The urban cowboy syndrome revisited: case report.

Abstract: Inspired by the 1980 movie Urban Cowboy, many drinking establishments offered mechanical bull riding to their patrons. As the use of mechanical bulls became more popular, associated injuries became increasingly reported in the literature as the "urban cowboy syndrome." We report a case of severe straddle injury resulting in symphysis diastasis, urethral injury, and significant retroperitoneal hematoma resulting in cardiovascular instability secondary to mechanical bull riding. This unique case is the most severe mechanical bull injury reported in the literature and the only report of the urban cowboy syndrome since the early 1980s.

Key Words: mechanical bull, pelvic fracture, straddle injury, urban cowboy syndrome

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In the late 1970s and early 1980s, mechanical bull riding enjoyed widespread popularity. Inspired by the 1980 movie Urban Cowboy, many drinking establishments offered mechanical bull riding to their patrons. As the use of mechanical bulls increased, associated injuries became increasingly recognized. In 1981, Seager et al (1) were the first to describe the "urban cowboy syndrome," that is, patients with little mechanical bull riding experience who sustain orthopedic injuries after combining alcohol consumption and mechanical bull riding. Also described as "mechanical bull syndrome" and "empty saddle syndrome," multiple reports of mechanical bull-associated injuries were published in the early 1980s (1-3) We present a case of urban cowboy syndrome in the 21st century.

Discussion

In the early 1980s, the popular movie Urban Cowboy highlighted recreational mechanical bull riding in a drinking establishment. Spurred by the success of this movie and the popularity of the "cowboy western" macho image, mechanical bull use became a popular pastime in the United States and parts of Canada.

[FIGURE 1 OMITTED]

Mechanical bulls were initially designed to train professional rodeo riders by simulating the bucking of a live bull. (2) The mechanical bull consists of a metal object covered with leather and a saddle, on which a rider sits. The mechanical bull is attached to the floor by a mechanism that allows for 360-degree movement. Persons riding the bull are subjected to unpredictable movements up and down and side-to-side at various speeds. Success is measured by a rider's ability to stay in the saddle for an increasing duration of time while the mechanical bull "bucks."

Various orthopedic injuries secondary to mechanical bull riding have been described in the literature. (1-5) McConnell and Rush (2) published their experience treating 68 patients who presented after traumatic injury from riding a mechanical bull. Of the 84 injuries found, 32% involved the hip, groin, or lower extremity. In addition, a high incidence of facial and metacarpal injuries was associated with falls from the mechanical bull.

Seager et al, (1) who coined the phrase urban cowboy syndrome, described 20 cases of mechanical bull-associated trauma. Injuries ranged from minor sprains to fractures of the thumb and lumbar vertebra. Interestingly, the authors noted that patients in their series were for the most part inexperienced bull riders, had consumed alcohol, and had isolated orthopedic injuries.

Eyck et al (3) described 30 patients with orthopedic injuries after mechanical bull falls. In this study, injuries were more likely to be in the upper extremity (74%), and ranged in severity from sprains and contusions to fractures and dislocations. Three of the 30 patients required hospital admission, but no instability was described in any.

Myoglobinuria associated with mechanical bull use has been described twice in the literature, both cases in otherwise healthy males with no other orthopedic injury. (6), (7) Neither patient developed renal insufficiency and the myoglobinuria cleared without additional morbidity.

Overall, injuries reported in the literature associated with mechanical bull use are orthopedic in nature and predominately involve the upper extremities. Injury involves one of two mechanisms. First, trauma associated with forceful, unpredictable movements of the mechanical bull while the patient is seated in the saddle produce the common hand and upper extremity injuries. Second, patients thrown from the bull sustain additional injuries when they strike either the floor or the mechanical bull itself. In this view, our patient is unique, as his injury occurred before even entering the saddle.

We report a case of severe straddle injury resulting in symphysis diastasis, urethral injury, and significant retroperitoneal hematoma resulting in cardiovascular instability secondary to mechanical bull riding. To our knowledge, this is the most severe mechanical bull injury reported in the literature. Also, no reports of injuries since the early 1980s were found, and no previous reports describe mechanical bull trauma occurring in any country other than the United States.

Conclusion

Mechanical bull injuries may still occur and result in significant injury. Physicians caring for trauma patients should be aware of the potential for unstable patients presenting after mechanical bull riding.

Check your hand the next time you point your finger At someone else. Notice that three fingers are pointing back at you.

--Author unknown

Accepted March 24, 2003.

References

(1.) Seager SB, Jui-Aenile L, Faux N. The urban cowboy syndrome. Ann Emerg Med 1981;10:252-253.

(2.) McConnell RY, Rush GA III. Mechanical bull syndrome. South Med J 1982;75:681-686.

(3.) Ten Eyck RP, Longmire AW. Mechanical bull injuries: The empty saddle syndrome. Ann Emerg Med 1981;10:582-584.

(4.) Ginthner TP, Schabel SI. The "mechanical bull" thumb. Skeletal Radiol 1981;7:131-133.

(5.) Williamson JE, Allison EJ Jr, Williams RM. Fractures of the hand associated with riding the mechanical bull. Ann Emerg Med 1982;11:452-454.

(6.) Upham AT, Cooper WL. "Urban cowboy" myoglobinuria. JAMA 1981;245:1216 (letter).

(7.) Powers RD, Lamb GC, Matyasz RC, et al. Urban-cowboy rhabdomyolysis. N Engl J Med 1981;304:427 (letter).

RELATED ARTICLE: Key Points

* The urban cowboy syndrome refers to injuries that combine mechanical bull riding, alcohol use, and subsequent orthopedic injury.

* Mechanical bull injuries may occur and require acute care.

* Hemodynamic instability can be associated with the urban cowboy syndrome.

RELATED ARTICLE: Case Report

A previously healthy 32-year-old man presented via ambulance to the emergency department with a chief complaint of low back pain. Two hours before presentation, the patient had attempted to ride a mechanical bull after consuming an undetermined amount of alcohol. While straddling the seat, the mechanical bull was inadvertently engaged, striking the subject in the perineal area. The patient was thrown from the bull to the ground, which was padded with foam. Witnesses stated that there was no head trauma and no loss of consciousness. The patient felt immediate low back pain, but was able to ambulate after the fall.

After returning home, the patient experienced increasing lumbar and suprapubic pain. He was able to void, and denied gross hematuria but had difficulty initiating urination. The patient's wife contacted the emergency medical services and he was transported by ambulance to the emergency department, approximately 1 hour after falling from the mechanical bull.

On assessment in the emergency department, the patient's initial vital signs were blood pressure, 132/75 mm Hg; heart rate, 71 beats/min; and respiratory rate, 16 breaths/min. He denied any loss of consciousness or head, neck, or chest pain. He had moderate low back pain but was able to ambulate with assistance. The patient was found to have no cervical spine tenderness and had a normal neurologic, cardiovascular, and respiratory examination. Abdominal examination revealed diffuse pain over his lower abdomen but normal bowel sounds and no voluntary or involuntary guarding. Genitourinary examination revealed no bruising or other signs of trauma except for tenderness over the symphysis pubis. There was also midline pain over the lower lumbar spine but no gross pelvic movement. No other evidence of trauma was found on completion of the secondary survey. Initial laboratory investigation revealed hemoglobin of 134 g/L (13.4 g/dl), a white blood cell count of 20 X [10.sup.9]/L (20,000/[mm.sup.3]), and a hematocrit of 0.383 (38.3%), with normal indices. Electrolytes, blood glucose, urea, and creatinine were within normal limits.

The patient had IV administration of normal saline and received morphine 5.0 mg IV for analgesia. Approximately 30 minutes after the morphine administration, the patient's blood pressure decreased to 72/42 mm Hg, at which time a second IV line was inserted and the patient was administered a bolus of 1,000 ml of normal saline. Repeat blood pressure was 100/62 mm Hg and hemoglobin measured approximately 1 hour later was 116 g/L (11.6 g/dl).

After hemodynamic stabilization, radiographs of the chest, lumbar spine, and pelvis were obtained. The chest and lumbar spine radiographs were normal, but the pelvic radiograph demonstrated a symphysis diastasis of 2.5 cm (Fig. 1).

The patient then attempted to void, which produced gross hematuria. Repeat blood pressure was 110/60 mm Hg and the patient complained of increasing lower abdominal pain and the need to urinate. Abdominal examination revealed increased tenderness and guarding in the suprapubic area.

An abdominal computed tomographic scan demonstrated symphysis diastasis, mild widening of the bilateral sacroiliac joints, and a retroperitoneal hematoma in the space of Retzius. A retrograde urethrogram and cystogram demonstrated a Type 1 posterior urethral injury (mild "stretching" of the prostatic urethra).

The patient remained stable and was admitted to the hospital for observation by the trauma service after the urology service inserted a Foley catheter. On the ward, the patient complained of ongoing abdominal discomfort. Repeat complete blood count assessment revealed hemoglobin of 67 g/L (6.7 g/dl) approximately 18 hours after emergency department presentation. The patient remained hemodynamically stable and received a transfusion of 2 U of packed red blood cells (PRBCs).

Abdominal computed tomography was repeated because of presumed ongoing blood loss and demonstrated an enlargement of the previously noted retroperitoneal hematoma, but no previously unreported injuries. In addition, a repeat cystogram was obtained, which again demonstrated no bladder injury. No acute intervention was deemed necessary and the patient received transfusion of an additional 2 U of PRBCs. Repeat hemoglobin measured after 4 U of PRBCs was 71 g/L (7.1 g/dl), and the patient remained stable.

Over the next few days, the patient's hemoglobin stabilized and he was gradually able to ambulate. He was discharged to home 8 days after admission with hemoglobin of 81 g/L (8.1 g/dl). Follow-up assessment with the trauma and urology service 9 days after discharge found the patient to be ambulatory with only mild difficulty. He was able to urinate without problem and had no other complaints. His measured hemoglobin was 98 g/L (9.8 g/dl).

Shortly after this incident, this mechanical bull was removed. At present, there are no mechanical bulls in Winnipeg.

Robert S. Green, BSC, MD, FRCPC, and Ron Maier, MD

From the Department of Emergency Medicine and Department of Critical Care, Queen Elizabeth II Health Sciences Center, Dalhousie University, Halifax, Nova Scotia, Canada, and Department of Emergency Medicine, Health Sciences Center, University of Manitoba, Winnipeg, Manitoba, Canada.

Reprint requests to Robert S. Green, MD, FRCPC, Departments of Emergency Medicine and Critical Care Medicine, Dalhousie University, Queen Elizabeth II Health Sciences Centre, Room 351, Bethune Building, 1278 Tower Road, Halifax, Nova Scotia B3H 2Y9, Canada. Email: [e-mail]

Copyright [c] 2003 by The Southern Medical Association

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