Non-motorized vehicles and walkers: going for “broke”

Walkers 

A 9-month-old girl was referred to the ED after rolling down the stairs in her walker. The surface at the bottom of the stairs was carpeted. There was no loss of consciousness. She was crying and vigorous, her vital signs were normal except for a heart rate of 160, and she had a contusion to her left forehead. Her head computed tomography (CT) scan showed no skull fracture or intracranial injury; she was discharged home after tolerating oral fluids. The treating physician recommended to the family that they get rid of the walker.

Baby walkers are common in the homes of young families. In the past 20 years, use has been reported to range from 53% to 92%; a recent survey reported that 46% of families had used a walker in the previous six years.6, 7 Walkers are used for convenience and entertainment, in part because they are believed to keep a child occupied so that the parent can complete household tasks. Parents also report a belief that walkers help children learn to walk. In 1999, an estimated 8,800 children younger than 15 months old were treated in US EDs for injuries associated with infant walkers. The rate of injury appears to be declining, as there were more than twice as many injuries reported in 1995. The actual number of injuries is probably greater, as many are likely minor and managed at physicians’ offices or treated by parents at home.6 The numbers of injuries are slightly higher than those associated with other infant products, including baby carriers, strollers, and high chairs.8, 9, 10

Falls are the most frequent mechanism of injury, either from the walker or with the infant remaining in the walker. More than 75% of injuries are related to falls down stairs; other reported mechanisms include falls from other elevated surfaces (single step or curb), tip-overs, and finger pinches in and contusions from the walker frame.11, 12, 13 Improved mobility among infants has resulted in burns and ingestions.12, 14 All serious injuries result from stair falls.11, 12

The head or face is the most frequent anatomic site of injury. While many injuries are minor (contusions/abrasions or lacerations), skull fractures account for approximately 10% of all walker-related injuries. It has been reported that 4% of injured children are admitted to the hospital for management of their injuries. Injuries observed among admitted patients include subdural hematoma, intracerebral hemorrhage, and cerebral edema.11

Strategies to prevent infant walker-related injuries include public education as to their risks and behaviors that allow less dangerous walker use, design changes to prevent falls down stairs, and legislation to prohibit walker manufacture and sales. It is clear that the prevention of stairway falls is a critical step in reducing walker-related injuries. Public education through warning labels on walkers and anticipatory guidance has had limited success in eliminating walker-related injuries. It appears that parents are aware of the hazards related to walker use: in one series of injured children, 59% of parents reported knowledge of dangers related to walkers, and a recent survey observed that 89% of mothers reported walker-related hazards.7, 11 Improved parental supervision to prevent stair falls is impractical: parents place children in walkers so that they can do other things, and stair falls occur among “supervised” children.11 Information about the protective efficacy of properly attached stair gates is limited; falls have been reported when gates were left open or improperly attached.15

Voluntary manufacturing standards for walkers established in 1996 stipulated that walkers be wider than the standard 36” door frame width or must have a braking mechanism designed to stop the walker if one or more wheels drop off the riding surface. Overall industry compliance has not been evaluated.6 Stationary playstations, or exersaucers, have been developed and marketed as a walker alternative without wheels. These appear to be an acceptable walker alternative; they are reasonably priced and readily available. A study examining trends (1994-1999) in their use in one community reported significant downward trends for walker use and significant upward trends for exersaucer use.7 Currently, exersaucers appear to represent a safe and appealing walker alternative.

Bicycles 

A 9-year-old boy was referred to the ED after falling from his bicycle on the street in front of his home. He was not wearing a bicycle helmet. There was no loss of consciousness. He was alert, could describe the details of the fall, and complained of pain to his forehead and his right arm. He had a forehead laceration and an abrasion to his right arm that contained pieces of gravel. The right arm had no deformity or point tenderness and the elbow had full range of motion. The neurologic examination was normal. The laceration was sutured and the abrasion cleaned, and he was discharged home. The ED physician discussed with the child the importance of using a bicycle helmet to prevent head trauma in the future.

In 2000, there were approximately 740 deaths from bicycle-related injuries in the US; 227 (31%) were among youth younger than 20 years old.16 An additional 341,000 children and adolescents were treated in EDs for nonfatal injuries. Children between the ages of 5 and 14 have the highest injury rates, an estimated 566/100,000 (5-9 years old) and 711/100,000 (10-14 years old). Within this age group, an estimated 8,400 are admitted to the hospital each year to manage their injuries. Although injury rates are lower among younger cyclists (< 5 years old), they are also commonly injured (estimated 156/100,000/yr).17

Trauma registry data suggest that a collision with a motor vehicle accounted for almost half of the circumstances of injury among hospitalized cyclists 5 to 14 years old, and 80% were injured in a street location.18 Among those who sought care in the ED, a cohort with less severe injuries, fewer than 10% had been involved with a motor vehicle, and less than half were injured in a street location.19 Younger cyclists (<5 years old) were less frequently involved in a collision with a motor vehicle than were older children. Among young cyclists who were hospitalized, 31% had been involved in a bicycle-motor vehicle collision and 46% had been injured in the street. Among those who were treated in the ED, <1% had been involved in a motor vehicle collision and 24% had been injured in the street.18, 19

Head injuries account for about two-thirds of deaths related to bicycling, slightly greater than half of bicycle-related injury hospitalizations, and approximately 10% of bicycle-related ED visits.18, 19, 20 Face injuries are also common, occurring in up to one-third of injured cyclists treated in the ED.19, 21 Limited data suggest mountain biking, an activity popular among some adolescents, may be associated with more severe face trauma, specifically, facial bone fractures.22 Extremity fractures account for approximately 20% of injuries treated in the ED, and occur in about 38% of injured child and adolescent bicyclists admitted to the hospital.18, 19 Although abdominal and pelvic injuries are less common diagnoses, they can be quite serious. The bicycle handlebars have been implicated as the injury mechanism in many cases.23

The prevention of bicycle-related injuries has involved several strategies. While separation of bicycles from motor vehicle traffic with bike paths would likely reduce injury from collisions, evaluations of this intervention to prevent injuries are limited. In addition, collisions with motor vehicles account for less than half of the injuries among youth with serious injuries. There is little information on risk factors for bicycle falls, or for collisions with pedestrians, other bicycles, or with stationary objects.24

Bicycle helmet use is the most important strategy to reduce serious injury or death from a bicycle collision. Helmets are very effective in preventing head and brain injuries. A population-based case-control study which included children (61% ≤ 14 years old) observed that helmet use decreased the risk of head injuries by 85%.2 A second case control study which included over 3,000 injured cyclists of all ages found that helmets were effective in both collisions that involved motor vehicles as well as those that did not.25 Over a 5-year period in England (1991-1995), head injuries as a proportion of monthly admissions for trauma related to bicycles fell (40% to 28%) while total admissions for bicycle-related trauma remained unchanged.26 Helmets are also partially effective in preventing face trauma, particularly to the forehead.21

While market forces have made helmets affordable, only 15% to 25% of children and adolescents report always wearing a helmet when bicycling.27, 28 Both education and legislation have been shown to increase helmet use. Education strategies have included classroom curricula, physician counseling, and community programs. School-based programs and physician counseling have had limited success in improving helmet use rates.29, 30, 31, 32, 33 Comprehensive, community based efforts had success in increasing helmet use rates among youth in Seattle; this program has been used as a model by others.34 Enforcement through legislation seems to be an effective method to increase helmet use. This has increased helmet use rates among youth in some geographic areas to as high as 50%.5, 35, 36, 37, 38, 39 It is important that efforts to encourage the use of helmets among all youth bicyclists are ongoing, and that programs that aim to achieve this goal are evaluated.40

Specific information about tricycle-related injuries is limited. There is no external cause of injury code for tricycle in the International Classification of Diseases (9th edition).41 Trauma registry data is often coded using this system (National Pediatric Trauma Registry), as are other national data sources (National Hospital Ambulatory Medical Care Survey). Thus, these sources of injury data are not helpful in learning the incidence, circumstances, or severity of tricycle-related trauma, as they are lumped in with bicycle-related injuries. It is imprecise to use age criteria, as small bicycles, designed for use by 3-year-old children, are in the marketplace. The US Consumer Product Safety Commission (CPSC) National Electronic Injury Surveillance System (NEISS) separately codes bicycles, tricycles, and wheeled toys. Among children younger than 5 years old, these data suggest that tricycle-related injuries requiring ED care are far outnumbered by bicycle injuries (ratio of 1:5). Among children with tricycle-related injuries, an estimated two-thirds had head trauma, and 3% were admitted to the hospital.18 The efficacy of helmets to prevent head injury among children riding tricycles is not clear; however, it is clear that children riding tricycles sustain head trauma, and thus it is likely that helmet use would be protective.

Bicycle-mounted child seats and bicycle-towed child trailers are both used for travel with young children. National injury estimates suggest injuries related to either bicycle accessory are low: using denominators based on census data, the estimated annual injury rate for children younger than 5 years old was 1.3 per 100,000 (bicycle-mounted child seats) and 0.2 per 100,000 (bicycle-towed child trailers).42 As only children who use these products are exposed to injury related to their use, the actual rate of injury to those who use either of them is higher. The number of cases of injured children is low, thus information about the mechanisms and types of injuries likely lacks precision.

Among those injured using bicycle-mounted child seats, collisions with motor vehicles accounted for less than 10% of injury circumstances. The most common mechanism of injury (estimated 70%) was a fall, either from the seat or with a bicycle tip-over. Spoke injuries to extremities accounted for an estimated 20% of injuries. Injuries to the head or face accounted for 50% to 70% of injuries; most of the remaining injuries were extremity trauma.42, 43 A young child has a high center of gravity and a relatively large head, which is often the impacting body part in falls. As head trauma related to the use of bicycle-mounted child seats is common and potentially severe, bicycle helmet use is likely to reduce injury severity and frequency. To prevent ankle and foot injuries some seats are designed with foot wells; others use spoke guards. The efficacy of these designs to prevent injuries remains in question.

Bicycle-mounted child trailers appear to have fewer injuries related to their use than do bicycle-mounted child seats. It is not clear if this is because there are fewer bicycle-towed child trailers, resulting in lower exposure, or if there truly is a lower risk of injury associated with this product. The mechanisms of injury associated with the use of bicycle-towed trailers include collisions with a motor vehicle (30%), falls from the trailer (50%), or contact with moving surfaces outside the trailer (17%).42 A collision with a motor vehicle seems to have the most potential for serious injury associated with the use of a bicycle-towed child trailer. The near ground position limits visibility and places occupants at risk for crush injury in motor vehicle collisions. Because of their near ground position, bicycle-towed trailers have a low center of gravity and are quite stable. This limits the height of falls to less than 30 cm. The two-wheel axis is perpendicular to the axle of the bicycle, which helps to prevent tipping. Many trailers are also designed with an attachment mechanism that prevents tipping, even if the bicycle is laid on the ground. The head or the face was the most common anatomical site of injury; helmet use would be protective for injuries of these types. Thus, bicycle helmets should be used when children are placed in bicycle-towed child trailers.

Scooters 

An 8-year-old boy came to the ED after falling from his scooter in the park. He was not wearing any safety equipment. There was no loss of consciousness. He was alert, and described the incident as traveling over uneven ground, loosing his balance, and falling. He complained of pain to his left wrist. He had point tenderness of the distal left forearm; the radiograph showed a torus fracture of the left radius. He was placed in a splint and sling and discharged home. The physician caring for the child discussed with the family the importance of supervision and use of protective gear, including a helmet, and knee and elbow pads.

Non-motorized scooters achieved immense popularity among US youth in 2000. The scooters are new versions of the foot-propelled scooters first popular in the 1950s; most are aluminum and weigh less than 10 pounds, have small, low friction wheels, and can be folded for easy portability. A report released by the CPSC in September 2000 showed there had been a 700% increase in ED treated scooter-related injuries since January 2000, and that 4000 injuries had been treated during August 2000.44 The NEISS, using weightings, suggests there were an estimated 27,600 scooter-related injuries between January and October 2000. Children and adolescents younger than 15 years old accounted for 85% of those injured; 23% were younger than 8 years old, and two-thirds were male.45

Population-based information about the circumstances of scooter related injury is limited. Among 15 children treated at a single US institution, 13 (87%) had falls, and 2 (13%) had collisions (1 wall, 1 motor vehicle). One child was injured while riding in the street; other injuries occurred in the park (n = 6) or on the sidewalk (n = 6).46 Data from an ED in Australia (n = 59) suggested similar circumstances of injury among youth, as 6 (10%) had collisions (5 stationary objects, 1 motor vehicle). Half reported uneven ground as the cause of the fall; the number of injuries on horizontal ground was similar to the number on sloping ground. Seven (12%) of the injury events occurred on roadways.47 Adult supervision was present about half the time in both series.46, 47

National data report the head or face (29%), arm or hand (44%), or leg or foot (22%) as the most common anatomic sites of injury. Injury diagnoses included soft tissue injuries such as contusion, abrasion, or laceration (45%), strain or sprain (15%), or fracture or dislocation (29%). Seventy-three percent of the fractures/dislocations involved the arm or hand.44 Both case series had fracture rates around 40%.46, 47 National data suggest an estimated 3% had injuries requiring admission to the hospital; admission rates in the case series were 16% to 20%.44, 46, 47 No child in either case series had a skull fracture or intracranial injury.46, 47

In 2001, there were 10 deaths related to scooters among US children younger than 15 years old reported to the CPSC. Nine involved a motor vehicle and one a fall on a steep slope; the specific injuries in these cases are not known.48 This is possibly an undercount, as reporting is not complete from some data sources.

The data suggest that traffic avoidance is important in preventing serious injuries. The CPSC recommends that those using scooters avoid streets, or surfaces with water, sand, gravel, or dirt. Although scientific data about the efficacy of safety equipment to protect against scooter-related injuries is not available, information about the benefits of protective gear in similar recreational activities is instructive (bicycling, in-line skate use).2, 3 Use of safety gear would likely prevent or reduce in severity some scooter-related injuries. Case series data suggest that safety equipment use by injured scooter users is low (3-13%).46, 47, 49 The use of helmets and knee and elbow pads should be encouraged whenever youth use scooters. It is less clear if wrist guards should be recommended: wearing them may make it difficult to grip the scooter handle and steer it. Public education directed to parents is essential to increase awareness of the injury potential related to scooter use, and the need for safety measures when using them. The American Academy of Pediatrics has endorsed the CPSC recommendation that children younger than 8 years old should not ride scooters without close adult supervision.50

Skateboards 

A 12-year-old boy came to the ED after falling from his skateboard. He had been riding in the street and was not wearing any safety equipment. There was a brief loss of consciousness. He was alert, and described the incident as hitting a pothole, losing his balance, and falling. He complained of pain to the back of his head, where he had a 3 cm laceration. His head CT was negative, the scalp laceration was closed with staples, and he was discharged home. The ED physician and child discussed the hazards of riding a skateboard in traffic and the importance of helmet use.

Skateboard-related injuries have paralleled the sport’s popularity, which has consistently risen and then fallen since skateboards were first marketed in the 1960s. National data suggest the annual incidence of skateboard-related injuries peaked in 1977 (150,000) and fell through the early 1980s (estimated 16,000 injuries in 1983). Increasing popularity through the 1990s resulted in more injuries among children and adolescents, an estimated 51,000 in 1999.50

Injured children were more often male, accounting for 90% of those who sought care in the ED and 76% of those admitted to the hospital for management of their injuries.50, 51 Young adolescents between the ages of 10 and 14 accounted for approximately half of those treated in the ED. Although obscured by standard age groupings, 15-year-olds were similar to younger adolescents in the incidence of injury and gender distribution.52 Hospitalized skateboarders tended to be older than those treated in the ED: youth 5 to 9 years old accounted for less than 20% of those requiring admission.51

National ED information about injury circumstances suggests that an estimated 30% of injuries occurred on a street or highway and 3% involved a collision with a motor vehicle. An irregularity of the skating surface (stone, hole) has been reported as a direct cause in the injury sequence in some cases.53 The most frequent anatomic sites of injury were the extremities (an estimated 75%); injury diagnoses included fractures, dislocations, strains, or sprains. Head or face trauma accounted for approximately 20% of injuries, usually contusions, abrasions, or lacerations.52, 54

Among children hospitalized with skateboard-related trauma and reported to the National Pediatric Trauma Registry (1988-1997), 63% were injured on roads and 25% involved in a motor vehicle collision. Half had associated head trauma. When compared to those injured using in-line or roller skates, skateboarders appeared to have more serious injuries: they had higher injury severity scores and, on average, longer hospitalization (6 days vs 3 days).51

The data suggest that traffic avoidance is important in preventing serious injuries. The CPSC recommends those using skateboards to avoid streets, and before riding to screen the area for holes, bumps, rocks, and debris. National data about the use of safety equipment by skateboarders is limited. In one observational study (n = 35), just 14% of skateboarders were using helmets.49 Specific data about the efficacy of safety equipment to protect against skateboard-related injuries are not available. However, use of safety gear would likely prevent or reduce in severity some skateboard-related injuries. As head trauma clearly accounts for the high injury severity among hospitalized skateboarders, it is particularly important that helmets be recommended and used. The use of wrist guards and knee and elbow pads should also be encouraged among all youth using skateboards.

In-line skates 

A 12-year-old boy was brought to the ED after falling while in-line skating. He had been skating down his parent’s sloped paved drive and on the sidewalk and street in front of his home. He was not wearing any safety equipment. He was alert, and described the incident as losing his balance and falling. He complained of arm pain. He had an obvious deformity of his left forearm. The x-ray showed a fractured radius and ulna. The fracture was reduced and the arm placed in a cast; the child was discharged home. The treating physician discussed the importance of safety gear, helmets, wrist guards, and knee and elbow pads, and the risks associated with skating in traffic.

Between 1991 and 1995, the estimated number of in-line skaters increased from 6 to 22.5 million, making it one of the fastest growing recreational sports in the 1990s. In 1996, there were an estimated 17.7 million in-line skaters younger than 18 years old. These trends were accompanied by an increase in the number of injuries, an estimated 76,000 among children and teens younger than 21 years old during that year.55 National CPSC data report the average age of injured skaters to be 20 years old; youth 7 to 15 years old have the highest rates of injury, and account for approximately half of those injured. In 1993, the incidence of injury among youth between the ages of 10 and 14 was 75/100,000. Among children and adolescents, 68% of injuries involved males.54, 56

National data about circumstances of injury suggest the most typical fall involved a skater with limited experience who lost their balance or fell after hitting a defect in the pavement or road debris.3 In one case series, college students reported sustaining minor injuries during the first 1 to 2 times using skates; serious injuries tended to occur after at least 50 times on skates.57 Circumstances among injured in-line skaters treated in a single ED suggest that injury mechanisms included traveling too fast (35%), striking an object in the pavement (20%), or an inability to brake (19%).58 Among youth hospitalized with their injuries (National Pediatric Trauma Registry, 1988-1997), 83% were male, 55% were injured on the road, and 22% had injuries resulting from a collision with a motor vehicle.51 Collisions with motor vehicles accounted for most of the fatal injuries reported to the US CPSC.55

National ED data report that among youth, extremity trauma was most common, accounting for 80% of injuries; the lower arm or wrist was the most frequent extremity injured. Lower arm fractures accounted for 66% of injuries to that site. Other injuries included contusions, abrasions, strains, or sprains. Fractures accounted for fewer of the injury diagnoses of the other extremities: 9% of injuries to the lower leg and 5% of injuries to the elbow. The head or face was the most severely injured anatomic site for 12% of youth younger than 20 years old. Among youth admitted to the hospital, 2.5% of the group seeking care in the ED, 11% had head or face trauma.56 Injury patterns among youth hospitalized (National Pediatric Trauma Registry) with in-line skating injuries include head trauma (34%), upper extremity trauma (48%), or lower extremity trauma (22%). Eighty-three percent were male. The average length of stay was three days.51

It appears that avoiding traffic would likely prevent the more serious injuries. Additional information is needed about the protective efficacy of paths isolated from motor vehicles. These paths frequently carry a high volume of individuals traveling at different speeds, walkers and runners, bicyclists, and in-line skaters.

Observational data suggest that the use of protective equipment among in-line skaters is low, with some community specific variations. Information collected in 8 Texas communities (n = 55) noted that 18% of youth were wearing helmets.49 The use of protective gear from observations from sites around Winnipeg, Canada (n = 123), showed that 12% used helmets, 16% used wrist guards, 10% used knee pads, and 7% used elbow pads.59 In Milwaukee, Wisconsin, only 3% of in-line skaters used helmets, while 64% of skaters were observed to be using wrist guards.60 A case-control study based on a national sample which included children (greater than half were children or adolescents) reported that wrist guard use could reduce the number of wrist injuries by 87%, elbow pad use could reduce the number of elbow injuries by 82%, and knee pad use could reduce the number of knee injuries by 82%.3 These data do not provide sufficient detail to allow us to know the efficacy of protective gear to prevent fractures. The protective efficacy of a helmet to prevent or reduce head injury also could not be determined from these data; however, other data clearly demonstrate the effectiveness of helmets in recreational activities with similar injury mechanisms.2 Both the CPSC and the American Academy of Pediatrics recommend that protective gear (helmet, wrist guards, and knee and elbow pads) always be used when in-line skating.5