All-terrain vehicle major injury patterns in children: a five-year review in Southwestern Ontario

Pediatrics

CJEM 2006;8(4):277-280

Abstract

Résumé

Introduction

All-terrain vehicles (ATVs) are commonly used in both urban and rural areas of Canada by children under the age of 16 for both recreational and occupational needs. They appeal to children and their families for many reasons, ranging from their perceived off-road capabilities to their exciting nature. Children, however, may not understand the potential risk of personal injury. Similarly, their parents may be unaware of the potential threat these vehicles pose.

To reduce these risks, the Canadian Paediatric Society (CPS) introduced an evidence-based position statement in 2004 recommending that children <16 years of age should not operate or ride as passengers on all-terrain vehicles.1 This position was taken without the risks having been adequately quantified. In Western Ontario ATVs are commonplace, especially in the rural areas. The Children's Hospital of Western Ontario (CHWO), within the London Health Sciences Centre (LHSC), serves as a regional referral centre providing specialized pediatric services to children in Southwestern Ontario. CHWO, situated in London, Ont., also serves a significant rural population within Southwestern Ontario.

An increasing number of children in Ontario are being hospitalized as a result of ATV-related trauma. The number of trauma hospitalizations in Ontario related to ATVs increased 45.6% between 1997 and 2002, with 36% of these patients aged 5 through 19 years.2 The objective of this report is to describe the nature of injuries sustained by ATVs in children visiting our emergency department (ED).

Methods

A retrospective medical record review was conducted to characterize the nature of the injuries sustained by pediatric patients (<18 years of age) involved in ATV crashes in Southwestern Ontario over a 5-year period between Sept. 1, 1998, and Aug. 31, 2003.

Patients were included if they were <18 years of age and presented to the ED with ATV-related trauma and an Injury Severity Score (ISS) = 12, which is considered to be indicative of a major trauma. CHWO's ED has an annual census of approximately 37 000 visits. Data elements collected were age, gender, ISS, site of injury, helmet use, injuries sustained, ED intervention, blood transfusion history, surgical therapy, hospital length of stay and patient disposition.

Patients were identified by the LHSC Trauma Program Registry, and their charts were then retrieved and reviewed by the principal investigator (K.A.). The Trauma Registry at the LHSC is a prospectively collected comprehensive data set for all severely injured patients (ISS = 12) treated at the LHSC, which is 1 of 2 lead trauma hospitals in Southwestern Ontario. The database is maintained by 2 data analysts who are trained in ISS scoring, ICD-10-CA injury coding3 and data entry procedures, with input from an injury epidemiologist. Data are downloaded to the Ontario Trauma Registry at the Canadian Institute for Health Information on a monthly basis. The Collector Trauma Registry software from Digital Innovations is used in a similar manner to most other provinces and many trauma centres in the United States. There are provincial differences in both the inclusion criteria and data elements collected on trauma patients. (i.e., Nova Scotia collects data on all penetrating injures with an ISS = 9, as well as all deaths at the scene and en route to hospital, whereas LHSC only collects ISS = 12 for blunt and penetrating injuries and only deaths that occur in the ED or in-hospital. Approval of the study was granted by the University of Western Ontario Ethics Review Board.

Results

A total of 17 patients (14 males [82%]) met the inclusion criteria. Their ages ranged from 8–17 years, with an average age of 13.7 years. Thirteen (77%) patients were <16 years of age. During the 5-year review period, there were 186 221 visits to CHWO's ED. ATV-related trauma was responsible for 87 visits. Overall, there were 392 major trauma patients <18 with an ISS = 12 during the same study period. ATV-related injury, therefore, comprised 1.4% (17/392) of major pediatric trauma. Interestingly, in the same region during the same review period there were 26 patients =18 with an ISS = 12 who presented to the adult hospital's ED with ATV-related trauma.

Overall there were 7 different systems injured in these 17 patients. Fourteen patients sustained an injury to more than 1 system. The average ISS was 22.8, and there were no deaths. The average length of hospital stay was 9.7 days. All 17 patients were involved in an ATV rollover mechanism of trauma.

Six patients (35.3%) sustained a significant head injury, and 1 patient sustained a diffuse axonal injury. Focal injuries included 2 with intracerebral contusions, an intraparenchymal hemorrhage, an epidural hematoma and a subarachnoid hemorrhage. Four of these 6 patients were not wearing a protective helmet. Overall, 11 patients (65%) wore helmets.

Eight patients (47%) suffered splenic injuries; 5 of them had Grades II, III or IV injuries, and the other 3 sustained Grade V injuries. Three of the patients with Grades I, II and III splenic injuries were managed non-operatively. Two patients suffered Grade IV splenic injuries, with 1 of them requiring a splenectomy. All 3 patients sustaining Grade V injuries required blood transfusions, and 2 of these patients required a splenectomy.

Thirteen patients (76%) sustained fractures. Four of these patients had skull fractures, and there were 3 patients each with pelvic fractures, lower limb fractures, lumbar spine fractures and ribs fractures. One patient sustained an upper limb fracture and 1 sustained a clavicle fracture. One patient required operative fixation for a radius fracture, and another required operative fixation for a femur fracture. One patient sustained a debilitating brachial plexus injury.

Discussion

This paper describes the demographics and characteristics of injuries seen in a population of patients with major ATV-related injuries presenting to a pediatric tertiary referral centre in Southwestern Ontario. There were insufficient cases to identify a specific pattern of injuries, if one exists. The recent CPS position statement outlined several preventive strategies and recommended that children <16 years not use ATVs.1 Thirteen patients were <16 in this study. The American Academy of Pediatrics (AAP) drafted its policy regarding the use of ATVs by children in 1987, similarly recommending legislation prohibiting the use of ATVs by those <16 years of age.4 A recent US case–control study highlights the importance of an age limitation, as outlined by both the CPS and the AAP. The study estimated that ATV drivers =15 years of age were nearly 4 times as likely as drivers aged =16 or older to be injured.5

Splenic injury was the second most common injury in our patients, after fractures. Moreover, the rates of splenic injury and splenectomy in this study were higher than has been reported in the literature, placing those patients at risk for the greater morbidity and mortality associated with post-splenectomy infection.6 Upon detailed review, the 3 patients did meet criteria for splenectomy. Two patients with Grade V injuries were noted to have ongoing intraoperative bleeding, and the 1 patient with a Grade IV injury was noted to have continued, significant active bleeding that was not responding to blood transfusion therapy.

Murphy and Yanchar7 described the injuries in 92 patients <16 years admitted to the IWK Health Centre, Halifax, NS, over a 12.5-year period. However, only 13 of those patients had an ISS = 12 compared with 17 in our study. They recorded only 3 patients with splenic injuries compared with our 8. We could not identify any factors that would explain the difference in injury rate. It is possible that patients in our study may have been travelling at higher speeds or may have been taking more risks due to their older ages. Given the study methodology, it is difficult to know if either greater speed and/or greater risk-taking are valid explanations. The advent of more powerful ATV engines with greater speed capabilities and acceleration may also be contributory. Another 5-year review, also conducted in Nova Scotia but involving patients between 16 and 34 years, revealed only 2 patients with splenic injury, neither of whom was reported to require splenectomy.8 Yanchar most recently compared patients who presented to the ED of the IWK Health Centre between January 1993 and December 2002 with injuries sustained from bicycling, dirt-biking and motocross bikes, ATVs and motorized vehicles. ATV-related injuries were determined to more closely resemble those from motor vehicle crashes.9

Limitations

Our study has several limitations. Sample size does not allow directed comment on injury pattern, preventing any recommendations about preventive interventions. This was not a population-based study but a regional sample of children who were injured severely and required hospitalization. As such, this study may not be generalizable. Moreover, failure to document other pre-existing circumstances limits our understanding of the reasons for the underlying behaviour that led to the ATV crash.

Rural practitioners should be aware of the relevant laws and regulations surrounding ATV use in their particular province or territory. The CPS position statement provides a summary of provincial and territorial ATV vehicle legislation, age restrictions and helmet requirements.1 Physicians (i.e., family physicians, emergency physicians and pediatricians alike) should incorporate the CPS position statement in their anticipatory guidance in patients <16 years of age. Further research is required to gain a better understanding of the awareness and attitudes of adolescents and their parents regarding ATVs.

Conclusion

ATV crashes have led to serious injury in children in Southwestern Ontario. These results support the CPS recommendation that children <16 years of age should be prohibited from operating or riding on ATVs.

References

1. Canadian Paediatric Society Injury Prevention Committee. Preventing injuries from all-terrain vehicles [position statement]. Paediatr Child Health 2004;9:337-40.
2. Canadian Institute for Health Information. All terrain vehicle (ATV)-related trauma hospitalizations in Ontario, 2001–2002. Ont Trauma Reg Analytic Bull 2003;Dec.
3. Canadian Institute for Health Information. The Canadian enhancement of ICD-10 (International statistical classification of diseases and related health problems, 10th rev). Final Report. 2001. Available: www.cihi.ca/cihiweb/dispPage.jsp?cw_page =codingclass_icd10_e(accessed 2006 Mar 27).
4. American Academy of Pediatrics Committee on Injury and Poison Prevention. All terrain vehicle injury prevention: two-, three-, and four-wheeled unlicensed motor vehicles. Pediatrics 2000; 105:1352-4.
5. Rodgers GB, Adler P. Risk factors for all-terrain vehicle injuries: a national case–control study. Am J Epidemiol 2001;153 (11): 1112-8.
6. Bisharat N, Omari H, Lavi I, et al. Risk of infection and death among post-splenectomy patients. J Infect 2001;43:182-6.
7. Murphy N, Yanchar N. Yet more pediatric injuries associated with all-terrain, vehicles: Should kids be using them? J Trauma 2004; 56:1185-90.
8. Sibley AK, Tallon JM. Major injury associated with all-terrain vehicle use in Nova Scotia: a 5-year review. Can J Emerg Med 2002; 4(4):263-67
9. Yanchar NL, Kennedy R, Russell C. ATVs: motorized toys or vehicles for children? Inj Prev 2006;12:30-4.