Playground injuries in the 90's.

For members of the park and recreation field, the number of playground injuries requiring medical treatment remains a major topic of concern. Numerous steps have been taken by various organizations, including the National Recreation and Park Association, in an attempt to make playgrounds safer. However, while extremely beneficial and progressive, much of this effort has been based on relatively old information. For example, the works of Tinsworth and Kramer (1989 & 1990) and Ramsey and Preston (1990) are still widely cited. Though this body of literature is still extremely pertinent, additional updated research is also necessary. Thus, the purpose of this article is to review playground injury statistics over a six-year period in the 1990s in an attempt to provide a broader, more complete picture of how and where children are being injured on today's playgrounds.

All statistics are based on data obtained from the U.S. Consumer Product Safety Commission's (CPSC) National Electronic Injury Surveillance System (NEISS) during 1990-95. NEISS collects data on playground product-related injuries that are recorded in more than 90 hospital emergency departments throughout the United States. Thus, only emergency-room injury statistics are recorded, and the national statistics are estimates.(*) It should also be noted that an Arizona Department of Health study found that only 72 percent of students with reportable playground injuries were actually taken to an emergency room or doctor (Arizona Department of Health Service, 1993). Thus, NEISS-based statistics may represent only seven of every 10 actual injuries.

How Many Children are Injured?

As illustrated in Figure 1, the number of playground injuries has remained fairly constant during the five-year period. Each year, there were approximately 208,260 children under the age of 14 who received emergency-department care. Broken down by age, there were 63,320 children ages 0-4 and 144,940 children ages 5-14 injured annually. On average, 68 percent of the playground injuries occurred on public playgrounds.

[Figure 1 ILLUSTRATION OMITTED]

For children ages 0-4, injuries to the head and face accounted for nearly 60 percent of all injuries. Injuries to the arm and hand accounted for another 21 percent, while injuries to the leg and foot were involved in 12 percent. For children ages 5-14, the most commonly injured body parts were the arm and hand, constituting 43 percent of all injuries. Injuries to the head and face were involved in 30 percent of the reports, and injuries to the leg and foot accounted for another 15 percent.

Boys were involved in a slightly higher percentage of NEISS-reported playground injuries (53.4 percent) than were girls (46.6 percent). These differences were slightly more pronounced for preschool-aged children, with 56.1 percent involving boys and 43.9 percent involving girls. For children ages 5-14, slightly more boys (52.2 percent) than girls (47.8 percent) were injured.

How Serious are the Injuries?

There was an average of 17 playground-related deaths reported in each year of the study. Strangulation from ropes, strings, or clothing accounted for 49 percent of the fatalities. Falls to the surface were reported in 24 percent of the cases, and 11 percent involved equipment falling on the individual. Entrapment (3.5 percent) and being struck by a swing (3.5 percent) were the remaining multiple occurrences over this time period. All other fatalities were singular occurrences, such as being struck by rotating playground equipment, having one's face burrowed in the sand, and hitting the swing set. More fatalities involved boys (62 percent) than girls (38 percent). Overall, 67 percent of the deaths occurred on home playgrounds.

For this six-year period, 36 percent of the NEISS-reported injuries were classified as severe, with three percent requiring hospitalization. Severe injuries included concussions, dislocations, fractures, internal injuries, amputations, and crushings. An additional 16 percent of the injuries were considered moderately severe and approximately 48 percent of the injuries were classified as relatively minor (lacerations, contusions, and abrasions). However, even though classified as relatively minor, it should be noted that the injuries were severe enough to prompt a visit to the hospital emergency room.

The percentages of severe, moderately severe, and relatively minor injuries also varied according to the type of equipment involved. Relatively minor injuries were most common for the majority of the equipment including seesaws, swings, slides, and "other." The lone exception was climbers, on which severe injuries were most frequent. Severe injuries also accounted for a significant percentage of injuries involving slides, swings, seesaws, "other," and "not specified," (Table 1).

TABLE 1. SEVERITY OF INJURIES FOR DIFFERENT TYPES OF EQUIPMENT

Equipment             Severe         Moderately Severe

Climbers              43 percent     17 percent

Slides                32 percent     19 percent

Swings                32 percent     16 percent

Not Specified         28 percent     22 percent

Seesaw                27 percent     14 percent

Other Equipment       20 percent     23 percent

Equipment             Minor

Climbers              40 percent

Slides                49 percent

Swings                52 percent

Not Specified         50 percent

Seesaw                59 percent

Other Equipment       57 percent

Additionally, the specific types of diagnoses have remained relatively constant in the 1990s. The most prevalent diagnoses each year were fractures (65,729), lacerations (55,265), and contusions/abrasions (49,423). Other common diagnoses were strains or sprains (25,572) and internal injuries (8,373). Regarding individual types of equipment, a fracture was the predominant diagnosis for climbers each year. Injuries associated with slides tended to alternate between fractures and lacerations. The most prevalent injuries associated with swings were lacerations, then fractures. Finally, the most common seesaw injuries each year were lacerations, contusions/abrasions, and fractures, respectively.

Types of Playground Equipment Involved

NEISS statistical information identifies several types of playground equipment: swings, climbers, slides, seesaws, merry-go-rounds, "other" equipment, and "equipment not specified." The number of injuries associated with each type of equipment for the years 1990-95 is presented in Graph 2.

As illustrated, children were injured most often when playing on swings, followed by climbers and slides. These three pieces of equipment represented nearly 87 percent of all playground injuries to children ages 0-14. Seesaws and merry-go-rounds were the other two major pieces of equipment on which injuries occurred, accounting for less than six percent of the injuries.

For this six-year time frame, an estimated 73,140 children ages 14 and under received emergency-department care annually for injuries associated with swings or swing sets. However, only 40 percent of these injuries occurred on public playgrounds. Thus, while associated with the largest number of total injuries, swings accounted for less than 21 percent of all public-playground injuries. As illustrated in Figure 2, swings ranked third when examining only public-playground injuries.

[Figure 2 ILLUSTRATION OMITTED]

The various types of climbing equipment, referred to as climbers, were associated with 65,220 injuries annually. Public playgrounds were involved in 87 percent, which makes climber injuries the most common public-playground injury (40 percent). An additional 42,150 children received emergency-department care each year for injuries associated with slides or sliding boards. Seventy-four percent of these injuries occurred on public playgrounds. Thus, slides accounted for more than 22 percent of all public-playground injuries.

Due to a lack of complete information, NEISS compiles a category entitled "playground equipment, not specified." Recorded in this category were playground injuries that did not identify a particular type of equipment. Approximately 9,160 of these injuries were reported each year, with public playgrounds accounting for 95 percent.

For the years 1990-95, seesaws averaged 7,900 emergency-department injuries, with 70 percent of these occurring on public playgrounds. Merry-go-rounds were associated with 4,000 injuries and 95 percent occurred on public playgrounds. The final classification of playground equipment as reported by NEISS was listed as "other equipment." Other equipment included items such as sliding poles, sandboxes, spring rockers, tunnels, bridges, and ropes. There were approximately 6,690 injuries associated with other equipment each year, and 85 percent occurred on public playgrounds.

When Do Injuries Occur?

Another topic of interest pertains to the percentage of injuries occurring each month. Not surprisingly, the highest percentages occurred during the warmer months of the year (Figure 3). The majority (70.8 percent) occurred in April through September, with May recording the highest number of playground injuries. In contrast, relatively few injuries were reported in December and January. It was also interesting to note that an increase occurred in September, the traditional start of school in many areas of the country. Based on these results, it is apparent that playground inspection and maintenance schedules should be adjusted to reflect the heavy usage that produces a substantial number of injuries.

[Figure 3 ILLUSTRATION OMITTED]

What Factors are Involved?

The remarks and comments describing each injury were analyzed in an attempt to ascertain the factors that contributed to each incident. Because of the limited information contained in most NEISS remarks, contributing factors were restricted to: 1) falls to the surface; 2) falls to the equipment; 3) ran into or hit by the equipment; and 4) other. The classifications were based on remarks that included phrases describing the incident. For example, the classification of falls to the surface was based on phrases such as "fell off (equipment)," "fell from (equipment)," "landed on (surface)," and "fell onto (surface)." Key words or phrases for the falls-to-equipment classification included "fell onto (equipment)," "fell and hit (body part) on (equipment)," and "straddle" injuries. It should also be noted that three percent of the NEISS comments had unknown contributing factors and were excluded from the analysis. Examples of unknown factors were comments such as " hurt at playground" or a description of the injury, "DX: Greenstick Fracture."

The percentage of contributing factors for each type of playground equipment is given in Table 2. Because the various categories of playground equipment have differing contributing factors, not all of the classifications were used in each analysis.

TABLE 2. CONTRIBUTING FACTORS TO PLAYGROUND INJURIES, 1990-1995

Contributing factors        Swings    Climbers   Slides   Seesaws

Fails to surface             63.7       85.3      69.2      54.0
Fails to equipment            2.7        8.8      17.0      14.7
Ran into/Hit by equipment    21.5        2.5        NA      24.2
Others                       12.1        3.4      13.8       7.1

                             Merry-go-       Not
Contributing factors          Rounds       Specified      Other

Fails to surface               60.4           61.3        28.7
Fails to equipment             16.3           22.1        24.7
Ran into/Hit by equipment        NA             NA        35.3
Others                         23.3           16.6        11.3

NA = Not Applicable (was either not appropriate or was included in the "others" because of the limited number of cases).

Falls to the surface was the number one contributing factor for most of the equipment. In fact, when all of the playground equipment was combined, falls to the surface was a contributing factor in 70.5 percent of the known occurrences. This undoubtedly reflects the results of the three major categories of equipment (swings, climbers, and slides), which accounted for 87 percent of all playground injuries. The unusually high percentage of falls to surface-related injuries associated with climbers is particularly noteworthy. However, it should be noted that while the end result was a fall to the surface for 70 percent of the injuries, it is unclear what actually caused the fall. It could be that lack of maintenance, inadequate supervision, inappropriate age design, on some other factor contributed to the fall.

Another significant contributing factor for many types of equipment was falls onto the equipment. Overall, falls to the equipment accounted for 9.6 percent of the known occurrences. Specifically, this was a contributing factor in a large number of slide, seesaw, merry-go-round, and miscellaneous equipment injuries.

A third factor associated with a significant number of injuries was being hit by or running into the playground equipment. This was especially significant for swings and seesaws, accounting for approximately one of every four injuries.

The final contributing factor classification was "others." Included in the others category were splinters, entrapments, burns, jumping off equipment, and protrusions. Because of the emphasis the CPSC's (1994) Handbook for Public Playground Safety places on these hazards, the number of injuries related to protrusions and projections was examined separately. Results indicated that protrusions were contributing factors in 1.2 percent of all NEISS-reported playground injuries. Thus, while protrusions are a hazard that can and should be remedied, they appeared to be factors in a relatively small percentage of injuries.

What Does This Mean to Me?

For recreation professionals, playground safety has been an area of great concern for more than 30 years. Unfortunately, much of the research data in this area is nearly 20 years old. Thus, the purpose of this article was to provide a comprehensive overview of playground injuries in the 1990s.

Results indicated that more than 208,000 children received emergency-department care for playground-related injuries each year, 17 of which resulted in death. Nearly one-third of all injuries were classified as severe, with fractures most prominent. Slightly more boys than girls were involved, and the majority of injuries occurred in April through September. Overall, more injuries were associated with swings than with any other category of equipment. However, most of these occurred on home playgrounds. For public playgrounds, climbers accounted for 40 percent of all injuries, followed by slides and swings. Finally, an in-depth analysis revealed that the vast majority of injuries involved a fall to the surface.

Based on these findings, a number of suggestions can be made to he]p reduce the number and severity of playground injuries. First, suitable surfacing located under and around the equipment should be a top playground-management priority. Results indicate that it is absolutely imperative that all playgrounds have proper depths of acceptable surface materials that are proportionate to the height of the equipment. Hard materials, such as concrete, asphalt, and dirt or grass, are simply unacceptable as playground surfaces. It is estimated that a child who falls eight feet onto concrete experiences an impact the equivalent of hitting a brick wall at 30 mph in a car (Ward, 1987). Furthermore, once adequate fall zones and surfaces are installed, they must be regularly inspected and maintained. This is particularly critical during the peak usage months.

Next, because one of every four swing injuries involved being hit by the moving swing, it is important that playground managers follow CPSC suggestions regarding swings. The Handbook for Public Playground Safety suggests that swing structures be located away from other activities and equipment. Providing a separate area specifically for swings helps to prevent young children from inadvertently running into the path of moving swings. Extra protection can also be provided by installing a low barrier, such as a hedge or fence. For the same reason, it is suggested that no more than two "to-fro" (single-axis) swings be hung in each bay of the supporting structure. Thus, it would appear that if all playground administrators would implement CPSC guidelines, the number of swing injuries could be dramatically reduced.

Another common source of injury concerns children running into the equipment. While incidents like these can never be totally eliminated, precautions can be taken to reduce the likelihood. First, the layout of the playground should be organized into different areas. Separating active and passive activities serves to reduce the number of children running between conflicting activities. Another solution is to scatter the popular pieces of equipment to avoid crowding in any one area. Playground managers also need to ensure that play and traffic patterns of children using the various pieces of equipment are complementary. For example, slide exits should not be located in the traffic pattern of adjacent climbing equipment. Finally, the layout of equipment, areas, and amenities should ensure that there are no visual barriers that would inhibit supervision. Establishing clear sight lines allows adults to actively monitor the behavior of children on the playground.

In conclusion, playground safety is a complex issue requiring multiple solutions. As caretakers of America's youth, it is our responsibility to ensure that playing on the playground is a fun-filled learning experience. Thus, it is our duty to continually monitor playground injury factors and trends. Hopefully, by identifying how and why children are being injured, park and recreation professionals can take steps to make America's playgrounds safer.

Acknowledgments

This publication was supported by Grant Number U17/CCU 712119-02 from the Centers for Disease Control and Prevention. The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the CDC.

The authors wish to thank the following individuals for their assistance in analyzing the data: Sheila Sires, Phyllis Boelts, Stacy Pierce, and Donna Mokricky.

References

Arizona Department of Health Service, Community and Family Health Services, Office of Women's and Children's Health. (1993). A study of the nature, incidence, and consequences of elementary school playground-related injuries. Phoenix, AZ.

Ramsey, L.F. & Preston, J.D. (1990). Impact attenuation performance of playground surfacing materials. Washington, DC: U.S. Consumer Product Safety Commission.

Tinsworth, D.K. & Kramer, J.T. (1989). Playground equipment-related injuries involving falls to the surface. Washington, DC: U.S. Consumer Product Safety Commission.

Tinsworth, D.K. & Kramer, J.T. (1990). Playground equipment-related injuries and deaths. Washington, DC:

U.S. Consumer Product Safety Commission. 11994). Handbook for public playground safety. Washington, DC: U.S. Government Printing Office.

U.S. Consumer Product Safety Commission. (1997). Handbook for public playground safety. Washington, DC: U.S. Government Printing Office.

Ward, A. (1987). Are playground injuries inevitable? The Physician and Sports Medicine, 15(4), 162-168.

(*) All of the statistics in this review have been adjusted to reflect out-of-scope cases that were reported to NEISS. In 1988, an in-depth study performed by the CPSC found that cases were reported that were not associated with playground equipment. Thus, the number of reported cases has been adjusted to reflect this finding.