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Helmet under-utilization by children during equestrian events is associated with increased traumatic brain injury
Journal of Pediatric Surgery 53 (2018) 545–547
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Trauma/Critical Care
Helmet under-utilization by children during equestrian events is associated with increased traumatic brain injury☆ Scott S. Short ⁎, Stephen J. Fenton, Eric R. Scaife, Brian T. Bucher Division of Pediatric Surgery, Department of Surgery, University of Utah School of Medicine, 100 N. Mario Ceppechi Drive, Suite 3800, Salt Lake City, UT 84113, United States
a r t i c l e
i n f o
Article history: Received 18 January 2017 Received in revised form 10 March 2017 Accepted 12 March 2017 Key words: Pediatric Equestrian Helmet Traumatic brain injury
a b s t r a c t Purpose: Awareness of equestrian related injury remains limited. Studies evaluating children after equestrian injury report under-utilization of safety equipment and rates of operative intervention as high as 33%. Methods: We hypothesized that helmets are underutilized during equestrian activity and lack of use is associated with increased traumatic brain injury. We queried the trauma database of a level one pediatric trauma center for all cases of equestrian and rodeo related injury from 2005 to 2015. Analysis was conducted using SAS 9.4. Results: Of 312 children identified, 142 were assessed for use of a helmet. Only 28 children (19.7%) had documented use of a helmet. Most injuries occurred while riding a horse (83%) or bull (13%) with traumatic brain injury being the most common injury (51%). Helmet use was associated with decreased ISS (7.1 vs. 11.3, p b 0.01), TBI (32.4% vs. 55.3%, p = 0.03), and ICU admission (10.7% vs. 29%, p = 0.05). Multivariable analysis reveals lack of helmet use to be an independent predictor of TBI (OR 2.5, 95% CI 1.1–6.3). Conclusion: Helmets are underutilized by children during equestrian related activity. Increased awareness of TBI and education encouraging helmet use may decrease morbidity associated with equestrian activities. Level of Evidence: Retrospective comparative study, Level III. © 2017 Elsevier Inc. All rights reserved.
Equestrian events are a common cause of pediatric sports-related injuries, represented 14% of injuries in a recent review from the National Trauma Databank [1]. Prior studies of equestrian related trauma in children indicate that traumatic brain injury (TBI) is one of the most common injuries sustained with reported incidence of 15.3%–23% and may be responsible for up to 57% of mortality associated with equestrian activity [2]. Despite these alarming facts, utilization of helmets and other safety equipment appear underutilized with a 1995 study reporting use of helmets in less than 2/3 of children. [3]. In this study, we aim to report our experience with children who sustained equestrian related injury and specifically focus on the utilization of helmets and injury patterns. We hypothesize that helmets are underutilized during equestrian activity and lack of use is associated with increased TBI.
☆ Presented at the Western Pediatric Trauma Conference, Snowmass, Colorado on July 20th, 2016. ⁎ Corresponding author at: 100 N. Mario Cappechi Drive, Suite 3800, Salt Lake City, UT 84132, United States. E-mail addresses: [email protected] (S.S. Short), [email protected] (S.J. Fenton), [email protected] (E.R. Scaife), [email protected] (B.T. Bucher). http://dx.doi.org/10.1016/j.jpedsurg.2017.03.043 0022-3468/© 2017 Elsevier Inc. All rights reserved.
1. Methods 1.1. Patient population We performed a single center retrospective review of all children (b 18 years old) identified from the institution's prospectively collected trauma database from 2005 to 2015. All patients who experienced an equestrian related injury (horse, bull, sheep, or calf) were included in the study. Children who did not have documentation of helmet use (presence or absence) were excluded (Fig. 1). Institution review board approval was obtained at Primary Children's Hospital, Salt Lake City, UT.
1.2. Description of variables Demographic factors including gender and age were recorded. Trauma related factors include type of animal involved (e.g., bull, horse, sheep, calf), type of injury (e.g., fall from animal, kicked by animal, stepped/ stomped by animal), location of injury (e.g., home, recreational facility), type of injury suffered (TBI, spinal cord/nerve injury, liver, spleen, extremity), injury severity score, revised trauma score, and Glasgow coma score. Helmet use was assessed. Outcomes included admission to the hospital, intensive care unit (ICU) admission, need for neurosurgical intervention, exploratory laparotomy, length of stay, disposition, and mortality.
546
S.S. Short et al. / Journal of Pediatric Surgery 53 (2018) 545–547
Number of Children Presenting with Equestrian Related Injuries from 2005 to 2015 N = 312
Children with Unknown Helmeted Status N= 170
Children Assessed for Presence or Absence of a Helmet N= 142
Children Evaluated in Study N= 142
Excluded from Analysis
Fig. 1. Patients Enrolled in Study.
1.3. Statistical analysis All data were recorded into a standardized database program (Microsoft Excel©, Seattle, WA). Univariate analysis was performed using Wilcoxon test on continuous variables and Fischer's Exact test for categorical variables. A p-value b 0.05 was considered significant. Multivariable logistic regression was performed using SAS 9.4.
time of injury (OR 5.4, 95% CI 1.9–16, p b 0.01). In addition, children whose injuries occurred at a recreation center were more likely to be wearing a helmet compared to children who were injured at home (OR 5.6, 95% CI 1.9–15.7, p b 0.01) (Table 3). Lack of helmet use was found to be an independent predictor of TBI (OR 2.6, 95% CI 1.1–6.3, p = 0.03) and had a trend towards ICU admission (OR 3.4, 95% CI 0.96–3.6, p = 0.06).
2. Results From 2005 to 2015, 312 children were evaluated for equestrian associated trauma. Of these 142 (45.5%) were assessed for use of helmet (Table 1). The majority were female (54%) with a median age of 11 (±5.5) years. Only 28 children (19.7%) had documented use of a helmet at the time of injury. Horses (82%) were the most common animals involved in injuries followed by bulls (13%), calves (3%), and sheep (2%). The majority of injuries occurred at either home (42%) or a recreational facility (31%). Falls (70%) were the most common mechanism of injury followed by kick injury (18%), step/stomp injury (10%), and rollover injury (3%). Children suffered from a TBI in 50.7% of cases, an extremity injury in 16.9% of cases, a liver injury in 8.5%, and a spleen injury in 2.8%. The majority of children (97%) evaluated required admission to the hospital with 25.4% requiring an ICU related admission. Only 5.6% of patients required neurosurgical intervention and no child required a laparotomy. No child suffered from a mortality from these types of injuries. When comparing the outcomes of children with helmet use to those without we found significant differences between the two groups on univariate analysis. Those with helmet use had a significantly lower ISS (7.1 ± 5.5 vs. 11.3 ± 6.5, p b 0.001) and lower rates of TBI (32.4% vs. 55.2%, p = 0.03), and were less likely to be admitted to the ICU (10.7% vs. 29%, p = 0.05). There were no differences in age, gender, revised trauma score, Glasgow Coma Scale, and length of stay (Table 2). To identify independent patient and injury factors associated with the use of a helmet we performed logistic regression on the primary outcome of documented helmet use. Compared to horse riding, children riding on a bull or a calf were more likely to be wearing a helmet at the
Table 1 Demographics (N = 142). Gender (male) Age (median, range) Helmet use Animal Horse Bull Calf Sheep Location of injury Home Recreation Other Mechanism of injury Fall Kick Step/Stomp Rollover Other Multiple mechanismsa Injury TBI Extremity injury Liver Spleen Hospital admission ICU admission Required craniotomy Survival
46% 11 (1.5–17) years 19.7% 82.4% 12.7% 2.8% 2.1% 41.5% 31% 27.5% 70% 17.6% 10.6% 2.8% 9.8% 8.4% 51% 16.9% 8.5% 2.8% 96.5% 25.4% 5.4% 100%
a Some children experienced more than one mechanism, e.g., fell from horse and then kicked.
S.S. Short et al. / Journal of Pediatric Surgery 53 (2018) 545–547 Table 2 Helmet vs. no helmet use.
Gender (% male) Age, years, mean (SD) Injury Severity Score, mean (SD) Revised Trauma Score, mean (SD) Glasgow Coma Scale, mean (SD) Traumatic brain injury Craniotomy(ectomy) Intensive care unit admission Length of Stay, days (SD)
547
Table 3 Multivariable analysis of factors associated with helmet use. Helmet (n = 28)
No helmet (n = 114)
p Value
50% 11.1 (±3.7) 7.1 (±5.5) 7.6 (±0.9) 14.4 (±2.3) 32.4% 0% 10.7% 2 (±1.5)
44% 10.4 (±4.4) 11.3 (±6.5) 7.4 (±1.2) 13.8 (±3.3) 55.3% 7% 29% 3.5 (±4.7)
0.67 0.44 b0.001 0.81 0.33 0.03 0.35 0.05 0.20
SD = standard deviation. Bold values indicate statistical significance.
3. Discussion This is one of the largest studies evaluating helmet use among children suffering from equestrian related injury. More than half the children in this study suffered from a traumatic brain injury and a quarter of them required admission to the ICU. Further, we found that helmet utilization is directed toward activities that may be perceived as higher risk such as bull riding. Utilization was also more common at recreational events that may require or encourage helmet use. It is alarming that less than one fifth of children utilized a helmet for protection, a rate much lower than reported by Bond and colleagues [3] in 1995 and is indicative of the lack of the public knowledge of equestrian dangers. Multiple studies have reported that equestrian activities are riskier than motorcycles, automobile racing, skiing, and football [4]. Data from Cuenca et al. [5] reported a higher rate of hospitalization among children without helmets (64% vs. 39%, p b 0.05) and others [6] have reported posttraumatic amnesia as high as 46% in children hospitalized for equestrian injuries. Persistent neurologic symptoms occurred in 13% of those riders following discharge [6]. Moreover, injuries are common among equestrian athletes with 44% suffering from a concussion during their career and many reporting neck pain, headaches, dizziness, poor balance, poor concentration, fatigue, and irritability [7]. Many athletes may return to riding without proper medical assessment [7], thereby putting them at risk of a secondary neurologic injury that may result in cognitive, behavioral, mood, or motor symptoms [8]. Our data suggest that helmets are protective against TBI and may result in fewer ICU admissions among pediatric equestrian trauma victims. Despite this and other prior reports [2,5], there is a shockingly low rate of helmet use in our study and rates as low as 9% in the adult populous [9]. Some authors have suggested a Western cultural bias against the use of helmets by equestrian athletes [9,10]. Others have suggested that the wider public may not be knowledgeable of equestrian related risk. Kuhl and colleagues [7] reported that less than 40% of equestrian riders had any education about TBI. Increased awareness of TBI risk may be one method to improve helmet utilization. Prior educational campaigns with activities such bicycling and football have led to wider scrutiny and implementation of safety mechanisms for TBI prevention. Examples include the mandates for helmet use for pediatric bicyclists in California, which have led to wider helmet utilization [11]. Currently there are efforts to mitigate equestrian injuries such as TBI. The United States Pony Club requires helmets for all activities and the AAP recommends helmets for all mounted activities. However, others including the National High School Rodeo Association only require helmet use in specific events such as bull riding and allow Western hats in many of the activities [6]. While our data suggest that these recommendations have had some impact on helmet use at places of
Recreational Facilities Bull riding vs. horseback riding
OR
Lower CI
Upper CI
P
5.6 5.4
1.9 1.9
15.7 16
b0.01 b0.01
recreation, rates of use remain shockingly low and are even lower when activities occur at home. While our study is one of the largest contemporary studies evaluating use of helmets in pediatric equestrian trauma, it is limited by a number of factors. It is retrospective and we are limited by the accuracy of the data input to the trauma database. Further, our trauma center is the only level one pediatric trauma center in the region with a large percentage of our patients being transferred from outside facilities. Therefore, our patient sample may not be reflective of the entire equestrian population as we may receive a more severely injured cohort. This likely accounts for the significantly high rate of admission to the hospital seen in our population (98%) compared to the 50% reported by Cuenca and colleagues [5]. We also had a large number of children (54.5%) suffering from equestrian related trauma during the time of our study who did not have documentation for presence of absence of a helmet. These children were excluded and our remaining cohort is subject to inherent risk of sampling error. 4. Conclusions In conclusion, our data demonstrate that TBI is a common injury associated with equestrian trauma and that utilization of helmets is underwhelming in this population. This under-utilization appears to occur more frequently at home and is associated with higher rates of admission to the ICU, TBI, and may contribute to the high rate of TBI associated symptoms reported by other authors. It is the author's recommendation that helmets be mandatory for all equestrian activities and increased education is needed to increase helmet utilization at home and recreational events. Further, when one is considering the role of mandatory helmet use, they should recognize that the American Academy of Pediatrics (AAP) recently questioned whether recreational benefits of football, an activity thought to be less risky than equestrian sports, were outweighed by the risks of brain trauma and associated attention deficits, mood disorders, and behavioral problems [12]. References [1] Yue JK, Winkler EA, Burke JF, et al. Pediatric sports-related traumatic brain injury in United States trauma centers. Neurosurg Focus 2016;40(4):E3. [2] Bixby-Hammett DM. Pediatric equestrian injuries. Pediatrics 1992;89(6 Pt 2):1173–6. [3] Bond GR, Christoph RA, Rodgers BM. Pediatric equestrian injuries: assessing the impact of helmet use. Pediatrics 1995;95(4):487–9. [4] Zuckerman SL, Morgan CD, Burks S, et al. Functional and structural traumatic brain injury in equestrian sports: a review of the literature. World Neurosurg 2015;83(6): 1098–113. [5] Cuenca AG, Wiggins A, Chen MK, et al. Equestrian injuries in children. J Pediatr Surg 2009;44(1):148–50. [6] Jagodzinski T, DeMuri GP. Horse-related injuries in children: a review. WMJ 2005; 104(2):50–4. [7] Kuhl HN, Ritchie D, Taveira-Dick AC, et al. Concussion history and knowledge base in competitive equestrian athletes. Sports Health 2014;6(2):136–8. [8] Montenigro PH, Bernick C, Cantu RC. Clinical features of repetitive traumatic brain injury and chronic traumatic encephalopathy. Brain Pathol 2015;25(3):304–17. [9] Ball CG, Ball JE, Kirkpatrick AW, et al. Equestrian injuries: incidence, injury patterns, and risk factors for 10 years of major traumatic injuries. Am J Surg 2007;193(5):636–40. [10] Temes RT, White JH, Ketai LH, et al. Head, face, and neck trauma from large animal injury in New Mexico. J Trauma 1997;43(3):492–5. [11] Ji M, Gilchick RA, Bender SJ. Trends in helmet use and head injuries in San Diego County: the effect of bicycle helmet legislation. Accid Anal Prev 2006;38(1):128–34. [12] Bachynski KE. Tolerable risks? Physicians and youth tackle football. N Engl J Med 2016;374(5):405–7.
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Trauma/Critical Care
Helmet under-utilization by children during equestrian events is associated with increased traumatic brain injury☆ Scott S. Short ⁎, Stephen J. Fenton, Eric R. Scaife, Brian T. Bucher Division of Pediatric Surgery, Department of Surgery, University of Utah School of Medicine, 100 N. Mario Ceppechi Drive, Suite 3800, Salt Lake City, UT 84113, United States
a r t i c l e
i n f o
Article history: Received 18 January 2017 Received in revised form 10 March 2017 Accepted 12 March 2017 Key words: Pediatric Equestrian Helmet Traumatic brain injury
a b s t r a c t Purpose: Awareness of equestrian related injury remains limited. Studies evaluating children after equestrian injury report under-utilization of safety equipment and rates of operative intervention as high as 33%. Methods: We hypothesized that helmets are underutilized during equestrian activity and lack of use is associated with increased traumatic brain injury. We queried the trauma database of a level one pediatric trauma center for all cases of equestrian and rodeo related injury from 2005 to 2015. Analysis was conducted using SAS 9.4. Results: Of 312 children identified, 142 were assessed for use of a helmet. Only 28 children (19.7%) had documented use of a helmet. Most injuries occurred while riding a horse (83%) or bull (13%) with traumatic brain injury being the most common injury (51%). Helmet use was associated with decreased ISS (7.1 vs. 11.3, p b 0.01), TBI (32.4% vs. 55.3%, p = 0.03), and ICU admission (10.7% vs. 29%, p = 0.05). Multivariable analysis reveals lack of helmet use to be an independent predictor of TBI (OR 2.5, 95% CI 1.1–6.3). Conclusion: Helmets are underutilized by children during equestrian related activity. Increased awareness of TBI and education encouraging helmet use may decrease morbidity associated with equestrian activities. Level of Evidence: Retrospective comparative study, Level III. © 2017 Elsevier Inc. All rights reserved.
Equestrian events are a common cause of pediatric sports-related injuries, represented 14% of injuries in a recent review from the National Trauma Databank [1]. Prior studies of equestrian related trauma in children indicate that traumatic brain injury (TBI) is one of the most common injuries sustained with reported incidence of 15.3%–23% and may be responsible for up to 57% of mortality associated with equestrian activity [2]. Despite these alarming facts, utilization of helmets and other safety equipment appear underutilized with a 1995 study reporting use of helmets in less than 2/3 of children. [3]. In this study, we aim to report our experience with children who sustained equestrian related injury and specifically focus on the utilization of helmets and injury patterns. We hypothesize that helmets are underutilized during equestrian activity and lack of use is associated with increased TBI.
☆ Presented at the Western Pediatric Trauma Conference, Snowmass, Colorado on July 20th, 2016. ⁎ Corresponding author at: 100 N. Mario Cappechi Drive, Suite 3800, Salt Lake City, UT 84132, United States. E-mail addresses: [email protected] (S.S. Short), [email protected] (S.J. Fenton), [email protected] (E.R. Scaife), [email protected] (B.T. Bucher). http://dx.doi.org/10.1016/j.jpedsurg.2017.03.043 0022-3468/© 2017 Elsevier Inc. All rights reserved.
1. Methods 1.1. Patient population We performed a single center retrospective review of all children (b 18 years old) identified from the institution's prospectively collected trauma database from 2005 to 2015. All patients who experienced an equestrian related injury (horse, bull, sheep, or calf) were included in the study. Children who did not have documentation of helmet use (presence or absence) were excluded (Fig. 1). Institution review board approval was obtained at Primary Children's Hospital, Salt Lake City, UT.
1.2. Description of variables Demographic factors including gender and age were recorded. Trauma related factors include type of animal involved (e.g., bull, horse, sheep, calf), type of injury (e.g., fall from animal, kicked by animal, stepped/ stomped by animal), location of injury (e.g., home, recreational facility), type of injury suffered (TBI, spinal cord/nerve injury, liver, spleen, extremity), injury severity score, revised trauma score, and Glasgow coma score. Helmet use was assessed. Outcomes included admission to the hospital, intensive care unit (ICU) admission, need for neurosurgical intervention, exploratory laparotomy, length of stay, disposition, and mortality.
546
S.S. Short et al. / Journal of Pediatric Surgery 53 (2018) 545–547
Number of Children Presenting with Equestrian Related Injuries from 2005 to 2015 N = 312
Children with Unknown Helmeted Status N= 170
Children Assessed for Presence or Absence of a Helmet N= 142
Children Evaluated in Study N= 142
Excluded from Analysis
Fig. 1. Patients Enrolled in Study.
1.3. Statistical analysis All data were recorded into a standardized database program (Microsoft Excel©, Seattle, WA). Univariate analysis was performed using Wilcoxon test on continuous variables and Fischer's Exact test for categorical variables. A p-value b 0.05 was considered significant. Multivariable logistic regression was performed using SAS 9.4.
time of injury (OR 5.4, 95% CI 1.9–16, p b 0.01). In addition, children whose injuries occurred at a recreation center were more likely to be wearing a helmet compared to children who were injured at home (OR 5.6, 95% CI 1.9–15.7, p b 0.01) (Table 3). Lack of helmet use was found to be an independent predictor of TBI (OR 2.6, 95% CI 1.1–6.3, p = 0.03) and had a trend towards ICU admission (OR 3.4, 95% CI 0.96–3.6, p = 0.06).
2. Results From 2005 to 2015, 312 children were evaluated for equestrian associated trauma. Of these 142 (45.5%) were assessed for use of helmet (Table 1). The majority were female (54%) with a median age of 11 (±5.5) years. Only 28 children (19.7%) had documented use of a helmet at the time of injury. Horses (82%) were the most common animals involved in injuries followed by bulls (13%), calves (3%), and sheep (2%). The majority of injuries occurred at either home (42%) or a recreational facility (31%). Falls (70%) were the most common mechanism of injury followed by kick injury (18%), step/stomp injury (10%), and rollover injury (3%). Children suffered from a TBI in 50.7% of cases, an extremity injury in 16.9% of cases, a liver injury in 8.5%, and a spleen injury in 2.8%. The majority of children (97%) evaluated required admission to the hospital with 25.4% requiring an ICU related admission. Only 5.6% of patients required neurosurgical intervention and no child required a laparotomy. No child suffered from a mortality from these types of injuries. When comparing the outcomes of children with helmet use to those without we found significant differences between the two groups on univariate analysis. Those with helmet use had a significantly lower ISS (7.1 ± 5.5 vs. 11.3 ± 6.5, p b 0.001) and lower rates of TBI (32.4% vs. 55.2%, p = 0.03), and were less likely to be admitted to the ICU (10.7% vs. 29%, p = 0.05). There were no differences in age, gender, revised trauma score, Glasgow Coma Scale, and length of stay (Table 2). To identify independent patient and injury factors associated with the use of a helmet we performed logistic regression on the primary outcome of documented helmet use. Compared to horse riding, children riding on a bull or a calf were more likely to be wearing a helmet at the
Table 1 Demographics (N = 142). Gender (male) Age (median, range) Helmet use Animal Horse Bull Calf Sheep Location of injury Home Recreation Other Mechanism of injury Fall Kick Step/Stomp Rollover Other Multiple mechanismsa Injury TBI Extremity injury Liver Spleen Hospital admission ICU admission Required craniotomy Survival
46% 11 (1.5–17) years 19.7% 82.4% 12.7% 2.8% 2.1% 41.5% 31% 27.5% 70% 17.6% 10.6% 2.8% 9.8% 8.4% 51% 16.9% 8.5% 2.8% 96.5% 25.4% 5.4% 100%
a Some children experienced more than one mechanism, e.g., fell from horse and then kicked.
S.S. Short et al. / Journal of Pediatric Surgery 53 (2018) 545–547 Table 2 Helmet vs. no helmet use.
Gender (% male) Age, years, mean (SD) Injury Severity Score, mean (SD) Revised Trauma Score, mean (SD) Glasgow Coma Scale, mean (SD) Traumatic brain injury Craniotomy(ectomy) Intensive care unit admission Length of Stay, days (SD)
547
Table 3 Multivariable analysis of factors associated with helmet use. Helmet (n = 28)
No helmet (n = 114)
p Value
50% 11.1 (±3.7) 7.1 (±5.5) 7.6 (±0.9) 14.4 (±2.3) 32.4% 0% 10.7% 2 (±1.5)
44% 10.4 (±4.4) 11.3 (±6.5) 7.4 (±1.2) 13.8 (±3.3) 55.3% 7% 29% 3.5 (±4.7)
0.67 0.44 b0.001 0.81 0.33 0.03 0.35 0.05 0.20
SD = standard deviation. Bold values indicate statistical significance.
3. Discussion This is one of the largest studies evaluating helmet use among children suffering from equestrian related injury. More than half the children in this study suffered from a traumatic brain injury and a quarter of them required admission to the ICU. Further, we found that helmet utilization is directed toward activities that may be perceived as higher risk such as bull riding. Utilization was also more common at recreational events that may require or encourage helmet use. It is alarming that less than one fifth of children utilized a helmet for protection, a rate much lower than reported by Bond and colleagues [3] in 1995 and is indicative of the lack of the public knowledge of equestrian dangers. Multiple studies have reported that equestrian activities are riskier than motorcycles, automobile racing, skiing, and football [4]. Data from Cuenca et al. [5] reported a higher rate of hospitalization among children without helmets (64% vs. 39%, p b 0.05) and others [6] have reported posttraumatic amnesia as high as 46% in children hospitalized for equestrian injuries. Persistent neurologic symptoms occurred in 13% of those riders following discharge [6]. Moreover, injuries are common among equestrian athletes with 44% suffering from a concussion during their career and many reporting neck pain, headaches, dizziness, poor balance, poor concentration, fatigue, and irritability [7]. Many athletes may return to riding without proper medical assessment [7], thereby putting them at risk of a secondary neurologic injury that may result in cognitive, behavioral, mood, or motor symptoms [8]. Our data suggest that helmets are protective against TBI and may result in fewer ICU admissions among pediatric equestrian trauma victims. Despite this and other prior reports [2,5], there is a shockingly low rate of helmet use in our study and rates as low as 9% in the adult populous [9]. Some authors have suggested a Western cultural bias against the use of helmets by equestrian athletes [9,10]. Others have suggested that the wider public may not be knowledgeable of equestrian related risk. Kuhl and colleagues [7] reported that less than 40% of equestrian riders had any education about TBI. Increased awareness of TBI risk may be one method to improve helmet utilization. Prior educational campaigns with activities such bicycling and football have led to wider scrutiny and implementation of safety mechanisms for TBI prevention. Examples include the mandates for helmet use for pediatric bicyclists in California, which have led to wider helmet utilization [11]. Currently there are efforts to mitigate equestrian injuries such as TBI. The United States Pony Club requires helmets for all activities and the AAP recommends helmets for all mounted activities. However, others including the National High School Rodeo Association only require helmet use in specific events such as bull riding and allow Western hats in many of the activities [6]. While our data suggest that these recommendations have had some impact on helmet use at places of
Recreational Facilities Bull riding vs. horseback riding
OR
Lower CI
Upper CI
P
5.6 5.4
1.9 1.9
15.7 16
b0.01 b0.01
recreation, rates of use remain shockingly low and are even lower when activities occur at home. While our study is one of the largest contemporary studies evaluating use of helmets in pediatric equestrian trauma, it is limited by a number of factors. It is retrospective and we are limited by the accuracy of the data input to the trauma database. Further, our trauma center is the only level one pediatric trauma center in the region with a large percentage of our patients being transferred from outside facilities. Therefore, our patient sample may not be reflective of the entire equestrian population as we may receive a more severely injured cohort. This likely accounts for the significantly high rate of admission to the hospital seen in our population (98%) compared to the 50% reported by Cuenca and colleagues [5]. We also had a large number of children (54.5%) suffering from equestrian related trauma during the time of our study who did not have documentation for presence of absence of a helmet. These children were excluded and our remaining cohort is subject to inherent risk of sampling error. 4. Conclusions In conclusion, our data demonstrate that TBI is a common injury associated with equestrian trauma and that utilization of helmets is underwhelming in this population. This under-utilization appears to occur more frequently at home and is associated with higher rates of admission to the ICU, TBI, and may contribute to the high rate of TBI associated symptoms reported by other authors. It is the author's recommendation that helmets be mandatory for all equestrian activities and increased education is needed to increase helmet utilization at home and recreational events. Further, when one is considering the role of mandatory helmet use, they should recognize that the American Academy of Pediatrics (AAP) recently questioned whether recreational benefits of football, an activity thought to be less risky than equestrian sports, were outweighed by the risks of brain trauma and associated attention deficits, mood disorders, and behavioral problems [12]. References [1] Yue JK, Winkler EA, Burke JF, et al. Pediatric sports-related traumatic brain injury in United States trauma centers. Neurosurg Focus 2016;40(4):E3. [2] Bixby-Hammett DM. Pediatric equestrian injuries. Pediatrics 1992;89(6 Pt 2):1173–6. [3] Bond GR, Christoph RA, Rodgers BM. Pediatric equestrian injuries: assessing the impact of helmet use. Pediatrics 1995;95(4):487–9. [4] Zuckerman SL, Morgan CD, Burks S, et al. Functional and structural traumatic brain injury in equestrian sports: a review of the literature. World Neurosurg 2015;83(6): 1098–113. [5] Cuenca AG, Wiggins A, Chen MK, et al. Equestrian injuries in children. J Pediatr Surg 2009;44(1):148–50. [6] Jagodzinski T, DeMuri GP. Horse-related injuries in children: a review. WMJ 2005; 104(2):50–4. [7] Kuhl HN, Ritchie D, Taveira-Dick AC, et al. Concussion history and knowledge base in competitive equestrian athletes. Sports Health 2014;6(2):136–8. [8] Montenigro PH, Bernick C, Cantu RC. Clinical features of repetitive traumatic brain injury and chronic traumatic encephalopathy. Brain Pathol 2015;25(3):304–17. [9] Ball CG, Ball JE, Kirkpatrick AW, et al. Equestrian injuries: incidence, injury patterns, and risk factors for 10 years of major traumatic injuries. Am J Surg 2007;193(5):636–40. [10] Temes RT, White JH, Ketai LH, et al. Head, face, and neck trauma from large animal injury in New Mexico. J Trauma 1997;43(3):492–5. [11] Ji M, Gilchick RA, Bender SJ. Trends in helmet use and head injuries in San Diego County: the effect of bicycle helmet legislation. Accid Anal Prev 2006;38(1):128–34. [12] Bachynski KE. Tolerable risks? Physicians and youth tackle football. N Engl J Med 2016;374(5):405–7.