Injury during contact with horses: Recent experience with 75 patients at a level I trauma center.Background. The objective of this study was to examine equine-related trauma at a trauma center trauma center n. A medical facility that is designated to treat severe physical trauma as a result of the specialized training of its staff and the availability of appropriate diagnostic and treatment tools. servicing a region in which there is significant contact between horses and humans. Methods. Data were collected on all patients admitted to the University of Kentucky The University of Kentucky, also referred to as UK, is a public, co-educational university located in Lexington, Kentucky. Medical Center from January 1994 to December 1998 for treatment of horse-related injuries. Results. Seventy-five patients were admitted to our center after injuries due to contact with horses (0.75% of all trauma admissions). There were 42 men (55%). The mean age was 37 years (range, 3 to 81 years). The majority of patients (67/75) were injured during recreational activities, and most fell or were thrown (40/75). Only 14% of patients were wearing helmets. The most common injuries were extremity fractures and head injuries, but thoracic and abdominal injuries were not rare. Of the 75 patients, 34 required surgery. Five patients (6.7%) died, all of head injury. During the study period, 11 people died in Kentucky due to contact with horses. Conclusions. Injury due to contact with horses is uncommon even at a center servicing a region with a large equine population. However, injuries are often serious and lead to significant morbidity and occasional mortality. Prevention of death from horse-related trauma is synonymous with synonymous with adjective equivalent to, the same as, identical to, similar to, identified with, equal to, tantamount to, interchangeable with, one and the same as prevention of head injury. ********** INJURY FROM HORSES can occur during ridino farming, and employment in the horse industry. Riders are unrestrained, and horses are fast and heavy and kick with extreme force. Approximately 30 million Americans ride horses annually, and in 1987 and 1988 an estimated 92,763 visits were made to emergency departments for injuries related to riding. (1) Horseback riding horseback riding: see equestrianism. may pose a greater threat to health than riding on a motorcycle. (1) The Bluegrass region Bluegrass region Area of central Kentucky, U.S. The region contains Kentucky's best agricultural land and thus became the first area to be settled. It became known for its abundant bluegrass and became famous for breeding fine horses; the calcium-rich soil imparts its of Kentucky has many equine activities and events, and it is estimated that the horse industry employs 130,000 Kentuckians. (2) The University of Kentucky Medical center is a level I trauma center In the United States, a Level I trauma center provides the highest level of surgical care to trauma patients. A Level I trauma center is required to have a certain number of surgeons and anesthesiologists on duty 24 hours a day at the hospital, an education program, located in the Bluegrass bluegrass, any species of the large and widely distributed genus Poa, chiefly range and pasture grasses of economic importance in temperate and cool regions. In general, bluegrasses are perennial with fine-leaved foliage that is bluish green in some species. . The objectives of this review were to examine horserelated trauma at our center, to compare it with reported experience elsewhere, and to highlight the patterns of serious injury during contact with horses. MATERIAL AND METHODS The University of Kentucky Medical Center in Lexington is an American College American College is the name of:
See Institutional Shareholder Services (ISS). ), Abbreviated Injury Scores (AIS) by body region, admission Glasgow Coma Scale Glas·gow Coma Scale n. A scale for measuring level of consciousness, especially after a head injury, in which scoring is determined by three factors: amount of eye opening, verbal responsiveness, and motor responsiveness. (GCS GCS Glasgow Coma Scale GCS Guilford County Schools (North Carolina) GCS Ground Control Station GCS Grand Central Station GCS Ground Control System GCS Ground Combat Systems GCS Group Communication Systems ) score, mechanism of injury, safety equipment use, blood alcohol level if tested, anatomic injuries, surgery, duration of hospital stay, and mortality. Clinical data were entered in a database for analysis. To determine the total number of horse-related deaths in the state of Kentucky during the study period, the State Medical Examiner's office was contacted. RESULTS During the 5-year study period, 10,020 blunt trauma blunt trauma Molecular Any injury sustained from blunt force, which may be related to MVAs, or mishaps, falls or jumps, blows or crush injuries from animals, blunt objects or unarmed assailants. Cf Penetrating trauma. victims were admitted to the University of Kentucky Medical Center. Seventy-five of these patients (0.75%) were admitted for injuries from contact with horses. The demographic data and information on the mechanism of injuries are shown in Tables 1 and 2. Of the 75 patients, 9 (12%) were less than 12 years of age. All 9 children were involved in recreational activity, and none were wearing protective helmets. The distribution of AIS scores by body region for the 75 study patients is shown in Table 3. Extremity fractures, the most common injuries in our series, occurred in approximately one half of all patients. There were 23 lower extremity lower extremity n. The hip, thigh, leg, ankle, or foot. Also called inferior limb, pelvic limb. fractures and 14 upper extremity upper extremity n. The shoulder, arm, forearm, wrist, or hand. Also called superior limb, thoracic limb. fractures. Head injuries were slightly less common, present in 33 (44%) of the 75 patients. However, many patients had moderate to severe head injuries, and head injury accounted for all 5 deaths in our series. These 5 patients had an average ISS of 29 and an average admission GCS score of 5. Two of these 5 patients had severe closed head injuries, had no surgical intervention, and died 2 and 3 days after injury, respectively. One patient had craniotomy Craniotomy Definition Surgical removal of part of the skull to expose the brain. Purpose A craniotomy is the most commonly performed surgery for brain tumor removal. for a subdural hematoma Subdural Hematoma Definition A subdural hematoma is a collection of blood in the space between the outer layer (dura) and middle layers of the covering of the brain (the meninges). but died on the first postoperative day. One patient had bilateral frontal contusions and diffuse edema edema (ĭdē`mə), abnormal accumulation of fluid in the body tissues or in the body cavities causing swelling or distention of the affected parts. and died 8 days after injury, and 1 patient with a massive head injury was in cardiorespiratory car·di·o·res·pi·ra·to·ry adj. Of or relating to the heart and the respiratory system. Adj. 1. cardiorespiratory - of or pertaining to or affecting both the heart and the lungs and their functions; "cardiopulmonary arrest on arrival and died in the emergency room. Seven of the 9 children sustained a head injury. There were no deaths among the children (age < 12). Forty-five percent (34/75) of patients had surgery related to their trauma. Fifty-three percent (18/34) of the operations were done to repair extremity fractures, and 42% (8/18) of these were tibial tibial pertaining to the tibia. tibial crest a longitudinal prominence on the cranial border of the proximal tibia. Its proximal end (tibial tubercle) has a growth plate separate from the proximal tibia; hyperflexion injuries to fractures. Facial fractures accounted for 20% of all operations (7/34). Four patients required surgery for thoracoabdominal injuries. One patient had a fracture of the thyroid cartilage necessitating emergency tracheostomy and repair of the laryngeal laryngeal /lar·yn·ge·al/ (lah-rin´je-al) pertaining to the larynx. la·ryn·geal or la·ryn·gal adj. Of, relating to, affecting, or near the larynx. fracture. Of the 4 patients who had pelvic fractures related to equine trauma, 1 required surgical repair. In the state of Kentucky, a total of 11 horse-related deaths (5 at our center and 6 elsewhere) occurred during the study period. DISCUSSION Our study describes a contemporary experience with horse-related injury at a level I trauma center located in a region in which horses and humans have significant contact. Although uncommon in relation to other mechanisms of blunt injury blunt injury A traumatic injury effected by a blunt object or force, in which the skin was not penetrated; usually results from assaults, abuse, accidents or resuscitative measures , these injuries are often serious and lead to significant morbidity and occasional mortality. The precise incidence of injuries due to horses is difficult to determine. The US Pony Club Pony Club is an international youth organization devoted to the educating youths about horses and horseback riding. Pony Club organizations exist in over 30 countries worldwide. estimates one accident per 158,607 hours of all pony club activities. In 5 years, only 150 injuries occurred among a population of 46,351 riders aged 6 to 21 years. Most of these injuries were bruises and abrasions. (3) From 1976 to 1987, 205 riding fatalities occurred in 27 states. (4) Of a total of 10,020 adult and pediatric pediatric /pe·di·at·ric/ (pe?de-at´rik) pertaining to the health of children. pe·di·at·ric adj. Of or relating to pediatrics. blunt trauma cases admitted to our center during the study period, only 75 (0.75%) patients had injuries that occurred during contact with horses. Clearly, the present report describes a fraction of all equine-related injuries in our region, reflecting only those admitted to the regional level I trauma center. In fact, the National Electronic Injury Surveillance System reports that only 4% of persons injured during contact with horses require hospitalization. (5) However, from our data, we can make a rough estimate of the death rate from equine activities in Kentucky. During the 5-year study peri peri (pēr`ē), in Persian mythology, supernatural being. Peris were said to be fallen angels who were denied paradise until they did penance. Originally agents of evil, in later mythology they were identified as benevolent spirits. od, 11 individuals died in Kentucky due to injuries from interaction with horses. Given an approximate state population of 3.7 million during the study period, approximately 0.06 deaths occurred per 100,000 persons per year due to horse-related injury in Kentucky. This estimated death rate is slightly lower than that reported in New Zealand New Zealand (zē`lənd), island country (2005 est. pop. 4,035,000), 104,454 sq mi (270,534 sq km), in the S Pacific Ocean, over 1,000 mi (1,600 km) SE of Australia. The capital is Wellington; the largest city and leading port is Auckland. and Australia. (6,7) For our 75 study patients, the mortality rate was 6.7%, and all deaths were due to head injury, consistent with all other reports. (5-10) The Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. (CDC See Control Data, century date change and Back Orifice. CDC - Control Data Corporation ) did a review of the English language English language, member of the West Germanic group of the Germanic subfamily of the Indo-European family of languages (see Germanic languages). Spoken by about 470 million people throughout the world, English is the official language of about 45 nations. literature on children and young adults injured by horses and found that head injuries caused the most deaths and hospitalizations. (9) It appears from our data and the published worldwide experience that prevention of death due to horse-related injury is synonymous with prevention of fatal head injury. The spectrum of injuries due to contact with horses is broad, though a certain injury pattern does emerge on review of our data and published series. Soft tissue contusions, lacerations, and abrasions are certainly the most common horse-related injuries, but these patients are unlikely to be referred to a level I trauma center. Apart from these injuries, upper and lower extremity fractures are the most common throughout the literature, often followed by head and facial injuries facial injuries, n.pl trauma to the face and its associated structures, most frequently from traffic accidents, contact sports, and domestic conflicts. . (5,11) In a 1990 survey of 706 professional jockeys in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. , 1,700 injuries were reported, 64% of which were fractures. (12) Pelvic fractures, spinal column spinal column, bony column forming the main structural support of the skeleton of humans and other vertebrates, also known as the vertebral column or backbone. It consists of segments known as vertebrae linked by intervertebral disks and held together by ligaments. fractures with or without spinal cord injury Spinal Cord Injury Definition Spinal cord injury is damage to the spinal cord that causes loss of sensation and motor control. Description Approximately 10,000 new spinal cord injuries (SCIs) occur each year in the United States. , and significant abdominal or thoracic injuries are less commonly reported. (13) Although our cohort of patients certainly represents a select sample of injured patients, the injuries we observed were consistent with previously published experience. At our center, extremity fractures were followed in frequency by head injur ies. Abdominal and thoracic injuries were common in our series, and four patients required surgery for truncal truncal /trun·cal/ (trung´k'l) pertaining to the trunk. trun·cal adj. 1. Of or relating to the trunk of the body. 2. Of or relating to an arterial or nerve trunk. injuries. This high frequency of blunt torso injuries likely reflects patient selection due to our status as a level I trauma center. More routine use of protective jackets or vests may minimize some of these injuries. Series of equine-related injury have generally been dominated by injuries to young females. (11) In a literature review by the CDC, young females were more commonly injured than males during contact with horses. (9) Likewise, in a study from Oxford, UK, females out-numbered males 3:1 in horse-related injury. (14) In contrast, there were more males than females (55% vs 45%) among our 75 study patients. This sex distribution may be due in part to the injuries related to horse farming, as opposed to those series comprised of riding injuries. Also, males may have a greater tendency for risk-taking behavior with horses. Humans can be injured during contact with horses by a variety of mechanisms. In our study, the most common mechanism (65%) was being thrown or falling from a horse. Of the remaining patients, 19% were kicked, 12% were crushed, and 4% were struck by a motor vehicle while riding a horse. This distribution of injury mechanism is similar to that reported from other regions with a large equine population. (15) In a study from England, (14) most injured patients (78%) were riders, and 83% of them fell from mount. The remainder of their patients were injured in horse-related occupations. (14) It has been suggested that English-style riding may be more risky than Western riding, given the greater frequency of jumping. (16) Despite the large number of persons employed in the horse industry in central Kentucky Central Kentucky is sometimes considered the Central and Southern part of the Bluegrass region, the Far Upper Western Eastern Mountain Coal Fields, and the Far Upper Eastern Pennyroyal regions. Its major cities include Lexington and Frankfort. (estimated to be 130,000), only 10% of the horse-related trauma we evaluated over the 5-year period was related to occupational exposure to horses. Both our report and others suggest that persons working with hor ses are relatively less likely to be injured than persons riding horses for recreation or competition. Such workers have likely developed defense and safety techniques, as well as a respect for the power and strength of the horse, to avoid injury. Of 150 injuries reported in Alberta, two thirds were claimed to have been caused by the horses and one third by patient risk-taking or inattention in·at·ten·tion n. Lack of attention, notice, or regard. Noun 1. inattention - lack of attention basic cognitive process - cognitive processes involved in obtaining and storing knowledge . (17) Unfortunately, we did not have sufficient data from our 75 patients to shed light on this issue. The role of alcohol use in such injuries is not extensively discussed in the literature. Not all of our patients had blood alcohol levels measured, but of those 47 patients who did, 8 (17%) had alcohol present. Given the plethora of data regarding the effect of alcohol intake on driving performance, it seems likely that the risk of injury during contact with horses is increased by ethanol ingestion ingestion /in·ges·tion/ (-chun) the taking of food, drugs, etc., into the body by mouth. in·ges·tion n. 1. The act of taking food and drink into the body by the mouth. 2. . It is clear that injuries are inevitable as long as people ride or work around horses. However, our study provides insight into the nature of possible preventive measures. In all published clinical series, including the present report, head injury is the most common cause of serious injury and death. (18-20) In one British study, 50% of hospital admissions after a horse-related injury were due to brain injury. (21) In our 75 patients, 5 died of a head injury, and another 28 survived after a significant head injury. A substantial body of epidemiologic evidence supports the use of approved helmets as a means of preventing brain injury during contact with horses. (22,23) A 1996 report from England showed a marked fall in the number of hospital admissions for horse-related injuries compared with the 1970s. The authors speculated that this change may have been due to the increased use of riding helmets in their region. (14) Despite the known risk and the documented benefits of helmet use, only 10 (14%) of 72 patie nts in our study were wearing a helmet. In 3 of our 75 patients, we could not get information on helmet use. Alarmingly, all 9 children in our study were injured during recreational equine activity, and none was wearing a helmet. Our finding of infrequent helmet use has been echoed by other authors. (15,17,24) There has been a perception that helmets are poorly designed, and a clinicopathologic study in 1984 suggested that the helmets in use at that time were inadequate. (22,25,26) McGhee et al (27) found occipital bone occipital bone n. A bone at the lower and posterior part of the skull, consisting of basilar, condylar, and squamous parts and enclosing the foramen magnum. fractures to be the most common skull fracture skull fracture, n a rupture or break in the cranial bones. skull fracture Orthopedics A fracture of one or more cranial bones, caused by MVAs, falls, assault, sports, occupational accidents and other forms of blunt trauma associated with horse contact and reported that some headgear headgear, n the apparatus encircling the head or neck and providing attachment for an intraoral appliance in use of extraoral anchorage. headgear, radiologic, n a device that is used to protect the head from injury by radiation. does not adequately protect the rider from these injuries. Despite these arguments, one wonders how many of the serious and fatal head injuries in our series might have been prevented by the use of modern approved riding helmets. Apart from helmet use, other safety initiatives are salient, including mechanical equipment such as safety stirrups stirrups The footholds in a lithotomy table and protective vests and educational issues such as training, supervision, and the presence of emergency medical services An Emergency medical service (abbreviated to initialism "EMS" in many countries) is a service providing out-of-hospital acute care and transport to definitive care, to patients with illnesses and injuries which the patient believes constitutes a medical emergency. at equestrian events. (11,27) We were unable to address these issues in the present study. In conclusion, this study has described the experience with human injury due to contact with horses at a level I trauma center servicing a region with a large equine population. Even at our center, horse-related injury is uncommon in comparison with other mechanisms of blunt trauma, such as motor vehicle crashes. However, injuries from contact with horses are often serious and lead to significant morbidity. Head injury remains the predominant cause of death. Prevention of death from horse-related trauma is synonymous with prevention of head injury. The low rate of helmet use in our study, especially among children, highlights a potential avenue for preventive strategies.
TABLE 1
Demographic Data (N = 75)
Age (years) (*) 37.0 [+ or -] 16.8 (37, 3-81)
Male patients 55%
Mortality 5/75 (6.7%)
LOS (days) (*) 4.5 [+ or -] 4.5 (3, 0-24)
GCS (*) 13.5 [+ or -] 3.2 (15, 3-15)
ISS (*) 12.0 [+ or -] 9.2 (9, 1-38)
(*)Mean [+ or -] standard deviation (median, range).
ISS = Injury severity score, GCS = admission Glasgow Coma Scale score,
LOS = length of hospital stay.
TABLE 2
Mechanism of Injury (N = 75)
Recreational 89%
Occupational 11%
Thrown 53%
Thrown and crushed 12%
Kicked 19%
Crushed 12%
Hit by vehicle while riding 4%
Helmet use (n = 72) (yes) 10 (14%)
Ethanol (n = 47) 8 (*)
(*)Presence of ethanol in blood.
TABLE 3
Abbreviated Injury Scale (AIS) Scores by Body Region for 75 Patients
Injured During Contact With Horses (*)
No. of Patients
AIS Score Head Face Neck Chest Abdomen
0 (No injury) 42 63 71 56 63
1-5 (Injury) 33 12 4 19 12
1 0 1 0 1 1
2 17 8 2 2 6
3 7 3 2 12 2
4 3 0 0 3 1
5 6 0 0 1 2
No. of Patients
AIS Score Extremity External
0 (No injury) 38 64
1-5 (Injury) 37 11
1 7 11
2 17 0
3 13 0
4 0 0
5 0 0
(*)The Abbreviated Injury Scale, 1990 revision, update 1998. Association
for the Advancement of Automotive Medicine. Des Plaines, IL 60018. AIS =
0 denotes no injury in body region, AIS = 5 denotes severe injury in
body region.
References (1.) Centers for Disease Control and Prevention: Injuries associated with horseback riding-United States 1987-1988. MMWR MMWR Morbidity & Mortality Weekly Report Epidemiology A news bulletin published by the CDC, which provides epidemiologic data–eg, statistics on the incidence of AIDS, rabies, rubella, STDs and other communicable diseases, causes of mortality–eg, Morb Mortal Wkly Rep 1990; 39:329-332 (2.) Statistics from Kentucky Thoroughbred Association, Lexington, 1999 (3.) Bixby-Hammett DM: Accidents in equestrian sports. Am Earn Physician 1987; 36:209-214 (4.) Alcohol use and horseback-riding-associated fatalities-- North Carolina North Carolina, state in the SE United States. It is bordered by the Atlantic Ocean (E), South Carolina and Georgia (S), Tennessee (W), and Virginia (N). Facts and Figures Area, 52,586 sq mi (136,198 sq km). Pop. 1979-1989. MMWR Morb Mortal Wkly Rep 1992; 41:341-342 (5.) Bixby-Hammett D, Brooks WH: Common injuries in horseback riding: a review. Sports Med 1990: 9:36-47 (6.) Pounder DJ: "The grave yawns for the horseman." Equestrian deaths in South Australia South Australia, state (1991 pop. 1,236,623), 380,070 sq mi (984,381 sq km), S central Australia. It is bounded on the S by the Indian Ocean. Kangaroo Island and many smaller islands off the south coast are included in the state. 1973-1983. Med J Aust 1984; 141:632-635 (7.) Buckley SM, Chalmers D, Langley J: Injuries due to falls from horses. Aust J Public Health 1993; 17:269-271 (8.) Aronson H, Tough SC: Horse-related fatalities in the province of Alberta. Am J Forensic Med Pathol 1993; 14:28-30 (9.) Nelson DE, Bixby-Hammett D: Equestrian injuries in children and young adults. Am J Dis Child 1992; 146:611-614 (10.) Bixby-Hammett D: Pediatric equestrian injuries. Pediatrics 1992; 89:1173-1176 (11.) Niskanen R, Lindahl J, Mokka R, et al: Is horse riding a dangerous recreation for young girls? a study at emergency departments of Lahti City hospital and Paijar-Hame Central hospital, Lahti. Ann Chir Gynaecol 1994; 83:225-228 (12.) Press JM, Davis PD, Wiesner SL, et al: The national jockey injury study: an analysis of injuries to professional horse-racing jockeys. Clin J Sports Med 1995; 5:236-240 (13.) O'Farrell D, Irshad F, Thorns B, et al: Major pelvic injuries in equestrian sports. Br J Sports Med 1997; 31:249-251 (14.) Chitnavis JP, Gibbons Famous people named Gibbons include:
(15.) Norwood S, McAuley C, Vallina VL, et al: Mechanisms and patterns of injuries related to large animals. J Trauma 2000; 48:740-744 (16.) Christey CL, Nelson D, Rivara F, et al: Horseback riding injuries among children and young adults. J Fam Practice 1994; 39:148-152 (17.) Thompson JM, von Hollen B: Causes of horse-related injuries in a rural western community. Can Earn Physician 1996; 42:1103-1109 (18.) Ingemarson H, Grevsten S: Lethal horse-riding injuries. J Trauma 1989; 29:25-30 (19.) Muwanga LC, Dove AF: Head protection for horse riders: a cause for concern. Arch Emerg Med 1985; 2:85-87 (20.) Kriss TC, Kriss VM: Equine-related neurosurgical trauma: a prospective series of 30 patients. J Trauma 1997; 43:97-99 (21.) Lloyd RG: Riding and other equestrian injuries: considerable severity. Br J Sports Med 1987; 21:22-24 (22.) Watt GM, Finch CF: Preventing equestrian injuries. locking the stable door. Sports Med 1996; 22:187-197 (23.) Bond G, Christoph R, Rogers B: Pediatric equestrian injuries: assessing the impact of helmet use. Pediatrics 1995; 95:487-489 (24.) Temes RT, White JH, Ketai L, et al: Head, face and neck trauma from large animal injury in New Mexico New Mexico, state in the SW United States. At its northwestern corner are the so-called Four Corners, where Colorado, New Mexico, Arizona, and Utah meet at right angles; New Mexico is also bordered by Oklahoma (NE), Texas (E, S), and Mexico (S). . J Trauma 1997; 43:492-495 (25.) Condie C, Rivara FP, Bergman A: Strategies of a successful campaign to promote the use of equestrian helmets. Public Health Rep 1993; 108:121-126 (26.) Ilgren EB, Teddy PJ, Vafadis J, et al: Clinical and pathological studies of brain injuries in horse-riding accidents: a description of cases and review with a warning to the unhelmeted. Clin Neuropathol 1984; 3:253-259 (27.) McGhee CN, Gullan RW, Miller JD: Horse riding and head injury: admissions to a regional head injury unit. Br J Neurosurg 1987; 1:131-135 RELATED ARITCLE: KEY POINTS * Seventy-five patients were admitted to our center during the study period, and only 14% were wearing protective helmets. * The majority of patients were injured during recreational activities rather than during occupational exposure to horses. * All deaths were due to head injuries. * Prevention of death from horse-related trauma is synonymous with prevention of head injury. From the Department of Surgery, University of Kentucky, Lexington. Reprint requests to Bernard R. Boulanger. MD, University of Kentucky Medical Center, Department of Surgery, 800 Rose St, C-220, Lexington, KY 40536-0084. |
|
||||||||||||||||||
Printer friendly
Cite/link
Email
Feedback
Reader Opinion