More than 350,000 children are treated for playground equipment-related injuries in United States hospital emergency rooms each year, and the cost of caring for these injuries is approximately $7.5 billion according to the United States Consumer Product Safety Commission’s 2000 data and estimates. Data from this study by the Consumer Product Safety Commission reveal that 41% of these injuries are fractures. With current treatment methods, most will heal predictably and without long-term sequelae. However, each year approximately 17 children die from incidents related to playground equipment and injuries. Most of these deaths are caused by head injuries sustained from falls or by strangulation from drawstrings caught on equipment. 28
Play activities are important to the healthy development of children. Historically, playgrounds were developed as places to separate children from adult traffic in concern for their safety. 23 Hudson et al 10 confirm that “most educators fully support the idea that playgrounds should be rich environments where children can stretch their physical, emotional, social, and intellectual skills. But, children need not experience pain, debilitating injuries, and even death, in order to grow and develop.”
Playground injury prevention is an appropriate function for parents, equipment manufacturers, regulatory agencies, and healthcare professionals. The current authors help make the orthopaedic community aware of current playground injury data, provide information regarding injury prevention measures, and introduce playground safety advocacy efforts.
Playground Injury Data
The term playground commonly may be used to describe playing fields for team sports or areas used for periods of free play. For the purpose of this article, playgrounds are defined as described by the National Program for Playground Safety: “designated areas where stationary or manipulative equipment is located to facilitate a child’s physical, emotional, social and intellectual development.”16
Although numerous studies have listed playground injury statistics, 7,8,19,25 the most significant statistics are from the Consumer Product Safety Commission. Since 1978, it has operated a statistically valid injury surveillance and follow-back system known as the National Electronic Injury Surveillance System. The primary purpose of the National Electronic Injury Surveillance System has been to provide timely data on consumer productrelated injuries. In 2000, the system was expanded to collect data on all injuries. Information gathered from the National Electronic Injury Surveillance System is used to set priorities for additional studies and to provide evidence for product recalls, public awareness campaigns, and product safety standards. 20
Tinsworth and McDonald 28 did a special study of patients with playground equipment-related injuries treated in United States hospital emergency rooms from November 1998 through October 1999. Injury cases were identified through a statistically selected sample of 100 hospital emergency rooms participating in the National Electronic Surveillance System. The hospitals were stratified by size and assigned weights that were used to make national projections. The 1999 estimate was 205,853 patients with playground-related injuries treated in hospital emergency rooms. Their database does not include injury reports of children who are seen only in physician offices, other healthcare facilities, or those who are not seen at all. Consequently, the actual number of playground injuries is much higher than reflected in the National Electronic Surveillance System data alone. Also, the severity and type of injuries may be different. However, it does include a large sample of playground equipment-related injuries of which a systematic sample was assigned for detailed telephone investigation. After deleting patients who could not be contacted, patients who were older than 15 years, or patients who had an injury that did not actually involve playground equipment, there were 454 cases that served as the basis for the analysis. In 409 of the 454 cases, on-site investigations were done to document the type of equipment involved.
For the purpose of the Consumer Product Safety Commission special report, playground equipment was divided into four groups: public playground equipment; preschool playground equipment (at licensed child care facilities, preschools, and separate public areas); home playground equipment (generally found in the yards of private residences and of lighter weight and less durable materials than public equipment); and soft contained playground equipment (generally found in commercial facilities and typically consists of plastic crawl tubes and slides, climbing nets, and ball pits). Based on the National Electronic Surveillance System adjusted 1999 estimate, 75.8% of the emergency room-treated injuries occurred on public playground equipment and 22.8% occurred on home equipment. Approximately 45% of the injuries on public equipment occurred in schools and 31% occurred in public parks.
Fractures were the most commonly reported injury (39%) followed by lacerations (22%), contusions or abrasions or both (20%), and sprains or strains or both (11%). Three-fourths of the fractures involved the arm, the hand, or both. On public and home equipment, four of five injuries involved falls, primarily to the surface below the equipment (Figs 1,2). Injuries on public equipment usually involved climbers, whereas those at home involved swings. Approximately 80% of public locations had protective surfacing under the equipment whereas only 9% of home locations had protective surfacing. In general, higher proportions of arm and hand injuries occurred on nonprotective surfaces. Differences in the severity of injury among specific types of surfaces (loose fill versus resilient mats and poured surfaces) could not be evaluated because of the small sample size.
A previous in-depth study of playground equipment injuries done by the Consumer Product Safety Commission was done in 1988. 28 A comparison with the current study confirms that falls continue to account for the majority of injuries. The current authors found that 79% of equipment in public locations was installed over protective surfacing, but in 1988, only 36% had protective surfacing. During both periods, the surfacing under home equipment was predominantly dirt or grass.
A separate review of Consumer Product Safety Commission data files for the 10-year period of January 1, 1990 to August 1, 2000 revealed 147 deaths associated with playground equipment. 28 One-third of these deaths occurred in children younger than 5 years. In cases with a known equipment location, 70% of the deaths occurred at home locations. The top three hazard patterns were hanging (82 deaths), falls (31 deaths), and tip-over or collapse of equipment (24 deaths). The hangings involved unintentional strangulation caused by entanglement in items that generally were not designed to be part of the equipment such as ropes and clothing drawstrings.
The preceding Consumer Product Safety Commission reports provide valuable information, but do not list specific fracture diagnoses or provide severity indices. However, an analysis of injury mechanisms for a specific fracture pattern was done by Farnsworth and coauthors 8 who analyzed 391 supracondylar humerus fractures in children. They found that 29% of fractures occurred on the playground with the majority of these resulting from a fall from monkey bars. They offered a prototypical scenario of a 6-year-old girl who slips from the monkey bars, attempts to hold on with her dominant hand, and lands on the ground with her extended nondominant arm. An article by Waltzman et al 29 called attention to injuries children sustain from monkey bars. In their series of patients evaluated in an emergency department, they found that 25% required hospitalization. Based on their analysis of the reported environment and mechanism of injury, they concluded that the surface below the equipment had no influence on the type or the severity of the injury, and that adult supervision did not influence the injury pattern. In a followup letter to the editor concerning that article, Thompson and Hudson 26 questioned those conclusions about playground surface safety and supervision. They stressed the importance of playground surfacing being well-maintained and at proper depth. In addition, they contrasted supervision from just being there. They cautioned about classifying all climbing equipment as monkey bars and called attention to the Consumer Product Safety Commission’s voluntary recall on monkey bars. Since the early 1980s, monkey bars have been declared unsuitable for public playgrounds. A recent study found that only 14% of the nation’s playgrounds still had monkey bars. 26
Helping to resolve some of this controversy, Sosin and coauthors 24 studied surface-specific fall injury rates on Utah school playgrounds and confirmed that impact-absorbing surfaces reduce fall injuries on playgrounds and are better than grass. Another study involved 930 children treated at children’s hospitals in Montreal during the summers of 1991 and 1995 was done to compare the risk of severe injuries after a fall on sand or grass. 12 These authors concluded that grass should not be considered as a safe surface under play equipment and reported that children sustained more severe injuries in residential playgrounds than in public playgrounds. In a separate article using a similar database of patients, the authors related surface characteristics and equipment height to the occurrence and severity of playground injuries. 13 They reported that risk of injury was related to surface resilience and height of equipment, and that severity of injury was related to the type of surfacing material. They concluded that a maximum acceptable height of equipment should be included in standards, and proposed a value of 2 m (6.6 feet).
A study done at the Hospital for Sick Children in Toronto found the risk of severe injury to be increased twofold with a height of fall greater than 1.5 m (5 feet). 15 Although the children in this study frequently fell to an impact absorbing surface, the median depth of the surface was well below the recommended safety standards for the surfaces involved. Although such epidemiologic studies confirmed that hard surfaces are dangerous, several important laboratory studies have recommended specific materials as protective surfaces beneath playground equipment.
The American Society for Testing and Materials is a not-for-profit organization that provides a forum for the development and publication of voluntary consensus standards for materials, products, systems, and services. 30 Testing protocols to compare the shock absorbency of surface materials in and around playground equipment have been established by the American Society for Testing and Materials. 2 This standard allows a critical height to be determined for the surface material. Falls below the critical height are not likely to produce life-threatening head injuries. Manufacturers of playground surface materials are able to provide these results and the selection of playground surfaces frequently is based on these test results. Lewis et al 14 tested and ranked playground surfaces with respect to impact attenuation under various simulated environmental conditions. They used coarse sand, medium gravel, uniform wood chips, and grass sod on clay soil and found the wood chips to be the best playground surface under various environmental conditions.
To test the impact attenuation of loose-fill playground surfaces, Mack and coauthors, 18 in a laboratory setting, dropped an instrumented head form on varying depths of loose-fill materials at different height increments. They found shredded rubber to be the best performer and pea gravel to be a poor choice for playground surfacing.
Using experimental and linear biomechanical models, Robinovitch and Chiu 21 studied the effect of surface stiffness on the impact force during a fall on the outstretched hand. Results suggested that feasible compliant surface designs may prevent wrist injuries during falls from standing height or lower, but not from greater heights.
Playground Injury Prevention
In 1974, concerned consumers successfully petitioned the Consumer Product Safety Commission to recommend safety standards for playground equipment. 31 As a result, surveys were done and confirmed that playground equipment was near the top of the list of hazardous consumer products. The National Park and Recreation Association subsequently accepted a call that was made for the development of standards for playground equipment. Testing protocols were established and by 1978 major reports were received regarding playground equipment and impact attenuation. This led to the formation of the National Playground Safety Institute, which now provides training and certification for playground safety inspectors.
Since 1981, the Consumer Product Safety Commission has issued its Handbook for Public Playground Safety. The most current edition was published in 1997. 9 Because of many factors that affect playground safety, the Consumer Product Safety Commission thinks they should serve as guidelines rather than mandatory standards. Their recommendations are not endorsed by the Commission as the sole method to minimize injuries, but should contribute to greater safety. Numerous states including California, Michigan, New Jersey, North Carolina, and Texas, recognizing the scope of the problem, have adopted some or all of these guidelines as law. (Tinsworth DK: Why Worry About Playground Safety? Presented at the United States Summit for Playground Safety, Des Moines, Iowa 2001.) The California law mandates playground inspections, upkeep, and adherence to the safety standards and guidelines developed by the Consumer Product Safety Commission and the American Society for Testing and Materials. 11
In 1994, the American Society for Testing and Materials first published the Standard Consumer Safety Performance Specification for Playground Equipment for Public Use. The most current edition was published in 1999. 4 It is technical and directed to equipment manufacturers, architects, and designers. Similar publications for home playground equipment 5 and for soft contained playground equipment 3 are now available from the American Society for Testing and Materials (Table 1).
Playground Safety Advocacy Efforts
The Federal government also recognized the need to coordinate playground safety research and recommendations by forming the National Program for Playground Safety in 1995. It is funded by a grant sponsored by the Centers for Disease Control and Prevention and is located at the University of Northern Iowa. Its major purpose is to increase the awareness of playground safety, which it does through a website, telephone hotline, videos, publications, seminars, and sponsorship of the National Playground Safety Day each April. It also has published a booklet, The National Action Plan for the Prevention of Playground Injuries, which provides a blueprint of action steps to develop safe playgrounds. 27 Emphasis has been given to effective supervision, age appropriate equipment, cushioning for falls to the surface, and equipment maintenance.
The International Play Equipment Manufacturers Association is a not-for-profit international trade association whose member companies manufacture play equipment and shock-absorbent surfacing material. Members of this organization participate in American Society for Testing and Materials committees to write safety standards for playground equipment and surfacing, and play a role in the development of Consumer Product Safety Commission guidelines on public playground equipment. In addition, the International Play Equipment Manufacturers Association provides third-party product certification services for public play equipment and surfacing materials by validating conformance to American Society for Testing and Materials standards.
In recent years, playground accessibility guidelines for children with disabilities have been developed under the Americans with Disabilities Act of 1990. A regulatory negotiation committee reached consensus on guidelines for newly constructed and altered play facilities and published its final report in July 1997. 6 The American Academy of Orthopaedic Surgeons is committed to playground injury prevention and safety and accessibility for children with impairments. Recently the American Academy of Orthopaedic Surgeons has tried to lead by example by voluntarily building playgrounds that adhere to the highest safety standards and also are accessible to children with physical impairments. These playgrounds feature wheelchair accessibility, and safety features such as shock absorbent surfacing, proper equipment design, and adequate open areas around the equipment. Three such playgrounds already have been built by Academy members and staff, working with members of the orthopaedic industry and local volunteers as part of their annual meeting activities in Florida, California, and Texas. Two nonprofit organizations, KaBOOM! and Boundless Playgrounds, participated in playground builds by helping in the site selection, design, and construction coordination. The American Academy of Orthopaedic Surgeons has provided important information on playground safety to the media through public service announcements, news releases, and media events. Information from the American Academy of Orthopaedic Surgeons is available in brochures, mailings, and on its website. 1 Individual orthopaedists are encouraged to speak to community groups and participate in coalitions to promote playground safety. Additional recommendations about the design, construction, and funding of such projects are available through the information sources and advocacy organizations shown in Table 1.
The effectiveness of playground injury prevention recommendations has been difficult to evaluate because of many variables. With time, specific playground sites may have wide variation in adult supervision, equipment maintenance, and environmental factors. However, several studies have attempted to document the effectiveness of injury prevention programs and regulations. Mack et al 17 reported that without proper monitoring and educational training, playground regulations alone do not seem to be an effective injury prevention tool. A study of schools in New Zealand confirmed that a structured program of providing information, coupled with an engineer’s report, regular contact and encouragement to act on the report, and assistance in funding, was effective in reducing hazards on the playground. 22 Reported successes in injury prevention have resulted from making the environment safer rather than just educating the children. 19 Consumer Product Safety Commission data confirm fewer head injuries and mortalities from heavy swings since changes in swing types were recommended.
The frequency of playground injuries can be reduced with appropriate adult supervision and parental input and proper equipment design and installation, which then is followed by regular inspection and maintenance. Parents, physicians, park officials, and school authorities should join together to be certain that playgrounds meet the highest standards of safety. Playground design and upkeep should be directed to challenge the imagination but avoid serious injury to children. Current initiatives hold promise but playground injuries continue to be a significant and costly health problem. Many accidents are the result of the normal desire of children for excitement and adventure. By identifying where and how children are injured, suggestions have been made to increase the safety of communities’ play areas. The medical community can help by joining with parents, equipment manufacturers, and government agencies in surveillance of these injuries, then use this information to direct research initiatives, recommend product changes, and direct advocacy efforts. The high incidence of fractures gives orthopaedists a unique opportunity to address awareness of playground safety during the treatment of these injuries by providing guidance to parents and children.
1. American Academy of Orthopaedic Surgeons. http://www.aaos.org
2. American Society for Testing and Materials: Standard specifications for impact attenuation of surface systems under and around playground equipment. F1292–5. Philadelphia, American Society for Testing and Materials 1995.
3. American Society for Testing and Materials: Standard safety performance specifications for soft play equipment. F1918. Philadelphia, American Society for Testing and Materials 1998.
4. American Society for Testing and Materials: Standard consumer safety performance specifications for playground equipment for public use. F1487. Philadelphia, American Society for Testing and Materials 1999.
5. American Society for Testing and Materials: Standard consumer safety performance specifications for home playground equipment. F1148. Philadelphia, American Society for Testing and Materials 2000.
6. Architectural and Transportation Barriers Compliance Board: Regulatory Negotiation Committee on Accessibility Guidelines for Play Facilities, Final Report. Washington, DC, Architectural and Transportation Barriers Compliance Board 1997.
7. Briss PA, Sacks JJ, Addiss DG, Kresnow MJ, O’Neil J: Injuries from falls on playgrounds. Arch Pediatr Adolesc Med 149:906–911, 1995.
8. Farnsworth CL, Silva PD, Mubarak SJ: Etiology of supracondylar humerus fractures. J Pediatr Orthop 18:38–42, 1998.
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11. Kelter A: The Experience of the Adoption of CPSC Guidelines by California. Des Moines, IA, United States Summit for Playground Safety 2001.
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20. National Injury Prevention Clearinghouse. Washington, DC, United States Consumer Product Safety Commission.
21. Robinovitch SN, Chiu J: Surface stiffness affects impact force during a fall on the outstretched hand. Orthop Res 16:309–313, 1998.
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25. Suecoff SA, Avner JR, Chou KJ, Crain EF: A comparison of New York City playground hazards in high- and low-income areas. Arch Pediatr Adolesc Med 153:363–6, 1999.
26. Thompson D, Hudson SD: Monkeybar injuries. Pediatrics 105:1174–1175, 2000. National Injury Information Clearinghouse.
27. Thompson D, Hudson SD: National Action Plan for the Prevention of Playground Injuries. Cedar Falls, IA, National Program for Playground Safety 1–24, 2000.
28. Tinsworth DK, McDonald JE: Special Study: Injuries and Deaths Associated with Children’s Playground Equipment. Washington, DC, United States Consumer Product Safety Commission 2001.
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30. What is ASTM? West Conshohocken, PA, American Standards and Testing Methods 1999.
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Maureen A. Finnegan, MD—Guest Editor