patients (5%) were discharged home directly from the emergency department. The remaining 76 patients were admitted to the hospital and form the basis of this study. Their demographics are displayed in Table 1. There were an equal number of male and female patients, and the mean age at presentation was 42 ⫾ 1 years (range, 15– 81 y). The most common mechanism of injury was a fall from the horse, accounting for more than two thirds (68%) of all injuries sustained (Fig. 1). Injury patterns were characterized by trauma to the head and face most frequently (38%) followed by thoracic injuries (26%), spinal column or cord injuries (22%), and pelvis
Figure 2 Distribution of injuries sustained in equine-related events. Injuries to the musculoskeletal system were most frequent. Other vulnerable body areas included the head/face and the thoracic region. Musculoskel ⫽ musculoskeletal; GU ⫽ genitourologic.
704
The American Journal of Surgery, Vol 195, No 5, May 2008
Comments
injury patterns may promote further investigation into the use of preventive strategies specifically directed at body regions most frequently and/or seriously injured during equine-related activities.
The results from this 10-year retrospective review indicate that although mortality from equine-related injury is low, more than half of the injured patients required rehabilitation after discharge from the acute-care facility. Moreover, except for gender predilection, mortality and injury patterns were similar to nationally reported data over the same time period [5]. Importantly, the 3 body regions identified to be most at risk for injury after equine-related activities were the musculoskeletal system, the head/face, and the thoracic region. Various reports over the past 20 years have detailed injury patterns associated with equestrian activities. Vulnerable body regions include the head, hand/wrist, foot/ankle, and spinal cord/column and preventive strategies have incorporated protective gear to minimize injury to these areas [6]. Interestingly, the use of riding helmets was associated with a 5-fold reduction in head injuries [7]. Other studies similarly have shown a reduction in the number and severity of head injuries in helmeted riders whereas the incidence and severity of injury to the unprotected upper extremities, particularly in female riders, has increased [8]. The injury patterns identified in the present study are consistent with past reports and taken together suggest that the use of protective gear targeting vulnerable body regions may minimize the severity and frequency of injury in equestrian events. Mayberry et al [9] stratified 679 horse riders by skill level as defined by subjective total hours of experience. Their analysis showed that 1 in 5 riders would have sustained a serious injury, defined as an injury requiring hospitalization, surgery, or resulting in disability. When riders were stratified according to skill level, the risk of injury for novice riders (ie, riders with ⬍100 hours of experience) was increased 3-, 5-, and 8-fold compared with intermediate, advanced, and professional riders, respectively. This study suggests that maximal risk reduction may be achieved through the use of preventive strategies by novice equestrians. Limitations of the present study included the retrospective design and the small sample size. The retrospective design did not allow for stratification according to skill level or experience with horses, nor were we able to identify whether protective gear was used. Our characterization of
Summary Equine-related trauma is associated with high morbidity secondary to the prevalence of musculoskeletal fractures and closed head injuries. As a direct result of the injuries sustained, patients presenting with equine-related trauma are likely to require rehabilitation after discharge from the acute-care facility. Further investigation is necessary to identify high-risk individuals and implement preventative strategies that may minimize annual health care expenditures incurred from hospitalization and rehabilitation. Until additional research is available, the use of helmets and protective extremity padding should be considered by novice riders.
References 1. Thomas KE, Annest JL, Gilchrist J, et al. Nonfatal horse-related injuries treated in emergency departments in the United States. Br J Sports Med 2006;40:619 –26. 2. Kriss TC, Kriss VM. Equine-related neurosurgical trauma: a prospective series of 30 patients. J Trauma 1997;43:97–9. 3. Finch CF, Ozanne-Smith J, Williams F. The feasibility of improved data collection methodologies for sports injuries. Report no. 69. Melbourne: Monash University Accident Research Centre, 1995. 4. Waller AE, Daniels JL, Weaver NL, et al. Jockey injuries in the United States. JAMA 2000;283:1326 – 8. 5. Griffen M, Boulanger BR, Kearney PA, et al. Injury during contact with horses: recent experience with 75 patients at a level I trauma center. South Med J 2002;95:441–5. 6. Whitlock MR. Injuries to riders in the cross country phase of eventing: the importance of protective equipment. Br J Sports Med 1999;33: 212– 6. 7. Chitnavis JP, Gibbons CL, Hirigoyen M, et al. Accidents with horses: what has changed in 20 years? Injury 1996;27:103–5. 8. Moss PS, Wan A, Whitlock MR. A changing pattern of injuries to horse riders. Emerg Med J 2002;19:412– 4. 9. Mayberry JC, Pearson TE, Wiger KJ, et al. Equestrian injury prevention efforts need more attention to novice riders. J Trauma 2007;62:735–9.
Society of Black Academic Surgeons
Equine-related injury: a retrospective analysis of outcomes over a 10-year period Callisia N. Clarke, M.D., Betty J. Tsuei, M.D., Karyn L. Butler, M.D.* Department of Surgery, Division of Trauma/Critical Care, University of Cincinnati, 231 Albert B. Sabin Way, Cincinnati, OH 45267-0828, USA KEYWORDS: Equine-related injuries; Horse activities; Equine injuries
Abstract BACKGROUND: Morbidity and financial loss caused by equine-related injuries may be significant. The purposes of this study were to determine the patterns of equine-related injury and the impact on outcomes. METHODS: A 10-year retrospective review of equine-related injuries was performed. Age, gender, mechanism, injury severity score, Glasgow Coma Score, length of stay, surgical interventions, and mortality were assessed. RESULTS: Of 80 emergency department evaluations, 76 patients were admitted and form the basis of this study. The most frequent mechanism of injury was fall (68%), followed by crush injuries (15%), kicks (8%), and trampling (5%). Musculoskeletal injuries were most common (64%). Thirty-eight (50%) patients required surgical intervention. Thirty-seven (52%) patients were discharged home; 34% required outpatient physical therapy, and 14% required inpatient rehabilitation. The mortality rate was 7%. CONCLUSIONS: Equine-related injuries resulted in significant morbidity; most victims required outpatient or inpatient rehabilitation. The use of preventive strategies may minimize mortality and reduce the financial impact of postinjury morbidity. © 2008 Elsevier Inc. All rights reserved.
Equine-related trauma accounts for a small percentage of emergency department visits in the United States. National data from the Centers for Disease Control, from 2001 to 2003, estimated that approximately 100,000 emergency room visits each year are attributed to equine-related activities [1]. Further, the data from the Centers for Disease Control concluded that women were more likely to be injured from horse-related activities than men, and 66% of all injuries occurred while riders were attempting to mount the horse. Although the mortality rate is low (⬍10%) rela-
* Corresponding author. Tel.: ⫹1-513-558-8931; fax: ⫹1-513-558-0456. E-mail address: [email protected] Manuscript received July 11, 2007; revised manuscript November 26, 2007
0002-9610/$ - see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2007.11.007
tive to other causes of blunt trauma, morbidity can be significant as a result of the increased incidence of skeletal fractures and head injury [2]. Moreover, areas with large numbers of equine activities potentially may incur significant financial loss owing to injury-related morbidity and mortality. Internationally, a large proportion of health care dollars are expended investigating strategies to reduce equine-related injury. In one Australian study, equine-related injury was among the top 20 recreational activities resulting in emergency evaluations, and, more significantly, these injuries ranked third in recreational activity requiring hospitalization [3]. In the United States, a high injury rate has been reported in competitive horse racing. The actual incidence of injury reported, however, may not include
C.N. Clarke et al. Table 1
Equine related injury
703
Demographic data
Age, y ISS Hospital length of stay, d Gender Glasgow Coma Score
42 ⫾ 1 13 ⫾ 1 5⫾1 50% male 14 ⫾ 0.2
those jockeys evaluated and treated by medical personnel at the track [4]. Ohio is home to 8 thoroughbred race tracks throughout the state and the greater Cincinnati area is home to 6 professional racing tracks within a 100-mile radius. Although these tracks predominantly reside within Kentucky, the University of Cincinnati is the primary level I trauma center for this catchment area. Moreover, enthusiasm for horse-related activities extends outside the professional arena of thoroughbred racing. Therefore, the purposes of this study were to determine the patterns of the equinerelated injuries and their impact on patient outcomes.
Methods The study design was reviewed and approved by the University of Cincinnati Institutional Review Board. Patients with equine-related injuries were identified by the University Hospital Regional Trauma Center Trauma Registry Data Base. A retrospective review of the medical records of these patients from July 1993 to July 2004 was performed. Demographic data collected and analyzed included age, gender, injury severity score (ISS), Glasgow Coma Score, hospital length of stay, surgical interventions, mortality, and the need for rehabilitation after discharge from the hospital. Data are expressed as mean ⫾ standard error of the mean.
Figure 1 Mechanism of injury in victims of equine-related trauma. Falls were the most common mechanism of injury followed by being crushed, kicked, or trampled.
and extremity injuries (21% each). When all injuries to the musculoskeletal system were combined, they accounted for 64% of all injuries sustained; far surpassing the frequency of head trauma (Fig. 2). Of the 76 patients admitted for management of their injuries, 38 patients (50%) required surgical intervention. Orthopedic procedures were performed most frequently (19%); however, other surgical services included neurosurgery (6%), general surgery (5%), and urology/vascular procedures (8%). There was no significant difference in ISS in patients requiring surgical intervention compared with patients who did not require surgery (15.5 ⫾ 2 vs 12.3 ⫾ 1; P ⫽ .14). The mortality rate in the study group was 7% (5 patients); the mean ISS of 35 ⫾ 8 in nonsurvivors reflects the severity of associated injuries. Four patients died from severe head trauma and 1 patient died from blunt abdominal trauma with injuries to the liver and spleen. Of the 71 surviving patients, 37 (52%) were discharged home without the need for further intervention; however, 24 (34%) patients required outpatient physical therapy. The remaining 10 (14%) patients were transferred to an inpatient rehabilitation center. Their injuries included closed head injury (3 patients), musculoskeletal trauma (3 patients), spinal cord injury (3 patients), and multisystem trauma (1 patient).
Results During the 10-year study period, 80 adult patients with equine-related injuries were evaluated by the trauma service at the University of Cincinnati trauma center. Four patients (5%) were discharged home directly from the emergency department. The remaining 76 patients were admitted to the hospital and form the basis of this study. Their demographics are displayed in Table 1. There were an equal number of male and female patients, and the mean age at presentation was 42 ⫾ 1 years (range, 15– 81 y). The most common mechanism of injury was a fall from the horse, accounting for more than two thirds (68%) of all injuries sustained (Fig. 1). Injury patterns were characterized by trauma to the head and face most frequently (38%) followed by thoracic injuries (26%), spinal column or cord injuries (22%), and pelvis
Figure 2 Distribution of injuries sustained in equine-related events. Injuries to the musculoskeletal system were most frequent. Other vulnerable body areas included the head/face and the thoracic region. Musculoskel ⫽ musculoskeletal; GU ⫽ genitourologic.
704
The American Journal of Surgery, Vol 195, No 5, May 2008
Comments
injury patterns may promote further investigation into the use of preventive strategies specifically directed at body regions most frequently and/or seriously injured during equine-related activities.
The results from this 10-year retrospective review indicate that although mortality from equine-related injury is low, more than half of the injured patients required rehabilitation after discharge from the acute-care facility. Moreover, except for gender predilection, mortality and injury patterns were similar to nationally reported data over the same time period [5]. Importantly, the 3 body regions identified to be most at risk for injury after equine-related activities were the musculoskeletal system, the head/face, and the thoracic region. Various reports over the past 20 years have detailed injury patterns associated with equestrian activities. Vulnerable body regions include the head, hand/wrist, foot/ankle, and spinal cord/column and preventive strategies have incorporated protective gear to minimize injury to these areas [6]. Interestingly, the use of riding helmets was associated with a 5-fold reduction in head injuries [7]. Other studies similarly have shown a reduction in the number and severity of head injuries in helmeted riders whereas the incidence and severity of injury to the unprotected upper extremities, particularly in female riders, has increased [8]. The injury patterns identified in the present study are consistent with past reports and taken together suggest that the use of protective gear targeting vulnerable body regions may minimize the severity and frequency of injury in equestrian events. Mayberry et al [9] stratified 679 horse riders by skill level as defined by subjective total hours of experience. Their analysis showed that 1 in 5 riders would have sustained a serious injury, defined as an injury requiring hospitalization, surgery, or resulting in disability. When riders were stratified according to skill level, the risk of injury for novice riders (ie, riders with ⬍100 hours of experience) was increased 3-, 5-, and 8-fold compared with intermediate, advanced, and professional riders, respectively. This study suggests that maximal risk reduction may be achieved through the use of preventive strategies by novice equestrians. Limitations of the present study included the retrospective design and the small sample size. The retrospective design did not allow for stratification according to skill level or experience with horses, nor were we able to identify whether protective gear was used. Our characterization of
Summary Equine-related trauma is associated with high morbidity secondary to the prevalence of musculoskeletal fractures and closed head injuries. As a direct result of the injuries sustained, patients presenting with equine-related trauma are likely to require rehabilitation after discharge from the acute-care facility. Further investigation is necessary to identify high-risk individuals and implement preventative strategies that may minimize annual health care expenditures incurred from hospitalization and rehabilitation. Until additional research is available, the use of helmets and protective extremity padding should be considered by novice riders.
References 1. Thomas KE, Annest JL, Gilchrist J, et al. Nonfatal horse-related injuries treated in emergency departments in the United States. Br J Sports Med 2006;40:619 –26. 2. Kriss TC, Kriss VM. Equine-related neurosurgical trauma: a prospective series of 30 patients. J Trauma 1997;43:97–9. 3. Finch CF, Ozanne-Smith J, Williams F. The feasibility of improved data collection methodologies for sports injuries. Report no. 69. Melbourne: Monash University Accident Research Centre, 1995. 4. Waller AE, Daniels JL, Weaver NL, et al. Jockey injuries in the United States. JAMA 2000;283:1326 – 8. 5. Griffen M, Boulanger BR, Kearney PA, et al. Injury during contact with horses: recent experience with 75 patients at a level I trauma center. South Med J 2002;95:441–5. 6. Whitlock MR. Injuries to riders in the cross country phase of eventing: the importance of protective equipment. Br J Sports Med 1999;33: 212– 6. 7. Chitnavis JP, Gibbons CL, Hirigoyen M, et al. Accidents with horses: what has changed in 20 years? Injury 1996;27:103–5. 8. Moss PS, Wan A, Whitlock MR. A changing pattern of injuries to horse riders. Emerg Med J 2002;19:412– 4. 9. Mayberry JC, Pearson TE, Wiger KJ, et al. Equestrian injury prevention efforts need more attention to novice riders. J Trauma 2007;62:735–9.