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Trauma: Original Article

All-Terrain Vehicle Injuries in Children

Kirkpatrick, Richard MD; Puffinbarger, William MD; Sullivan, J. Andy MD

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doi: 10.1097/BPO.0b013e3181558856
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Abstract

The inherent risk of all-terrain vehicles (ATV) has been recognized since their introduction to the United States in the 1970s. The ATVs have evolved into heavy, powerful machines with some models able to exceed 70 mph. They are designed for "off-road," single-rider use, and their ability to negotiate terrain inaccessible by other means leads to their recreational and vocational popularity. High rates of injury and mortality have made ATV safety a primary concern. The injury and mortality rates among children have perhaps been the most alarming.1-8 The Consumer Products Safety Commission (CPSC) 2002 annual report listed 5239 deaths since 1982, with 33% (1706) of these involving children younger than 16 years.9 Efforts during the past decades to limit ATV morbidity and mortality have had questionable benefit.5,7,10

The ATV Safety Institute was formed in the late 1980s with the goal of enhancing ATV safety awareness. Through the US Department of Transportation, the ATV Safety Institute and ATV manufacturers entered into a 10-year decree in 1988 that included the following provisions:

  • A ban of all 3-wheel ATVs
  • Retailers were to provide rider safety equipment and training
  • Extensive warning labels on the ATV
  • Prohibited the sale of adult-sized ATVs to children younger than 13 years.

Although all new ATVs are 4-wheel design, 3-wheel ATVs continue to be available on the used market. Despite the 1988 decree, a review of the 2002 CPSC report reveals a significant increase in deaths attributed to ATVs between 1997 and 2001.9 Rios-Reboyras et al11 in 2002 concluded that the 1988 decree has done nothing to limit the quantity, severity, or cost of ATV accidents and deaths. Some manufacturers argue that these data reflect the increased popularity and prevalence of ATVs over the last several years.

The ATVs are used primarily in rural communities. The University of Oklahoma Trauma Center in Oklahoma City serves the largely rural central and western regions of Oklahoma. The Oklahoma University Trauma Center opened as Oklahoma's only Level I Trauma Center in 2001. Children injured in ATV accidents often have multisystem trauma. The purpose of this study was to review ATV injuries in children younger than 16 years evaluated at our trauma center since its inception in 2001.

METHODS

A retrospective review of the University of Oklahoma Trauma Registry was performed after approval by the head of the Department of General Surgery Trauma Section and by the Institutional Review Board. All data were blinded for patient identity. Search criteria included all ATV injuries evaluated at our institution since 2001 in children younger than 16 years. Injuries involving 3- and 4-wheel ATVs were included. Information about date of injury, age of the patient, mechanism of injury, diagnosis, and final disposition where obtained. Injury Severity Scores (ISSs) were calculated for each patient. A thorough review of musculoskeletal injuries was also performed. Data on quantity and type of fractures were obtained as well as prevalence of open fractures.

RESULTS

A review of the trauma registry revealed 73 patients who fit our search description. Nineteen patients were evaluated as Level 1 trauma, 24 as Level 2 trauma, and 30 had trauma consultation after evaluation by the emergency department physician deemed it appropriate. The average age of all patients was 9.9 years (range, 1-15 years). The average age for Level 1 patients was 10.7 years and for Level 2 patients was 9.4 years. The ISSs for all patients averaged 10.3 (Level 1 was 20, Level 2 was 8.3).

Four-wheel ATVs were involved in 95% (70/73), whereas 3-wheel ATVs were involved in 5% (3/73). Common mechanisms of injury included rollover of the ATV or striking a stationary object. Younger patients often sustained injury by falling off the ATV or by being struck by another driver. The most serious injuries occurred to patients who were struck by another vehicle while riding an ATV.

Death occurred in 4 patients and is summarized in Table 1. The average age of these patients was 12.5 years (range, 10-15 years). The average ISS for these patients was 35.8. A 50% mortality was seen in patients with an ISS of 25 or greater (4/8 patients). Head injury was the cause of death in all 4 patients. None of the patients was wearing a helmet. Three of the deaths were caused by collision with another motor vehicle. Two children were killed while riding an ATV together on a highway when they were struck at highway speed by an oncoming car.

TABLE 1
TABLE 1:
Deaths

Analysis of injuries is summarized in Table 2. Extremity fractures were the most common injuries (36 in total), with 21 upper extremity and 15 lower extremity injuries. Head injuries occurred in 45% of the patients (33/73 patients). Twenty-seven percent of patients experienced face trauma (20/73). Others included 11 abdominal, 10 chest, 6 pelvis, and 4 spine injuries.

TABLE 2
TABLE 2:
Injuries by Body Region

Forty-six orthopaedic-related injuries were identified and are summarized in Table 3. Twenty-one upper extremity fractures were identified, with common types being fractures of the humeral shaft (9 fractures) and elbow (5, including olecranon and Monteggia fractures). Of the 15 lower extremity injuries, 7 involved the femur, 5 the tibia, and 3 the hip (all dislocations). Eight open fractures occurred, with 6 involving the upper extremity and 2 involving the lower extremity. All 6 open fractures of the upper extremity occurred about the elbow and involved the supracondylar humerus or olecranon. Two open tibia fractures were identified; all femur fractures were closed. Six pelvis fractures were identified, and all were classified as pelvic ring injuries. Four spine injuries were identified, with all involving the lumbar spine; no neurological sequela was identified.

TABLE 3
TABLE 3:
Orthopaedic Injuries

DISCUSSION

Since their introduction to the United States in the early 1970s, ATVs have gained increasing popularity for vocational and recreational use. Safety, however, has been a primary concern, particularly in children. The high rate of injury since their introduction has prompted past efforts to decrease ATV morbidity and mortality. The 1988 decree was a relatively aggressive effort that banned the unstable 3-wheel design and aimed to improve safety equipment and rider education.

Review of the CPSC data after the 1988 decree implementation has shown the decree to have questionable benefit. The 2001 CPSC report showed a significant increase in deaths between 1997 and 2001 (from 241 to 467), with over 30% of these deaths occurring in children younger than 16 years. Reviews from various institutions have also found the decree ineffective.5-8 Ross et al7 reviewed 76 patients at their institution between 1988 and 1998 and found that children younger than 16 years continued to comprise 50% of the patients injured by ATVs. A study comparing ATVs to motorcycles demonstrated that both have similar mortality but that ATVs have a higher incidence of head injuries.12 When ATV injuries were compared with bicycle injuries in children, those with an ATV injury required more operative intervention and longer lengths of stay. Despite severe injuries, most children injured by ATVs continued to ride, although for fewer hours per day, and safety behaviors were unaltered. It is difficult to argue with the conclusion of Rios-Reboyras et al11 that the decree has done nothing to limit the quantity, severity, cost, or frequency of ATV injuries and death.

Studies in Oklahoma reinforce this contention. Brandenburg et al10 reported the incidence of central nervous system injuries caused by ATV accidents in Oklahoma that occurred from 1992 through 2002. There were 369 traumatic brain injuries, 18 spinal cord injuries, and 4 persons with both injuries. Forty-five percent of patients who died were younger than 16 years. An average of 23 ATV-related injuries per year occurred before 1998. The number doubled in 1999 and 2000, and tripled in 2002 and 2003. Collision with a stationary or moving object was associated with a greater likelihood of experiencing a traumatic brain injury. Rollover occurred in 38% of ATV accidents, and in 28% of traumatic brain fatalities, occurred without a preceding collision. Brandenburg et al10 concluded that ATV use can result in significant neurological morbidity and mortality, especially in children and young adults. They recommended heightened public and parental awareness of this danger and state legislation to prohibit use by those younger than 16 years. They also recommended that design changes such as lowering the center of gravity and installation of protective rollover bars be considered.

The most common mechanisms of serious injury are rollovers, collision with another vehicle, and falls from the ATV.6 Children and adolescents have very low helmet use (as low as 8%-16%).1,4,7 Children, like adults, have been shown to continue risky behavior such as not wearing a helmet or protective gear after an accident.13

A review of our pediatric patients also confirmed that ATV use continues to be a health hazard to children younger than 16 years. Our trauma registry revealed 73 patients that fit our search description. Four-wheel ATVs were involved in 95% of our accidents, which is not surprising in that 3-wheel ATVs have not been in production for nearly 16 years now. The average age of our patients was 9.9 years, but patients with high ISS scores tended to be older. We found a high incidence (45%) of head injury in our patients, which is consistent with other published reports.3,4,7,8,11,12,14 All deaths in our study were attributed to traumatic brain injury. None of these patients was wearing a helmet.

Similar to other studies, orthopaedic injuries were so common as to be considered the norm in our patients.5,6,11 The fractures tend to have an adult fracture pattern, with 61% being classified as comminuted or open in 1 study.5 Extremity fractures occurred in nearly half of our patients with a slightly higher number of upper extremity injuries. The rate and severity of fractures about the elbow is especially alarming. All 6 open fractures involving the upper extremity occurred about the elbow. The high incidence of rollover and lack of safety equipment undoubtedly contributed to the rates of severe elbow trauma. Femur fractures were the most common lower extremity injuries, but none of these fractures was open. Tibia fractures were slightly less common, but 40% (2/5) were open. Relatively few pelvis and spine injuries were identified (6 and 4, respectively), most likely caused by the flexibility of these structures in children.

The fact that Oklahoma is a largely rural state must be considered when evaluating this group of patients. Rural residents have been found to be 50% more likely to die of trauma when compared with urban residents.15 Many factors likely contribute to this finding.16 The emergency response system in rural communities often leads to delay in presentation because of limited resources, limited manpower, rough terrain, or a combination of factors. Rural community response teams are often manned by well-trained volunteers who are dedicated to providing a high quality service to their community. They are limited, however, by the fact that when called, they must leave their current location (home, job, etc), travel to a central location, and then to the scene of the trauma. This process increases the time interval between trauma and the initiation of care. An additional factor is that rural trauma victims are prone to going undiscovered for significant periods. The importance of riding ATVs in a group so that another rider is available to provide assistance or go for help is intuitive when the above is considered.

Despite efforts to blunt the quantity and frequency of ATV injuries, the 1988 decree has had no lasting benefit. Children continue to sustain alarming rates of head and extremity injuries attributed to ATVs. It is likely that most children younger than 16 years lack the physical dexterity and judgment required to safely operate an ATV. The American Academy of Pediatrics has adopted a policy that an ATV should not be operated by children younger than 16 years. The American Academy of Orthopedic Surgeons has also adopted a similar policy. Unacceptable injury and death rates, however, continue to occur in children. Legislation will have limited benefit because ATVs are mainly used off road and on private property. Banning use on public roads is difficult to enforce because these are often used on rural roads.

Several strategies are suggested:

  1. Ban and enforce laws that prevent use of ATVs on public roads and lands.
  2. Require helmets. Although this will have limited use, 1 study showed higher helmet use in a state that required their use compared with one that did not require helmets.4
  3. Aggressive educational programs aimed at parents.

The only realistic solution to this continued threat to the health of our children is the banning of ATV use by children younger than 16 years. Passage of such laws in states with high rural use will be difficult. Efforts in the Oklahoma legislature to establish helmet use and age limits failed. Even if passed, enforcement will also be problematic.

REFERENCES

1. Carr AM, Bailes JE, Helmkamp JC, et al. Neurological injury and death in all-terrain vehicle crashes in West Virginia: a 10-year retrospective review. Neurosurgery. 2004;54(4):861-866. [discussion 866-867].
2. Dolan MA, Knapp JF, Andres J. Three-wheel and four-wheel all-terrain vehicle injuries in children. Pediatrics. 1989;84(4):694-698.
3. Greene MA, Metzler MH. Trauma associated with three and four-wheeled all-terrain vehicles. J Trauma. 1988;28(3):391-394.
4. Keenan HT, Bratton SL. All-terrain vehicle legislation for children: a comparison of a state with and a state without a helmet law. Pediatrics. 2004;113(4):e330-e334.
5. Lynch JM, Gardner MJ, Worsey J. The continuing problem of all-terrain vehicle injuries in children. J Pediatr Surg. 1998;33(2):329-332.
6. Murphy N, Yanchar NL. Yet more pediatric injuries associated with all-terrain vehicles: should kids be using them? J Trauma. 2004;56(6):1185-1190.
7. Ross RT, Stuart LK, Davis FE. All-terrain vehicle injuries in children: industry-regulated failure. Am Surg. 1999;65(9):870-873.
8. Smith LM, Pittman MA, Marr AB, et al. Unsafe at any age: a retrospective review of all-terrain vehicle injuries in two level I trauma centers from 1995 to 2003. J Trauma. 2005;58(4):783-788.
9. US Consumer Products Safety Commission 2003. 2002 Annual Report of ATV-Related Deaths and Injuries. Washington, DC: US Consumer Products Safety Commission.
10. Brandenburg MA, Archer P, Mallonee S. All-terrain vehicle-related central nervous system injuries in Oklahoma. J Okla State Med Assoc. 2005;98(5):194-199.
11. Rios-Reboyras LA, Grovis JE, Ramirez N, et al. Musculoskeletal trauma in four-wheeled all-terrain vehicles. Orthopedics. 2002;25(10):1079-1082.
12. Acosta JA, Rodriguez P. Morbidity associated with four-wheel all-terrain vehicles and comparison with that of motorcycles. J Trauma. 2003;55(2):282-284.
13. Mangus RS, Simons CJ, Jacobson LE, et al. Current helmet and protective equipment usage among previously injured ATV and motorcycle riders. Inj Prev. 2004;10(1):56-58.
14. Brown RL, Koepplinger ME, Mehlman CT, et al. All-terrain vehicle and bicycle crashes in children: epidemiology and comparison of injury severity. J Pediatr Surg. 2002;37(3):375-380.
15. Rogers FB, Shackford SR, Osler TM, et al. Rural trauma: the challenge for the next decade.[see comment]. [Review] [141 refs]. J Trauma. 1999;47(4):802-821.
16. Svenson JE, Spurlock C, Nypaver M. Factors associated with the higher traumatic death rate among rural children. Ann Emerg Med. 1996;27(5):625-632.
Keywords:

ATV; extremity; elbow fractures

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