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Nonmotorized wheeled activities are popular among children. However, these activities can result in significant injury if effective injury prevention measures are not taken. Recently, nonmotorized wheeled shoes have become increasingly popular among children. Preliminary research shows that these activities also result in significant injury. The purpose of the present study was to compare the injury profiles of nonmotorized wheeled activities among Canadian children presenting to the emergency department.
A two-year retrospective study was conducted using data from the Canadian Hospitals Injury Reporting and Prevention Program database, specific to the Alberta Children’s Hospital, Calgary, Alberta. Data were analyzed using cross tabulations of the type and nature of injury, helmet use, age and sex, with type of nonmotorized wheeled activity.
The most common mechanism of injury for a nonmotorized wheeled activity was bicycling (66.9%), while wheeled shoe use produced the fewest injuries (2.7%). The upper extremity was the most frequently injured body region in all groups, comprising more than 75% of the injuries in wheeled shoe users and approximately 50% of the injuries in participants of other nonmotorized wheeled activities. Forearm fractures were the most common type of injury. Wheeled shoe users had the greatest proportion of forearm fractures. Helmet use was most prevalent in bicyclists (84.6%) and least prevalent in wheeled shoe users (4.7%).
Nonmotorized wheeled activities can result in significant morbidity. Results from the present study suggest that wheeled shoe and push scooter activities can result in upper extremity injuries. Protective equipment, particularly wrist guards and helmets, should be used when participating in these activities.
Les activités non motorisées sur roues sont populaires chez les enfants. Cependant, elles peuvent entraîner des blessures importantes en l’absence de mesures de prévention efficaces. Récemment, les chaussures à roulettes non motorisées ont gagné en popularité chez les enfants. Les recherches préliminaires démontrent que ces activités provoquent également des blessures importantes. La présente étude visait à comparer le profil de blessures découlant d’activités non motorisées sur roues chez les enfants qui consultent au département d’urgence.
Les auteurs ont procédé à une étude rétrospective de deux ans à partir de la base de données du Système canadien hospitalier d’information et de recherche en prévention des traumatismes appartenant à l’Alberta Children’s Hospital de Calgary, en Alberta. Ils ont analysé les données au moyen de tableaux croisés sur le type et la nature de la blessure, le port du casque, l’âge et le sexe ainsi que le type d’activité non motorisée sur roues.
Le principal mécanisme de blessures des activités non motorisées sur roues est le vélo (66,9 %), tandis que les chaussures à roulettes en provoquent le moins grand nombre (2,7 %). Les membres supérieurs sont les plus touchés dans tous les groupes, constituant plus de 75 % des blessures causées par des chaussures à roulettes et environ 50 % des blessures chez les participants à d’autres activités non motorisées sur roues. Les fractures de l’avant-bras sont les plus courantes. Les utilisateurs de chaussures à roulettes affichent la plus forte proportion de fractures de l’avant-bras. La prévalence du port du casque est la plus élevée chez les cyclistes (84,6 %) et la moins élevée chez les utilisateurs de chaussures à roulettes (4,7 %).
Les activités non motorisées sur roues peuvent être responsables d’une importante morbidité. D’après les résultats de la présente étude, les activités avec des chaussures à roulettes et des trottinettes peuvent provoquer des blessures des membres supérieurs. Il faudrait porter un équipement protecteur, notamment des protège-poignets et un casque de vélo, pour participer à ces activités.
Nonmotorized wheeled activities are popular among children. Usage has been reported to be 85% for bicycles, 55% for in-line skates and 21% for skateboards (1). Other small-wheeled devices such as push scooters and wheeled shoes have gained popularity over the past few years (2).
As one might expect, nonmotorized wheeled equipment can cause injuries. In the United States (US), children sustain more than 275,000 nonfatal bicycle injuries each year, with more than one-half of these injuries occurring in children younger than 15 years of age (3). The National Safe Kids Campaign in the US estimated that, in 2002, the number of children treated in the emergency department (ED) for push scooter, skateboard and in-line skating injuries was between 29,000 and 60,000 (2). Injuries from non-motorized wheeled activities can be severe, resulting in head injuries, fractures and soft tissue injuries (2,4–13).
Injuries caused by cycling, skateboarding and in-line skating, although severe, have declined because helmet and other safety equipment use has been promoted (6,14). Initial studies (10,12,15) involving wheeled shoes show that this activity can also result in serious injuries. Most of the studies on injuries caused by nonmotorized wheeled activities are from the US and Europe. The few Canadian studies on such activities are limited either by the number of activities compared or by the lack of focus on childhood injuries (13,15). Given the geographical and cultural differences between Canada and the US and Europe, it is important to determine the injury profile of nonmotorized wheeled activities in the Canadian population. Therefore, the purpose of the present study was to investigate the injury profile of nonmotorized wheeled activities among children presenting to the ED at a tertiary care hospital in Calgary, Alberta.
Data on patients with injuries caused by nonmotorized wheeled activities presenting to the ED of the Alberta Children’s Hospital (ACH) from June 2005 to June 2007 were obtained from the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) (16). The ED of the ACH is a tertiary care facility for paediatric emergencies and is located in Calgary, a city with a population of approximately one million people (17). It is estimated that the ACH has a total catchment area of approximately two to 2.3 million people when considering those from southern Alberta, southeastern British Columbia and southwestern Saskatchewan. In 2007, the ED of the ACH saw 13,594 injuries out of a total of 52,546 patients.
CHIRPP is a national ED injury surveillance system. Voluntary completion of a structured injury report form is requested of all patients presenting to the ED with an injury. Information regarding the injury time, location, activities preceding the injury and use of protective equipment is recorded on the report form by the patient or parent/care-giver. The nature of the injury and the patient’s disposition are recorded by the attending physician. Completed injury report forms are sent to the national CHIRPP centre where they are coded by a trained data entry clerk (16). Ethical approval for the study was obtained through the University of Calgary Conjoint Health Research Ethics Board.
The national CHIRPP data centre provided an electronic spreadsheet copy of the June 2005 to June 2006 data, whereas the July 2006 to June 2007 data were extracted from the injury report forms at the ACH that had not yet been sent to the national CHIRPP centre. The specific fields that were used in the present study were age (younger than six years, six to nine years, 10 to 14 years, 15 to 18 years), sex, injury date, injury location, type of activity (bicycles, in-line skates, wheeled shoes, skateboards, push scooters), use of helmets, nature of injury (cuts or bruises, soft tissue, fracture or dislocation, concussion, sprain or strain), body part injured, number of injuries and patient disposition (advice only, treated by an emergency doctor, hospitalization).
Two independent researchers reviewed the national CHIRPP data to identify eligible records by electronically filtering the narrative injury event variable for the following terms: ‘heely OR heelie OR wheeled’; ‘scoot OR scooter’; ‘rollerblad OR roller blad OR rollerskat OR roller skat OR roller hockey OR in-line OR in line’; ‘bike OR biking OR bicycl OR cycling OR tricycle’; ‘skateboard OR skate board OR longboard OR long board’. Identified records were confirmed by scanning the narrative injury event variable. Injury events involving motorized scooters, motocross bikes or dirt bikes were excluded. The reviewers also excluded any injury events in which wheeled equipment was involved but not being used in the expected manner (eg, a running child tripped over a bicycle lying in the grass).
The July 2006 to June 2007 CHIRPP injury report forms were read by two researchers and manually sorted by activity using the same criteria as for the electronic records. The forms reporting injuries related to the use of bicycles, wheeled shoes, skateboards, in-line skates and push scooters were selected, and the data were entered into a database. The two data sets were then combined, and duplicate records were removed.
The data were analyzed using STATA 10 software (StataCorp, USA). The data were presented using cross tabulations of the type of nonmotorized wheeled activity with type and nature of injury, use of safety equipment, age (younger than six years, six to nine years, 10 to 14 years, 15 to 18 years) and sex. Group differences were assessed for statistical significance using a χ2 test.
Table 1 shows the demographic characteristics of the injured subjects by type of activity. Most of the children were injured from bicycling (66.9%), and the least from wheeled shoe use (2.7%). The highest proportion of male participants was observed in skateboarding (86.1%), while more girls than boys were injured using wheeled shoes (48.8% male). Scooter injuries were most common among children younger than 10 years of age, while there were no injuries from wheeled shoes among children 15 years and older.
Fractures and dislocations were the most common injury among all activities, although the proportion varied from 39.6% in bicyclists to 60.5% in those using wheeled shoes (data not given). No concussions were reported for wheeled shoe users, while these injuries were reported by 6.6% of those injured while cycling. The upper extremity was the most frequently injured body region in all groups, comprising more than three-quarters of the injuries in wheeled shoe users and approximately one-half of the injuries in other non-motorized wheeled activities (Table 2). There were fewer than five head or face injuries reported by wheeled shoe users, with the proportion in other groups ranging from 15% (skate-boarding) to 22.3% (bicycling). Neck injuries only occurred in cyclists (1.4%). Forearm fractures were the most common injury for all activities, ranging from 18.9% in cyclists to 39.5% in wheeled shoe users. Head and face injuries were the next most common injuries for cyclists, push scooter riders and in-line skaters, while other upper extremity injuries were the next most frequent injuries for wheeled shoe users (soft tissue, 18.6%; wrist or hand fractures/dislocations, 11.6%) and skateboarders (hand fractures, 7.1%).
Bicyclists and skateboarders were most likely to have multiple injuries (24% and 15%, respectively), while wheeled shoe users did not have any multiple injuries. Most of the injuries (more than 94%) in nonmotorized wheeled activities simply required treatment in the ED. No wheeled shoe users were admitted to hospital, while those injured by cycling had the highest proportion of hospital admissions (5.4%).
Overall helmet use among this injured series was 66.4% (Table 3). Helmet use was most prevalent in children riding bicycles (84.6%) and least prevalent in children using wheeled shoes (4.7%). Other protective safety equipment was used minimally across all activities, with no wheeled shoe users using such equipment (Table 3).
Injuries from nonmotorized wheeled activities can be severe. Bicyclists were the most frequently injured group, but there were also a significant number of injuries in other nonmotorized wheeled activities. The most common injury in all activities was a forearm fracture, which is in agreement with the current literature (4,6,10–12,18–22). When comparing the injury profiles of all the activities, it is surprising that wheeled shoes share a relatively similar injury profile as the other activities with the exception of head injuries. Additionally, wheeled shoe users had the largest proportion of fractures (60.5%), with forearm fractures being the most common (39.5%). These results are in general agreement with the CHIRPP wheeled shoe report, suggesting that the injury profile in Calgary is similar across the country (15). One major finding in the CHIRPP wheeled shoe report, which was not apparent in the present study, was that 5% of children had head injuries. This is likely a result of the larger sample size in the national report. Forearm fractures (especially of the dominant arm) can interfere with a child’s ability to perform fine motor tasks, such as printing, and basic self-care tasks, such as dressing independently. Additionally, the child experiences pain and suffering: the relatively frequent need for fracture reduction and associated risks of sedation and anesthesia, short- and long-term disability, possible lengthy duration of treatment, and work/school time losses related to the injury and its follow-up. These injuries are quite significant and can have a great impact on the child, family and health care system.
The injuries in the different age groups vary depending on the activity and are in agreement with previous studies. Bicycling, rollerblading and skateboarding injuries were most common among children older than 10 years of age, while injuries from scooters and wheeled shoes were most common among children younger than 10 years of age (18–20,23). These differences likely reflect exposure to participation in the activity rather than actual injury risk (6,10). Of note, the American Academy of Pediatrics recommends that children younger than five years of age not use skateboards because of the risk of injury (6). Such a recommendation might also be considered for push scooters given that almost 17% of children injured in this activity were younger than six years of age.
Helmet use was highest among bicyclists. The proportion of children who wore helmets was similar to that reported in the Canadian literature and considerably higher than that reported in the US literature (24,25). The difference is likely secondary to the legislation in Alberta requiring helmet use by bicyclists younger than 18 years of age. Helmet use was just below 50% among injured in-line skaters, while injured skateboarders, push scooter riders and wheeled shoe users were less likely to wear helmets. The literature reports helmet use to range substantially for each activity, but the general trend shows that children riding scooters and using wheeled shoes are less likely to wear helmets than those in the other activities (11,13,21,24). The low prevalence of head injuries in the latter group suggests that helmet use would not change their injury profile.
None of the wheeled shoe users wore protective equipment other than a helmet, while a very small percentage of in-line skaters, skateboarders and push scooter users wore protective equipment other than a helmet. The large proportion of fractures of the distal upper extremity in wheeled shoe and push scooter users suggests a role for wrist guards, which have been shown to be effective in in-line skating and snowboarding (5,26). The proportion of head injuries among skateboarders and in-line skaters is in agreement with the current literature (19). The fact that less than one-half of injured in-line skaters and less than one-third of injured skateboarders wore helmets suggests that we can improve helmet use in these groups.
Most of the injured children in the present study received some type of treatment. This is not unexpected because study participants were selected from the ED. Hospital admission was rare in all of the activity groups, ranging from no admissions among wheeled shoe users to 5.4% among cyclists. The current literature varies when the severity of injury among nonmotorized wheeled activities is measured in terms of hospital admission, ranging from 2% to 20% (19,21,23,27). Interestingly, although the study by Konkin et al (13) investigated more severe injuries (requiring a minimum of three days of hospitalization), extremity injuries were the most common injury among cyclists, in-line skaters and skateboarders. Our study had similar findings and, therefore, might suggest that the body region injured is similar regardless of the severity of the injury. Some of the variation among the studies might reflect differences in safety equipment use, local admission criteria and study populations (trauma centres versus ED).
The present study has several limitations. By using CHIRPP surveillance data, we limited our study participants to those who presented to the ACH in Calgary, Alberta. This would fail to capture any child injured in a nonmotorized wheeled activity who presents at another hospital, a walk-in clinic or their family doctor. Therefore, it is possible that the number of injuries reported in this study underestimates the actual number of injuries and may over-represent severity because patients were seen in an ED. However, the inter-activity comparisons and injury profiles within each activity should not be affected. Older children and adolescents might be missed by the CHIRPP surveillance system because they are more likely to visit an adult hospital. This would result in an over-representation of children injured in younger age groups. Finally, we do not have population data to estimate participation rates and, subsequently, injury rates in our study.
We report the first Canadian paediatric study to compare injuries caused by nonmotorized wheeled activities. Nonmotorized wheeled activities can result in significant morbidity. As expected, bicycling resulted in the largest number of injuries. However, more recent low-impact activities such as wheeled shoes and push scooters, although less frequently seen in the ED, resulted in a substantial number of upper extremity fractures. Although these types of injuries can cause significant limitations in the day-to-day life of a child, protective equipment is rarely used by individuals. Protective equipment, particularly wrist guards and helmets, might decrease upper extremity injuries when participating in such activities, while helmets should be recommended for high-impact activities (bicycling and skateboarding) in which head injuries are more likely.
Dr Brent E Hagel holds the Alberta Children’s Hospital Foundation Professorship in Child Health and Wellness, funded through the support of an anonymous donor and the Canadian National Railway Company, as well as the Alberta Heritage Foundation for Medical Research Population Health Investigator and Canadian Institutes of Health Research New Investigator Awards. Janna Tram received an Alberta Heritage Foundation for Medical Research Summer Studentship. Project funding for this study was provided through the Public Health Agency of Canada, Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP).