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Surfing USA: an epidemiological study of surfing injuries presenting to US EDs 2002 to 2013
American Journal of Emergency Medicine xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Original Contribution
Surfing USA: an epidemiological study of surfing injuries presenting to US EDs 2002 to 2013 Cole Klick, MD ⁎, Courtney M.C. Jones, PhD, MPH, David Adler, MD, MPH Department of Emergency Medicine, University of Rochester - Strong Memorial Hospital, Rochester, NY, USA
a r t i c l e
i n f o
Article history: Received 30 December 2015 Received in revised form 29 April 2016 Accepted 2 May 2016 Available online xxxx
a b s t r a c t Introduction: Surfing is a popular recreational and competitive sport in the United States and worldwide. Previous studies indicate surfers are frequently injured, but most studies are survey based, and little is known about surfing injuries that present to emergency departments (EDs). Aims: This study examines the epidemiology of surfing injuries presenting to US EDs. Methods: A retrospective analysis was performed using data from the National Electronic Injury Surveillance System database from the US Consumer Product Safety Commission from 2002 to 2013. Results: A total of 2072 cases were analyzed, corresponding to a national estimate of 131 494 total injuries over the 12-year period (95% confidence interval, 34 515-228 473). The median age of included cases was 27 years (interquartile range, 19-37). Lower extremity injuries were most common (25.9%), followed by the face (23.1%) and head and neck (22.7%). Lacerations were the most common injury type (40.7%), followed by sprains and strains (14.4%), contusions (12.9%), and fractures (11.9%); 95.7% of cases were treated and released. Patients older than 60 years, those injured to the trunk, and those suffering fractures or internal organ injuries were admitted at a statistically significant increased frequency (P b .05). Conclusion: Surfing injuries are common but rarely serious. The injuries most commonly affect the lower extremity, head, neck, and face and are most frequently lacerations. Age older than 60 years, injuries to the trunk, and internal organ injuries were associated with a statistically significant increased frequency of hospital admission. © 2016 Elsevier Inc. All rights reserved.
1. Introduction Surfing is a popular recreational and competitive sport. There are an estimated 37 million surfers worldwide, 2.1 million in the United States alone [1,2]. Furness et al [1] reported that up to one-third of surfers sustain an acute injury causing them to seek medical attention, miss work, or take time off surfing each year. A recent study by Woodacre et al [3] reported that 91% of surfers polled had sustained injuries while surfing during their lifetime. Despite knowledge of injury rates and mechanisms from peerreviewed studies, few studies have investigated injuries that present to emergency departments (EDs) around the United States. The purpose of this study is to describe the epidemiology of surfing injuries presenting to US EDs, using the National Electronic Injury Surveillance System (NEISS), a nationally representative sample. 2. Patients and methods 2.1. Data source The NEISS is a free, deidentified database of injuries related to consumer products. The database is produced and maintained by the US ⁎ Corresponding author at: 601 Elmwood Ave, Box 655, Rochester, NY 14642. Tel.: +1 585 463 2940; fax: +1 585 463 3516. E-mail address: [email protected] (C. Klick).
Consumer Product Safety Commission. An NEISS coordinator at each of the approximately 100 participating hospital EDs transcribes patient data, assigning a product code based on details found in the medical record [4]. Information regarding diagnoses, disposition, patient age, race, sex, body location, weight, and a brief narrative field describing the injury and mechanism are also recorded [5]. Coders are specifically trained and receive continuous training to ensure intercoder reliability, and participating hospitals provide approximately 400 000 records annually to the database [4]. Previous studies including articles describing skiing and snowboarding injuries and head and neck injuries in extreme sports have shown the utility of the database for identifying recreational sport injuries [6–9]. Injuries related to surfing among patients of all ages from 2002 to 2013 were identified by NEISS consumer product code 1261 (Surfing). Data before 2002 were excluded because it did not contain the narrative field. This study sought to describe injuries related to traditional stand up surfing, defined as a surfer paddling into a nature-generated wave, on an open body of water, and riding the wave in a standing position. Injuries identified by the narrative as bodyboarding, boogieboarding, bodysurfing, skimboarding, skinboarding, waterboarding, wakeboarding, stand up paddling, river surfing, kneeboarding, knee surfing, kitesurfing, kiteboarding, wakesurfing, and swimming were excluded by a trained data abstractor. Cases in which a narrative was not present or the injured body part was listed as not stated or not known were also excluded, as we
http://dx.doi.org/10.1016/j.ajem.2016.05.008 0735-6757/© 2016 Elsevier Inc. All rights reserved.
Please cite this article as: Klick C, et al, Surfing USA: an epidemiological study of surfing injuries presenting to US EDs 2002 to 2013, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.05.008
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were unable to determine the circumstances surrounding the injury. Finally, cases with injuries that did not occur during the act of surfing, for example, a decorative surfboard falling from a wall onto a person, or a case where a person was injured while repairing a surfboard was excluded. 2.2. Study variables To facilitate interpretation of findings and allow comparison with existing work, NEISS variables were regrouped into clinically meaningful categories. These categories included age, sex, race, body region injured, injury diagnosis, and ED disposition as detailed in Table 1. 2.3. Data analysis To generate a national estimate of surfing injuries presenting to US EDs, statistical weights were applied using the standard approaches as outlined by CPSC NEISS using the PROC SURVEYMEANS procedure in SAS version 9.3 (Carey, NC). Because of significant variability in the national estimate of total injuries, statistical weights were not applied to subsequent analyses. Rather, data were analyzed based on the actual cases contained in the NEISS data set. Descriptive statistics, including medians, proportions, and corresponding measures of variability (interquartile range [IQR] and 95% confidence intervals [CIs]), were used to describe the study sample and injury patterns. Differences in ED disposition based on injury type and body region injured were compared using χ2 tests and Fisher exact text where indicated. 3. Results Query of the NEISS database over the 12-year period from January 1, 2002, to December 31, 2013, yielded 3464 documented injuries, but 1391 entries were excluded due to insufficient information or activities that did not meet the aforementioned definition of surfing. Therefore, 2072 cases were included in the final data analysis (Figure). This corresponds to a national estimate of 131 494 total injuries over the 12-year period (95% CI, 34 515-228 473). There was no statistically significant difference in injury patterns over the years of the study period. In our final sample, at least 1 case was represented from 57 of the primary sampling units (individual participating hospitals). Three primary sampling units contributed more than 75% of the total cases. Age of subjects ranged from 4 to 82 years, with a median age of 27 years (IQR, 19-37). The sample was 81.9% male and 76.3% white. Table 2 summarizes the demographic characteristics of the included subjects.
body area (25.9%), followed by the face (23.1%), head and neck (22.7%), upper extremity (16.7%), and trunk (8.6%). The most common injury diagnoses were lacerations (40.7%), followed by sprains and strains (14.4%), contusions (12.9%), and fractures (11.9%). Lacerations were primarily to the face (41.3%) and lower extremity (28.3%). Concussions accounted for 2.7% of all injuries. Of note, head, neck, and face accounted for 62.7% of the lacerations. Fractures were relatively common and occurred primarily in the upper extremity (31.7%) and lower extremity (30.9%). Sprains and strains were most common in the lower extremity (34.8%) and neck (28.8%). Dislocations represented 4.5% of all injuries with 84.9% corresponding to the upper extremity, primarily the shoulder. Submersion injury was an uncommon diagnosis (n = 6); however, 1 case was fatal. There was 1 anterior myocardial infarction. Noteworthy but uncommon injuries included 1 finger amputation and several tympanic membrane ruptures. Although not explicitly coded for in NEISS, a search of the narrative fields for marine zoonoses revealed 1 sharkrelated injury, 1 seal attack, 2 urchin-related injuries, and 9 stingrayrelated punctures or envenomations. Surprisingly, there were no reported visits related to jelly fish envenomations. 3.2. Patient disposition Table 4 summarizes the overall disposition of injured surfers; 95.7% were treated and released, 3.5% admitted or transferred to another hospital, 0.8% of cases left without treatment, and there was 1 fatality (0.05%). The left without treatment (n = 16) and fatality (dead on arrival or died in ED) (n = 1) groups were excluded from bivariate analyses looking at differences in ED disposition based on sex, age, race, injury location, and body region injured due to insufficient sample size so calculations based on disposition included only 2055 of the total 2072 subjects (Table 5). We did not find a statistically significant difference in ED disposition (admitted vs treated and released) between males and females (3.8% vs 2.2%). There was a statistically significant difference in ED disposition based on patient age (P b .001), with older adult patients having increased frequency of hospital admission (13.6% and 9.4% of subjects aged 60-69 years and 70 years or older, respectively). There were statistically significant differences in ED disposition based on injury type and injured body region (P b .001 for both comparisons). Injuries to the trunk were the most likely to require hospital admission (10.3%), whereas injuries to the face were unlikely to require admission (0.4%). Injuries coded as internal, mostly closed head injuries in this study, and fractures were associated with the highest proportion of admissions (13.4% and 11%, respectively), whereas sprains, lacerations, and contusions very rarely required admission or transfer (0.8%, 0.3%, and 1.1%, respectively). 4. Discussion
3.1. Types and body areas injured Table 3 summarizes the types of injury and corresponding body region injured. The lower extremity was the most commonly injured
To our knowledge, this is the largest epidemiological study of surfing injuries to date and one of only a few studies looking at cases seeking medical attention.
Table 1 Study variables Study variables Sex
Age
Race
Body region injured
Injury diagnosis
Disposition
Male Female
0-9 10-19 20-29 20-39 40-49 50-59 60-69 70 and older
White Black Asian Other/Native/Hawaiian/Pacific Islanderc Unknown
Head/neck Face Trunk Upper extremity Lower extremity Othera
Concussion Contusion/Abrasion/Hematoma Laceration Fracture Dislocation Sprain/Strain Internal injury Otherb
Treated and Released Admitted or Transferred Left without treatment Dead on arrival or died in ED
a b c
Systemic (N25% of body area involved), pubic region, ear. Crush injury, nerve damage, puncture, amputation, hemorrhage, avulsion, foreign body, radiation injury, dermatitis, conjunctivitis, poisoning, dental injury, and submersion injury. Combined variable made up of the categories
Please cite this article as: Klick C, et al, Surfing USA: an epidemiological study of surfing injuries presenting to US EDs 2002 to 2013, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.05.008
C. Klick et al. / American Journal of Emergency Medicine xxx (2016) xxx–xxx
Figure. Included and excluded surfing cases.
Please cite this article as: Klick C, et al, Surfing USA: an epidemiological study of surfing injuries presenting to US EDs 2002 to 2013, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.05.008
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Table 2 Demographics of included patients (n = 2072) Patient characteristic
n
Median age (IQR) Age (y) 0-9 10-19 20-29 30-39 40-49 50-59 60-69 70 and older Sex Male Female Race White Black Asian Other Unknown
27 (19-37)
Table 4 Overall patient disposition (n = 2072) Percentage (95% CI)
39 528 629 448 283 105 33 7
1.9 (1.31-2.49) 25.5 (23.62-27.38) 30.4 (28.42-32.38) 21.6 (19.83-23.37) 13.7 (12.22-15.18) 5.1 (4.15-6.05) 1.6 (1.06-2.14) 0.3 (0.06-0.54)
1697 375
81.9 (80.24-83.56) 18.1 (16.44-19.76)
1579 18 47 156 272
76.2 (74.37-78.03) 0.9 (0.49-1.31) 2.3 (1.65-2.95) 7.5 (6.37-8.63) 13.1 (11.65-14.55)
Note. n = 2072.
The median age of 27 years and majority male sex (81.9%) of our sample are similar to previous work, both self-reporting studies, and those taking place in the health care setting [1–3,10–12]. Our results indicate that most surfing-related injuries presenting to US EDs appear to be consistent with acute traumatic injuries and not chronic injuries resulting from overuse. Our study found a very high proportion of lacerations (40.7%) that is consistent with previous studies [2,3,11,12]. In our study, the lacerations were most commonly on the head, neck, and face, accounting for 62.7% of all lacerations with the lower extremity accounting for 28.3%. Nathanson et al [10] described higher frequencies for lower extremity lacerations with approximately equal proportion of lacerations occurring on the head and neck region and the lower extremity (43.4% and 40.7%, respectively), whereas other studies by Taylor et al [12] and Hay et al [11] have a laceration location breakdown consistent with the findings in our study (65% head and neck, 29% lower extremity, and 75% head and neck and 14% lower extremity, respectively). This study was not designed to classify injuries based on mechanism, but a study by Nathanson et al [2] described lacerations resulting mostly from contact with the surfer's own board or a shallow, hard bottom such as a coral reef. Many surfing venues feature water that requires use of a neoprene rubber wetsuit for at least parts of the year, the rubber ranging from 1 to 6 mL thick offers some protection against lacerations; however, neoprene hoods are only worn in the coldest surf environments. The differences in laceration distributions may be reflective of wetsuit prevalence, with proportionately higher head, neck, and face lacerations where long wetsuits are worn, and more widely distributed lacerations where surfers wear only swim trunks. Concussions (2.7%) were relatively infrequent but consistent with frequencies previously described [3,10]. Additional head injuries that are not immediately apparent in the database are a significant portion of the
Disposition
n
Percentage (95% CI)
Treated and released Admitted or transferred Left without treatment Dead on arrival or Died in ED
1983 72 16 1
95.7 (94.83-96.57) 3.5 (2.71-4.29) 0.8 (0.42-1.18) 0.1 (−0.04 to 0.24)
Note. n = 2072. Percentages may not total to 100.0% due to rounding error.
injuries classified as internal injuries (n = 85). Closed head injuries that are not classified as concussion, including intracranial hematomas, are classified as internal organ injuries in the NEISS database [5]. These closed head injuries made up 4.1% of total cases and had a clinically significant admission frequency of 13.4%, much higher than the overall admission frequency of 3.5% for all cases in this study. It is unclear if variability exists between health care setting–based studies and self-reported surveys because concussion is a clinical diagnosis and familiar to many laypersons, whereas closed head injuries may be radiologic diagnoses and not accurately represented on participant surveys. In light of the clinically significant traumatic head injuries, helmets or other protective headgear would seem like a very good addition to the surfer's equipment quiver, and this has been proposed by several studies; however, surfers have been resistant to wearing head protection. Taylor et al conducted a study investigating the need for protective headgear in surfers and surfers' perceptions of head gear and found that surfers generally downplay the risk of head injuries while surfing but that significant surf culture barriers, especially revolving around fashion and appearance prevent widespread use [3,10–13]. Others have proposed more frequent use of padded or blunt nose guards to protect the surfer from the sharp front of their board and alternative construction surfboards with soft, padded foam, tops and rails, and soft, pliable, dulled fins that break away more easily on contact to help prevent lacerations and other traumatic injuries when they contact the surfer. These are, however, largely unpopular due to decreased performance characteristics and fashion within surf culture [10]. Sprains and strains were the second most common injuries presenting to the ED in this study (14.4%) with the lower extremity being the most common body region affected. This proportion is similar to that described by Nathanson et al [10]. Interestingly, our study found sprains and strains to be most common in the lower extremity followed by the neck which is consistent with several studies, whereas Hay et al found higher proportions of sprains and strains of the neck (43%), but a similar proportion to the lower extremity (33%) [2,10,14,11]. Differences among populations of the studies, for example, competitive or resident surfers as opposed to weekend warriors, may account for these differences. Fractures accounted for 11.9% of the injuries observed in this study and were only slightly more common in the upper extremity than the lower extremity and head, neck, and face. These findings are consistent with previous work [10,11]. Facial fractures, often resulting from contact with one's own surfboard or the seafloor, make up a significant proportion of fractures. Protective surfboards or avoidance of surf spots that
Table 3 Type and location of surfing injuries (n = 2072) Injury diagnosis
Injured body region
Head/neck Face Trunk Upper extremity Lower extremity Other Total
Concussion
Contusion
Laceration
Fracture
Dislocation
Sprain
Internal injury
Other
Total
56 – – – – – 56 (2.7%)
34 57 66 45 60 5 267 (12.9%)
180 349 12 54 239 10 844 (40.7%)
16 48 27 78 76 1 246 (11.9%)
– – – 79 14 – 93 (4.5%)
86 – 39 70 104 – 299 (14.4%)
87 – 5 – – 5 97 (4.7%)
11 24 29 19 44 43 170 (8.2%)
470 (22.7%) 478 (23.1%) 178 (8.6%) 345 (16.7%) 537 (25.9%) 64 (3.1%) 2072 (100%)
Note. n = 2072.
Please cite this article as: Klick C, et al, Surfing USA: an epidemiological study of surfing injuries presenting to US EDs 2002 to 2013, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.05.008
C. Klick et al. / American Journal of Emergency Medicine xxx (2016) xxx–xxx Table 5 Patient disposition based on demographics (n = 2055) Characteristic
Sex Male Female Age⁎ 0-9 10-19 20-29 20-39 40-49 50-59 60-69 70 and older Injured body region⁎ Head/neck Face Trunk Upper extremity Lower extremity Other Injury diagnosis⁎ Concussion Contusion Laceration Fracture Dislocation Sprain Internal injury Other
Treated and released (n = 1983)
Admitted or transferred (n = 72)
n
Percentage (95% CI)
n
Percentage (95% CI)
1621 362
96.2 (95.37-97.03) 97.8 (97.17-98.43)
64 8
3.8 (2.97-4.63) 2.2 (1.57-2.83)
36 515 618 424 266 89 29 6
94.7 (93.73-95.67) 97.7 (97.05-98.35) 99.0 (98.57-99.43) 95.5 (94.6-96.4) 94.7 (93.73-95.67) 86.4 (84.92-87.88) 90.6 (89.34-91.86) 100.0
2 12 6 20 15 14 3 0
5.3 (4.33-6.27) 2.3 (1.65-2.95) 1.0 (0.57-1.43) 4.5 (3.6-5.4) 5.3 (4.33-6.27) 13.6 (12.12-15.08) 9.4 (8.14-10.66) 0.0
447 473 157 332 515 59
95.3 (94.38--96.22) 99.6 (99.33-99.87) 89.7 (88.39-91.01) 97.9 (97.28-98.52) 96.4 (95.59-97.21) 93.7 (92.65-94.75)
22 2 18 7 19 4
4.7 (3.78-5.62) 0.4 (.013-0.67) 10.3 (8.99-11.61) 2.1 (1.48-2.72) 3.6 (2.79-4.41) 6.3 (5.25-7.35)
52 263 834 219 89 296 84 146
92.9 (91.79-94.01) 98.9 (98.45-99.35) 99.2 (98.81-99.59) 89.0 (87.65-90.35) 95.7 (94.82-96.58) 99.7 (99.46-99.94) 86.6 (85.13-88.07) 91.8 (90.61-92.99)
4 3 7 27 4 1 13 13
7.1 (5.99-8.21) 1.1 (0.65-1.55) 0.8 (0.41-1.19) 11.0 (9.65-12.35) 4.3 (3.42-5.18) 0.3 (0.06-0.54) 13.4 (11.93-14.87) 8.2 (7.01-9.39)
Note. n = 2055—sample limited to those treated and released from the ED and those admitted or transferred. Percentages may not total to 100.0% due to rounding error. ⁎ P b .05.
are especially shallow, including those with rock or reef bottoms, may prevent some of these injuries. Dislocations in this study were primarily shoulder dislocations (n = 77), accounting for 3.7% of all injuries. Previous studies have described frequencies between 1.7% and 9.4% [10–12]. Bottom depth and contours, wave size, and skill level may explain these ranges in dislocations. Work by Moraes et al [14] also found the upper extremity region responsible for the majority of dislocations. Our study found a very low incidence of marine life–related injuries (n = 19), a proportion similar to that found by Taylor et al, which was much lower than the 3% found in a previous self-reporting study. It may be that surfers with jellyfish stings, urchin injuries, and stingray envenomations generally do not seek medical attention [12,10]. The seal attack reported in this study is not the first; in a self-reported survey-based study with 1348 respondents, Nathanson et al reported 1 seal attack [10]. Shark attacks appear to be exceedingly rare (n = 1) in this study causing a laceration and (n = 3) in a survey based study by Nathanson et al [10]. Very little has been reported by other studies about submersion injuries, drowning, or death while surfing. Our study found few submersion related injuries (n = 6), yet one was fatal. Four cases of submersion injury were treated and released, and 1 patient was admitted for observation. Nathanson et al reported only 2 near drowning episodes of 6784 hours of contest surfing in a prospective study of injuries suffered by competition surfers requiring medical assistance; both were related to head injuries; however, there are no data as to whether these surfers required hospitalization for the submersion injury [2]. Overall, most submersion injuries are rare and often related to a more proximate injury, such as a head injury. It may be that surf leashes, 1.5- to 2.5-m rubber cords that tether a surfer to his or her board in the event of a wipe out, help prevent drowning. It is also possible that previous studies have been too small to detect such rare events. In addition, most
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previous work has been participant survey-based data collection and patients who drown or died surfing would be de facto excluded. Despite presenting to the ED, most injured surfers have only minor injuries and are treated and released. In our sample, 95.7% of cases were treated and released; only 3.5% of cases required admission or transfer to another facility. Hay et al published a higher proportion of admissions (10%) in their ED-based study in Cornwall, UK; similar to our study, surfers requiring admission had severe head and neck injuries or extremity fractures requiring operative intervention [11]. Our study also demonstrated a statistically significant increased admission frequency for injuries to the trunk and internal organ injuries, which as described previously were primarily closed head injuries, but also included rib fractures, several pneumothoraces, solid organ injuries, and several thoracic or lumbar spine injuries. Considering that two-thirds of surfers do not seek medical attention for their injuries, overall injuries requiring hospital admission are infrequent [3]. Our study also found a statistically significant increased frequency of hospital admission in surfers older than 60 years. Nathanson et al had previously found statistically significant increased rates of severe injury and hospital admission in surfers older than 40 years, those who self-reported advanced or expert ability, and in surfers surfing waves larger than 1.5 m measured on the face [10]. Based on our findings, death from surfing is extremely uncommon. 4.1. Study limitations Although the NEISS database offers easily accessible, deidentified data on injuries related surfing in the US, our study has important limitations to consider. First, although our study is the largest descriptive epidemiologic study of surfing-related injuries, we were unable to provide reliable national estimates due to the large variability of these estimates. There is likely significant geographic variability in the incidence of surfing injuries. This was evidenced in our data by greater than 75% of the cases being from 3 of the primary sampling units. Other studies using the NEISS data set have reported national injury estimates; however, the estimates calculated for surfing injuries have a very wide CI. This may indicate that the network of NEISS participating hospitals is not representative of the geographic distribution of surfers in the United States. The database may be more representative for injuries related to more ubiquitous sports such as basketball rather than sports that are mostly practiced on the coastline. As such, our findings should be interpreted cautiously. Our national injury estimate likely underestimates the true burden of surfing injuries due to the underrepresentation of hospitals from areas in which surfing is common (eg, Hawaii). The purpose of our study was to present a descriptive analysis of the cases contained within the dataset and may or may not mirror the national pattern of injuries related to surfing. Nevertheless, our results provide insight as to the patterns of surfing-related injuries presenting to the ED for care. In addition, injury severity is not always clearly represented by the data set; for example, a knee dislocation would be coded by injury code 55 and body location 35; this does not differentiate a patellar dislocation from the more severe posterior knee dislocation [5]. Despite this, our findings add information to the literature on the injury type, burden, and outcome related to surfing injuries. Second, the NEISS data are subject to coder interpretation of what constitutes a surfing injury, which was more inclusive than the definition of surfing used in this study. Although we used rigorous methods to review the case narratives to ensure our sample included only cases related to surfing, it is still possible that other types of surfing-related activities were included. We did exclude 40.2% of the queried cases assigned product code 1261 because of insufficient data or because their narrative field indicated they were not actually injuries caused by surfing. Although surfing is a popular sport, it may not be appropriate to expect nonsurfers to accurately differentiate between surfing as defined in this study and activities such as boogieboarding, bodysurfing, or skimboarding and to enter such details into the case narrative at the point of NEISS data collection.
Please cite this article as: Klick C, et al, Surfing USA: an epidemiological study of surfing injuries presenting to US EDs 2002 to 2013, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.05.008
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This study sought to describe the epidemiologic characteristics of surfing injuries that present to US EDs. Its results may be dependent on the unique health care structure of the United States and are not necessarily generalizable to other countries with different health care settings. Data in this study were limited to a preexisting database that was not designed specifically for investigation of surfing injuries. Diagnosis and body area data are limited to that specified by the database, which may not be clinically relevant to surfing injuries in particular. Another limitation of this study is that it only looked at injuries presenting to the ED and may miss patients who present to their primary care office; in addition, this study offers no information on injured surfers not seeking medical care, thus underestimating the true burden of surfing injuries. Our study may also underestimate actual deaths from drowning or related to surfing because deaths may be declared in the prehospital setting or after admission to the hospital.
5. Conclusions To our knowledge, this is the largest study on surfing injuries ever conducted, and one of the only studies looking solely at surfers that seek medical attention from US EDs. In our sample, serious injuries resulting from surfing were rare. This study has confirmed that injuries tend to be traumatic in nature, most commonly affecting the lower extremity, head, neck, and face and are most commonly lacerations. We found an overall low frequency of cases requiring hospital admission; however, patients older than 60 years, patients with injuries to the trunk and closed head injuries, and those with fractures had a statistically significant increased frequency of hospital admission. We found an overall low frequency of injuries resulting from marine animals. Future work using the NEISS database could be done to investigate injury patterns associated with activities such as skimboarding or boogieboarding that were excluded from this analysis but classified under the surfing product code.
Acknowledgments No monetary assistance or writing assistance was received for the writing of this manuscript. The authors have no financial or other conflicts of interest to disclose. References [1] Furness J, Hing W, Walsh J, Abbot A, Sheppard JM, Climstein M. Acute injuries in recreational and competitive surfers. AJSM 2015;43:1246–54. [2] Nathanson A, Bird S, Dao L, Tam-Sing K. Competitive surfing injuries: a prospective study of surfing-related injuries among contest surfers. AJSM 2007;35:113–7. [3] Woodacre T, Waydia SE, Weinand-Barnett S. Aetiology of injuries and the need for protective equipment for surfers in the UK. Injury 2014. http://dx.doi.org/10.1016/ j.injury.2014.07.019. [4] US Consumer Product Safety Commission. NEISS: National Electronic Injury Surveillance System: a tool for researchers. Washington, DC: US Consumer Product Safety Commission. Available from URL: http://www.cpsc.gov/PageFiles/106626/ 2000d015.pdf. Published March, 2000. [5] US Consumer Product Safety Commission. NEISS Coding Manual. Washington, DC: US Consumer Product Safety Commission. Available from URL: http://www.cpsc. gov//Global/Neiss_prod/completemanual.pdf. Accessed 19 March, 2015. [6] Xiang H, Kelleher K, Shields BJ, Brown KJ, Smith GA. Skiing- and snowboardingrelated injuries treated in US emergency departments, 2002. J Trauma 2005;58(1): 112–8. [7] Kurinsky RM, Rochette LM, Smith GA. Pediatric injuries associated with high chairs and chairs in the United States, 2003-2010. Clin Pediatr 2014;53(4):372–9. [8] Wang ML. Unicycle injuries in the United States. J Emerg Med 2013;45(4):502–7. [9] Sharma VK, Rango J, Connaughton AJ, Lombardo DJ, Sabesan VJ. The current state of head and neck injuries in extreme sports. Orthop J Sports Med 2015;3(1):1–6. [10] Nathanson A, Haynes P, Galanis D. Surfing injuries. Am J Emerg Med 2002;20(3): 155–60. [11] Hay CS, Barton S, Sulkin T. Recreational surfing injuries in Cornwall, United Kingdom. Wilderness Environ Med 2009;20(4):335–8. [12] Taylor DM, Bennett D, Carter M, Garewal D, Finch CF. Acute injury and chronic disability resulting from surfboard riding. J Sci Med Sport 2004;7(4):429–37. [13] Taylor DM, Bennett D, Carter M, Garewal D, Finch CF. Perceptions of surfboard riders regarding the need for protective headgear. Wilderness Environ Med 2005;16(2): 75–80. [14] Moraes GC, Guimaraes ATB, Gomes ARS. Analysis of injuries' prevalence in surfers from Parana seacoast. Acta Ortop Bras 2013;21(3):213–8 [online Available from URL: http://www.scielo.br/aob].
Please cite this article as: Klick C, et al, Surfing USA: an epidemiological study of surfing injuries presenting to US EDs 2002 to 2013, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.05.008
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Original Contribution
Surfing USA: an epidemiological study of surfing injuries presenting to US EDs 2002 to 2013 Cole Klick, MD ⁎, Courtney M.C. Jones, PhD, MPH, David Adler, MD, MPH Department of Emergency Medicine, University of Rochester - Strong Memorial Hospital, Rochester, NY, USA
a r t i c l e
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Article history: Received 30 December 2015 Received in revised form 29 April 2016 Accepted 2 May 2016 Available online xxxx
a b s t r a c t Introduction: Surfing is a popular recreational and competitive sport in the United States and worldwide. Previous studies indicate surfers are frequently injured, but most studies are survey based, and little is known about surfing injuries that present to emergency departments (EDs). Aims: This study examines the epidemiology of surfing injuries presenting to US EDs. Methods: A retrospective analysis was performed using data from the National Electronic Injury Surveillance System database from the US Consumer Product Safety Commission from 2002 to 2013. Results: A total of 2072 cases were analyzed, corresponding to a national estimate of 131 494 total injuries over the 12-year period (95% confidence interval, 34 515-228 473). The median age of included cases was 27 years (interquartile range, 19-37). Lower extremity injuries were most common (25.9%), followed by the face (23.1%) and head and neck (22.7%). Lacerations were the most common injury type (40.7%), followed by sprains and strains (14.4%), contusions (12.9%), and fractures (11.9%); 95.7% of cases were treated and released. Patients older than 60 years, those injured to the trunk, and those suffering fractures or internal organ injuries were admitted at a statistically significant increased frequency (P b .05). Conclusion: Surfing injuries are common but rarely serious. The injuries most commonly affect the lower extremity, head, neck, and face and are most frequently lacerations. Age older than 60 years, injuries to the trunk, and internal organ injuries were associated with a statistically significant increased frequency of hospital admission. © 2016 Elsevier Inc. All rights reserved.
1. Introduction Surfing is a popular recreational and competitive sport. There are an estimated 37 million surfers worldwide, 2.1 million in the United States alone [1,2]. Furness et al [1] reported that up to one-third of surfers sustain an acute injury causing them to seek medical attention, miss work, or take time off surfing each year. A recent study by Woodacre et al [3] reported that 91% of surfers polled had sustained injuries while surfing during their lifetime. Despite knowledge of injury rates and mechanisms from peerreviewed studies, few studies have investigated injuries that present to emergency departments (EDs) around the United States. The purpose of this study is to describe the epidemiology of surfing injuries presenting to US EDs, using the National Electronic Injury Surveillance System (NEISS), a nationally representative sample. 2. Patients and methods 2.1. Data source The NEISS is a free, deidentified database of injuries related to consumer products. The database is produced and maintained by the US ⁎ Corresponding author at: 601 Elmwood Ave, Box 655, Rochester, NY 14642. Tel.: +1 585 463 2940; fax: +1 585 463 3516. E-mail address: [email protected] (C. Klick).
Consumer Product Safety Commission. An NEISS coordinator at each of the approximately 100 participating hospital EDs transcribes patient data, assigning a product code based on details found in the medical record [4]. Information regarding diagnoses, disposition, patient age, race, sex, body location, weight, and a brief narrative field describing the injury and mechanism are also recorded [5]. Coders are specifically trained and receive continuous training to ensure intercoder reliability, and participating hospitals provide approximately 400 000 records annually to the database [4]. Previous studies including articles describing skiing and snowboarding injuries and head and neck injuries in extreme sports have shown the utility of the database for identifying recreational sport injuries [6–9]. Injuries related to surfing among patients of all ages from 2002 to 2013 were identified by NEISS consumer product code 1261 (Surfing). Data before 2002 were excluded because it did not contain the narrative field. This study sought to describe injuries related to traditional stand up surfing, defined as a surfer paddling into a nature-generated wave, on an open body of water, and riding the wave in a standing position. Injuries identified by the narrative as bodyboarding, boogieboarding, bodysurfing, skimboarding, skinboarding, waterboarding, wakeboarding, stand up paddling, river surfing, kneeboarding, knee surfing, kitesurfing, kiteboarding, wakesurfing, and swimming were excluded by a trained data abstractor. Cases in which a narrative was not present or the injured body part was listed as not stated or not known were also excluded, as we
http://dx.doi.org/10.1016/j.ajem.2016.05.008 0735-6757/© 2016 Elsevier Inc. All rights reserved.
Please cite this article as: Klick C, et al, Surfing USA: an epidemiological study of surfing injuries presenting to US EDs 2002 to 2013, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.05.008
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were unable to determine the circumstances surrounding the injury. Finally, cases with injuries that did not occur during the act of surfing, for example, a decorative surfboard falling from a wall onto a person, or a case where a person was injured while repairing a surfboard was excluded. 2.2. Study variables To facilitate interpretation of findings and allow comparison with existing work, NEISS variables were regrouped into clinically meaningful categories. These categories included age, sex, race, body region injured, injury diagnosis, and ED disposition as detailed in Table 1. 2.3. Data analysis To generate a national estimate of surfing injuries presenting to US EDs, statistical weights were applied using the standard approaches as outlined by CPSC NEISS using the PROC SURVEYMEANS procedure in SAS version 9.3 (Carey, NC). Because of significant variability in the national estimate of total injuries, statistical weights were not applied to subsequent analyses. Rather, data were analyzed based on the actual cases contained in the NEISS data set. Descriptive statistics, including medians, proportions, and corresponding measures of variability (interquartile range [IQR] and 95% confidence intervals [CIs]), were used to describe the study sample and injury patterns. Differences in ED disposition based on injury type and body region injured were compared using χ2 tests and Fisher exact text where indicated. 3. Results Query of the NEISS database over the 12-year period from January 1, 2002, to December 31, 2013, yielded 3464 documented injuries, but 1391 entries were excluded due to insufficient information or activities that did not meet the aforementioned definition of surfing. Therefore, 2072 cases were included in the final data analysis (Figure). This corresponds to a national estimate of 131 494 total injuries over the 12-year period (95% CI, 34 515-228 473). There was no statistically significant difference in injury patterns over the years of the study period. In our final sample, at least 1 case was represented from 57 of the primary sampling units (individual participating hospitals). Three primary sampling units contributed more than 75% of the total cases. Age of subjects ranged from 4 to 82 years, with a median age of 27 years (IQR, 19-37). The sample was 81.9% male and 76.3% white. Table 2 summarizes the demographic characteristics of the included subjects.
body area (25.9%), followed by the face (23.1%), head and neck (22.7%), upper extremity (16.7%), and trunk (8.6%). The most common injury diagnoses were lacerations (40.7%), followed by sprains and strains (14.4%), contusions (12.9%), and fractures (11.9%). Lacerations were primarily to the face (41.3%) and lower extremity (28.3%). Concussions accounted for 2.7% of all injuries. Of note, head, neck, and face accounted for 62.7% of the lacerations. Fractures were relatively common and occurred primarily in the upper extremity (31.7%) and lower extremity (30.9%). Sprains and strains were most common in the lower extremity (34.8%) and neck (28.8%). Dislocations represented 4.5% of all injuries with 84.9% corresponding to the upper extremity, primarily the shoulder. Submersion injury was an uncommon diagnosis (n = 6); however, 1 case was fatal. There was 1 anterior myocardial infarction. Noteworthy but uncommon injuries included 1 finger amputation and several tympanic membrane ruptures. Although not explicitly coded for in NEISS, a search of the narrative fields for marine zoonoses revealed 1 sharkrelated injury, 1 seal attack, 2 urchin-related injuries, and 9 stingrayrelated punctures or envenomations. Surprisingly, there were no reported visits related to jelly fish envenomations. 3.2. Patient disposition Table 4 summarizes the overall disposition of injured surfers; 95.7% were treated and released, 3.5% admitted or transferred to another hospital, 0.8% of cases left without treatment, and there was 1 fatality (0.05%). The left without treatment (n = 16) and fatality (dead on arrival or died in ED) (n = 1) groups were excluded from bivariate analyses looking at differences in ED disposition based on sex, age, race, injury location, and body region injured due to insufficient sample size so calculations based on disposition included only 2055 of the total 2072 subjects (Table 5). We did not find a statistically significant difference in ED disposition (admitted vs treated and released) between males and females (3.8% vs 2.2%). There was a statistically significant difference in ED disposition based on patient age (P b .001), with older adult patients having increased frequency of hospital admission (13.6% and 9.4% of subjects aged 60-69 years and 70 years or older, respectively). There were statistically significant differences in ED disposition based on injury type and injured body region (P b .001 for both comparisons). Injuries to the trunk were the most likely to require hospital admission (10.3%), whereas injuries to the face were unlikely to require admission (0.4%). Injuries coded as internal, mostly closed head injuries in this study, and fractures were associated with the highest proportion of admissions (13.4% and 11%, respectively), whereas sprains, lacerations, and contusions very rarely required admission or transfer (0.8%, 0.3%, and 1.1%, respectively). 4. Discussion
3.1. Types and body areas injured Table 3 summarizes the types of injury and corresponding body region injured. The lower extremity was the most commonly injured
To our knowledge, this is the largest epidemiological study of surfing injuries to date and one of only a few studies looking at cases seeking medical attention.
Table 1 Study variables Study variables Sex
Age
Race
Body region injured
Injury diagnosis
Disposition
Male Female
0-9 10-19 20-29 20-39 40-49 50-59 60-69 70 and older
White Black Asian Other/Native/Hawaiian/Pacific Islanderc Unknown
Head/neck Face Trunk Upper extremity Lower extremity Othera
Concussion Contusion/Abrasion/Hematoma Laceration Fracture Dislocation Sprain/Strain Internal injury Otherb
Treated and Released Admitted or Transferred Left without treatment Dead on arrival or died in ED
a b c
Systemic (N25% of body area involved), pubic region, ear. Crush injury, nerve damage, puncture, amputation, hemorrhage, avulsion, foreign body, radiation injury, dermatitis, conjunctivitis, poisoning, dental injury, and submersion injury. Combined variable made up of the categories
Please cite this article as: Klick C, et al, Surfing USA: an epidemiological study of surfing injuries presenting to US EDs 2002 to 2013, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.05.008
C. Klick et al. / American Journal of Emergency Medicine xxx (2016) xxx–xxx
Figure. Included and excluded surfing cases.
Please cite this article as: Klick C, et al, Surfing USA: an epidemiological study of surfing injuries presenting to US EDs 2002 to 2013, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.05.008
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Table 2 Demographics of included patients (n = 2072) Patient characteristic
n
Median age (IQR) Age (y) 0-9 10-19 20-29 30-39 40-49 50-59 60-69 70 and older Sex Male Female Race White Black Asian Other Unknown
27 (19-37)
Table 4 Overall patient disposition (n = 2072) Percentage (95% CI)
39 528 629 448 283 105 33 7
1.9 (1.31-2.49) 25.5 (23.62-27.38) 30.4 (28.42-32.38) 21.6 (19.83-23.37) 13.7 (12.22-15.18) 5.1 (4.15-6.05) 1.6 (1.06-2.14) 0.3 (0.06-0.54)
1697 375
81.9 (80.24-83.56) 18.1 (16.44-19.76)
1579 18 47 156 272
76.2 (74.37-78.03) 0.9 (0.49-1.31) 2.3 (1.65-2.95) 7.5 (6.37-8.63) 13.1 (11.65-14.55)
Note. n = 2072.
The median age of 27 years and majority male sex (81.9%) of our sample are similar to previous work, both self-reporting studies, and those taking place in the health care setting [1–3,10–12]. Our results indicate that most surfing-related injuries presenting to US EDs appear to be consistent with acute traumatic injuries and not chronic injuries resulting from overuse. Our study found a very high proportion of lacerations (40.7%) that is consistent with previous studies [2,3,11,12]. In our study, the lacerations were most commonly on the head, neck, and face, accounting for 62.7% of all lacerations with the lower extremity accounting for 28.3%. Nathanson et al [10] described higher frequencies for lower extremity lacerations with approximately equal proportion of lacerations occurring on the head and neck region and the lower extremity (43.4% and 40.7%, respectively), whereas other studies by Taylor et al [12] and Hay et al [11] have a laceration location breakdown consistent with the findings in our study (65% head and neck, 29% lower extremity, and 75% head and neck and 14% lower extremity, respectively). This study was not designed to classify injuries based on mechanism, but a study by Nathanson et al [2] described lacerations resulting mostly from contact with the surfer's own board or a shallow, hard bottom such as a coral reef. Many surfing venues feature water that requires use of a neoprene rubber wetsuit for at least parts of the year, the rubber ranging from 1 to 6 mL thick offers some protection against lacerations; however, neoprene hoods are only worn in the coldest surf environments. The differences in laceration distributions may be reflective of wetsuit prevalence, with proportionately higher head, neck, and face lacerations where long wetsuits are worn, and more widely distributed lacerations where surfers wear only swim trunks. Concussions (2.7%) were relatively infrequent but consistent with frequencies previously described [3,10]. Additional head injuries that are not immediately apparent in the database are a significant portion of the
Disposition
n
Percentage (95% CI)
Treated and released Admitted or transferred Left without treatment Dead on arrival or Died in ED
1983 72 16 1
95.7 (94.83-96.57) 3.5 (2.71-4.29) 0.8 (0.42-1.18) 0.1 (−0.04 to 0.24)
Note. n = 2072. Percentages may not total to 100.0% due to rounding error.
injuries classified as internal injuries (n = 85). Closed head injuries that are not classified as concussion, including intracranial hematomas, are classified as internal organ injuries in the NEISS database [5]. These closed head injuries made up 4.1% of total cases and had a clinically significant admission frequency of 13.4%, much higher than the overall admission frequency of 3.5% for all cases in this study. It is unclear if variability exists between health care setting–based studies and self-reported surveys because concussion is a clinical diagnosis and familiar to many laypersons, whereas closed head injuries may be radiologic diagnoses and not accurately represented on participant surveys. In light of the clinically significant traumatic head injuries, helmets or other protective headgear would seem like a very good addition to the surfer's equipment quiver, and this has been proposed by several studies; however, surfers have been resistant to wearing head protection. Taylor et al conducted a study investigating the need for protective headgear in surfers and surfers' perceptions of head gear and found that surfers generally downplay the risk of head injuries while surfing but that significant surf culture barriers, especially revolving around fashion and appearance prevent widespread use [3,10–13]. Others have proposed more frequent use of padded or blunt nose guards to protect the surfer from the sharp front of their board and alternative construction surfboards with soft, padded foam, tops and rails, and soft, pliable, dulled fins that break away more easily on contact to help prevent lacerations and other traumatic injuries when they contact the surfer. These are, however, largely unpopular due to decreased performance characteristics and fashion within surf culture [10]. Sprains and strains were the second most common injuries presenting to the ED in this study (14.4%) with the lower extremity being the most common body region affected. This proportion is similar to that described by Nathanson et al [10]. Interestingly, our study found sprains and strains to be most common in the lower extremity followed by the neck which is consistent with several studies, whereas Hay et al found higher proportions of sprains and strains of the neck (43%), but a similar proportion to the lower extremity (33%) [2,10,14,11]. Differences among populations of the studies, for example, competitive or resident surfers as opposed to weekend warriors, may account for these differences. Fractures accounted for 11.9% of the injuries observed in this study and were only slightly more common in the upper extremity than the lower extremity and head, neck, and face. These findings are consistent with previous work [10,11]. Facial fractures, often resulting from contact with one's own surfboard or the seafloor, make up a significant proportion of fractures. Protective surfboards or avoidance of surf spots that
Table 3 Type and location of surfing injuries (n = 2072) Injury diagnosis
Injured body region
Head/neck Face Trunk Upper extremity Lower extremity Other Total
Concussion
Contusion
Laceration
Fracture
Dislocation
Sprain
Internal injury
Other
Total
56 – – – – – 56 (2.7%)
34 57 66 45 60 5 267 (12.9%)
180 349 12 54 239 10 844 (40.7%)
16 48 27 78 76 1 246 (11.9%)
– – – 79 14 – 93 (4.5%)
86 – 39 70 104 – 299 (14.4%)
87 – 5 – – 5 97 (4.7%)
11 24 29 19 44 43 170 (8.2%)
470 (22.7%) 478 (23.1%) 178 (8.6%) 345 (16.7%) 537 (25.9%) 64 (3.1%) 2072 (100%)
Note. n = 2072.
Please cite this article as: Klick C, et al, Surfing USA: an epidemiological study of surfing injuries presenting to US EDs 2002 to 2013, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.05.008
C. Klick et al. / American Journal of Emergency Medicine xxx (2016) xxx–xxx Table 5 Patient disposition based on demographics (n = 2055) Characteristic
Sex Male Female Age⁎ 0-9 10-19 20-29 20-39 40-49 50-59 60-69 70 and older Injured body region⁎ Head/neck Face Trunk Upper extremity Lower extremity Other Injury diagnosis⁎ Concussion Contusion Laceration Fracture Dislocation Sprain Internal injury Other
Treated and released (n = 1983)
Admitted or transferred (n = 72)
n
Percentage (95% CI)
n
Percentage (95% CI)
1621 362
96.2 (95.37-97.03) 97.8 (97.17-98.43)
64 8
3.8 (2.97-4.63) 2.2 (1.57-2.83)
36 515 618 424 266 89 29 6
94.7 (93.73-95.67) 97.7 (97.05-98.35) 99.0 (98.57-99.43) 95.5 (94.6-96.4) 94.7 (93.73-95.67) 86.4 (84.92-87.88) 90.6 (89.34-91.86) 100.0
2 12 6 20 15 14 3 0
5.3 (4.33-6.27) 2.3 (1.65-2.95) 1.0 (0.57-1.43) 4.5 (3.6-5.4) 5.3 (4.33-6.27) 13.6 (12.12-15.08) 9.4 (8.14-10.66) 0.0
447 473 157 332 515 59
95.3 (94.38--96.22) 99.6 (99.33-99.87) 89.7 (88.39-91.01) 97.9 (97.28-98.52) 96.4 (95.59-97.21) 93.7 (92.65-94.75)
22 2 18 7 19 4
4.7 (3.78-5.62) 0.4 (.013-0.67) 10.3 (8.99-11.61) 2.1 (1.48-2.72) 3.6 (2.79-4.41) 6.3 (5.25-7.35)
52 263 834 219 89 296 84 146
92.9 (91.79-94.01) 98.9 (98.45-99.35) 99.2 (98.81-99.59) 89.0 (87.65-90.35) 95.7 (94.82-96.58) 99.7 (99.46-99.94) 86.6 (85.13-88.07) 91.8 (90.61-92.99)
4 3 7 27 4 1 13 13
7.1 (5.99-8.21) 1.1 (0.65-1.55) 0.8 (0.41-1.19) 11.0 (9.65-12.35) 4.3 (3.42-5.18) 0.3 (0.06-0.54) 13.4 (11.93-14.87) 8.2 (7.01-9.39)
Note. n = 2055—sample limited to those treated and released from the ED and those admitted or transferred. Percentages may not total to 100.0% due to rounding error. ⁎ P b .05.
are especially shallow, including those with rock or reef bottoms, may prevent some of these injuries. Dislocations in this study were primarily shoulder dislocations (n = 77), accounting for 3.7% of all injuries. Previous studies have described frequencies between 1.7% and 9.4% [10–12]. Bottom depth and contours, wave size, and skill level may explain these ranges in dislocations. Work by Moraes et al [14] also found the upper extremity region responsible for the majority of dislocations. Our study found a very low incidence of marine life–related injuries (n = 19), a proportion similar to that found by Taylor et al, which was much lower than the 3% found in a previous self-reporting study. It may be that surfers with jellyfish stings, urchin injuries, and stingray envenomations generally do not seek medical attention [12,10]. The seal attack reported in this study is not the first; in a self-reported survey-based study with 1348 respondents, Nathanson et al reported 1 seal attack [10]. Shark attacks appear to be exceedingly rare (n = 1) in this study causing a laceration and (n = 3) in a survey based study by Nathanson et al [10]. Very little has been reported by other studies about submersion injuries, drowning, or death while surfing. Our study found few submersion related injuries (n = 6), yet one was fatal. Four cases of submersion injury were treated and released, and 1 patient was admitted for observation. Nathanson et al reported only 2 near drowning episodes of 6784 hours of contest surfing in a prospective study of injuries suffered by competition surfers requiring medical assistance; both were related to head injuries; however, there are no data as to whether these surfers required hospitalization for the submersion injury [2]. Overall, most submersion injuries are rare and often related to a more proximate injury, such as a head injury. It may be that surf leashes, 1.5- to 2.5-m rubber cords that tether a surfer to his or her board in the event of a wipe out, help prevent drowning. It is also possible that previous studies have been too small to detect such rare events. In addition, most
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previous work has been participant survey-based data collection and patients who drown or died surfing would be de facto excluded. Despite presenting to the ED, most injured surfers have only minor injuries and are treated and released. In our sample, 95.7% of cases were treated and released; only 3.5% of cases required admission or transfer to another facility. Hay et al published a higher proportion of admissions (10%) in their ED-based study in Cornwall, UK; similar to our study, surfers requiring admission had severe head and neck injuries or extremity fractures requiring operative intervention [11]. Our study also demonstrated a statistically significant increased admission frequency for injuries to the trunk and internal organ injuries, which as described previously were primarily closed head injuries, but also included rib fractures, several pneumothoraces, solid organ injuries, and several thoracic or lumbar spine injuries. Considering that two-thirds of surfers do not seek medical attention for their injuries, overall injuries requiring hospital admission are infrequent [3]. Our study also found a statistically significant increased frequency of hospital admission in surfers older than 60 years. Nathanson et al had previously found statistically significant increased rates of severe injury and hospital admission in surfers older than 40 years, those who self-reported advanced or expert ability, and in surfers surfing waves larger than 1.5 m measured on the face [10]. Based on our findings, death from surfing is extremely uncommon. 4.1. Study limitations Although the NEISS database offers easily accessible, deidentified data on injuries related surfing in the US, our study has important limitations to consider. First, although our study is the largest descriptive epidemiologic study of surfing-related injuries, we were unable to provide reliable national estimates due to the large variability of these estimates. There is likely significant geographic variability in the incidence of surfing injuries. This was evidenced in our data by greater than 75% of the cases being from 3 of the primary sampling units. Other studies using the NEISS data set have reported national injury estimates; however, the estimates calculated for surfing injuries have a very wide CI. This may indicate that the network of NEISS participating hospitals is not representative of the geographic distribution of surfers in the United States. The database may be more representative for injuries related to more ubiquitous sports such as basketball rather than sports that are mostly practiced on the coastline. As such, our findings should be interpreted cautiously. Our national injury estimate likely underestimates the true burden of surfing injuries due to the underrepresentation of hospitals from areas in which surfing is common (eg, Hawaii). The purpose of our study was to present a descriptive analysis of the cases contained within the dataset and may or may not mirror the national pattern of injuries related to surfing. Nevertheless, our results provide insight as to the patterns of surfing-related injuries presenting to the ED for care. In addition, injury severity is not always clearly represented by the data set; for example, a knee dislocation would be coded by injury code 55 and body location 35; this does not differentiate a patellar dislocation from the more severe posterior knee dislocation [5]. Despite this, our findings add information to the literature on the injury type, burden, and outcome related to surfing injuries. Second, the NEISS data are subject to coder interpretation of what constitutes a surfing injury, which was more inclusive than the definition of surfing used in this study. Although we used rigorous methods to review the case narratives to ensure our sample included only cases related to surfing, it is still possible that other types of surfing-related activities were included. We did exclude 40.2% of the queried cases assigned product code 1261 because of insufficient data or because their narrative field indicated they were not actually injuries caused by surfing. Although surfing is a popular sport, it may not be appropriate to expect nonsurfers to accurately differentiate between surfing as defined in this study and activities such as boogieboarding, bodysurfing, or skimboarding and to enter such details into the case narrative at the point of NEISS data collection.
Please cite this article as: Klick C, et al, Surfing USA: an epidemiological study of surfing injuries presenting to US EDs 2002 to 2013, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.05.008
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This study sought to describe the epidemiologic characteristics of surfing injuries that present to US EDs. Its results may be dependent on the unique health care structure of the United States and are not necessarily generalizable to other countries with different health care settings. Data in this study were limited to a preexisting database that was not designed specifically for investigation of surfing injuries. Diagnosis and body area data are limited to that specified by the database, which may not be clinically relevant to surfing injuries in particular. Another limitation of this study is that it only looked at injuries presenting to the ED and may miss patients who present to their primary care office; in addition, this study offers no information on injured surfers not seeking medical care, thus underestimating the true burden of surfing injuries. Our study may also underestimate actual deaths from drowning or related to surfing because deaths may be declared in the prehospital setting or after admission to the hospital.
5. Conclusions To our knowledge, this is the largest study on surfing injuries ever conducted, and one of the only studies looking solely at surfers that seek medical attention from US EDs. In our sample, serious injuries resulting from surfing were rare. This study has confirmed that injuries tend to be traumatic in nature, most commonly affecting the lower extremity, head, neck, and face and are most commonly lacerations. We found an overall low frequency of cases requiring hospital admission; however, patients older than 60 years, patients with injuries to the trunk and closed head injuries, and those with fractures had a statistically significant increased frequency of hospital admission. We found an overall low frequency of injuries resulting from marine animals. Future work using the NEISS database could be done to investigate injury patterns associated with activities such as skimboarding or boogieboarding that were excluded from this analysis but classified under the surfing product code.
Acknowledgments No monetary assistance or writing assistance was received for the writing of this manuscript. The authors have no financial or other conflicts of interest to disclose. References [1] Furness J, Hing W, Walsh J, Abbot A, Sheppard JM, Climstein M. Acute injuries in recreational and competitive surfers. AJSM 2015;43:1246–54. [2] Nathanson A, Bird S, Dao L, Tam-Sing K. Competitive surfing injuries: a prospective study of surfing-related injuries among contest surfers. AJSM 2007;35:113–7. [3] Woodacre T, Waydia SE, Weinand-Barnett S. Aetiology of injuries and the need for protective equipment for surfers in the UK. Injury 2014. http://dx.doi.org/10.1016/ j.injury.2014.07.019. [4] US Consumer Product Safety Commission. NEISS: National Electronic Injury Surveillance System: a tool for researchers. Washington, DC: US Consumer Product Safety Commission. Available from URL: http://www.cpsc.gov/PageFiles/106626/ 2000d015.pdf. Published March, 2000. [5] US Consumer Product Safety Commission. NEISS Coding Manual. Washington, DC: US Consumer Product Safety Commission. Available from URL: http://www.cpsc. gov//Global/Neiss_prod/completemanual.pdf. Accessed 19 March, 2015. [6] Xiang H, Kelleher K, Shields BJ, Brown KJ, Smith GA. Skiing- and snowboardingrelated injuries treated in US emergency departments, 2002. J Trauma 2005;58(1): 112–8. [7] Kurinsky RM, Rochette LM, Smith GA. Pediatric injuries associated with high chairs and chairs in the United States, 2003-2010. Clin Pediatr 2014;53(4):372–9. [8] Wang ML. Unicycle injuries in the United States. J Emerg Med 2013;45(4):502–7. [9] Sharma VK, Rango J, Connaughton AJ, Lombardo DJ, Sabesan VJ. The current state of head and neck injuries in extreme sports. Orthop J Sports Med 2015;3(1):1–6. [10] Nathanson A, Haynes P, Galanis D. Surfing injuries. Am J Emerg Med 2002;20(3): 155–60. [11] Hay CS, Barton S, Sulkin T. Recreational surfing injuries in Cornwall, United Kingdom. Wilderness Environ Med 2009;20(4):335–8. [12] Taylor DM, Bennett D, Carter M, Garewal D, Finch CF. Acute injury and chronic disability resulting from surfboard riding. J Sci Med Sport 2004;7(4):429–37. [13] Taylor DM, Bennett D, Carter M, Garewal D, Finch CF. Perceptions of surfboard riders regarding the need for protective headgear. Wilderness Environ Med 2005;16(2): 75–80. [14] Moraes GC, Guimaraes ATB, Gomes ARS. Analysis of injuries' prevalence in surfers from Parana seacoast. Acta Ortop Bras 2013;21(3):213–8 [online Available from URL: http://www.scielo.br/aob].
Please cite this article as: Klick C, et al, Surfing USA: an epidemiological study of surfing injuries presenting to US EDs 2002 to 2013, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.05.008