Horse Related Injuries in Children

Horse Related Injuries in ChildrenAfter last week’s Morsel, many of you may have felt that I was unjust in my singling out dogs and cats as potential causes of trauma in our children. While they certainly are the most prevalent inflicters of pain and suffering for our patients who have had an unfortunate encounter with the wrong end of their sharp teeth and talons, there are also other animals who can be extremely dangerous. Having grown up with (and fallen off) many horses, I can certainly vouch for the potential trauma that come with equestrian interactions. Sure, horses do not generate as much “horsepower” as a motorcycle, but 8 year olds don’t typically ride Harleys. So, in an effort to raise our awareness, let us quickly review the potential Horse Related Injuries in Children:

 

Horse Related Injuries: Basics

Even though you may not be a “horse person,” asking what the breed of the horse involved was and what activity was (ex, steeplechase, trail riding, etc) can help you determine the mechanism.

  • The breed may affect the physics.
    • Hands High
      • Horses are traditionally measured in “Hands” – One hand = 4 inches.
        • The height of the horse is measured from the ground to the top of the withers (the bony prominence above the shoulders and at the base of the neck, near where the rider sits), not the top of the head.
        • A 5 foot (60 inch) horse would be 15 Hands High (60in divided by 4 inches = 15 hh).
        • Fun confusion – interesting trivia to know for “game night:”
          • Decimals are not fractions when discussing hands high. 
          • 15.1 = 15 hands, 1 inch
          • 15.2 = 15 hands, 2 inches (or 15 and a half hands)
          • 15.3 = 15 hands, 3 inches
          • 15.4 = 15 hands, 4 inches… which is 16 hh
          • 15.5 does not exist.
      • The average height of the horse is dependent upon the breed. [Reference.com]
        • American Quarter Horse average height – 15 hh
        • Draft horse average height – 18 hh (6 feet tall)
    • Weight
      • Once again, this depends on the breed.
      • Some adult horses may be as “light” as 750-900 lbs (ex, Appaloosa), while others can be from 1,000 – 2,000 lbs.
    • Speed
      • The breed also affects the speed and agility of the animal.
      • A Quarter horse can get up to 50 mph.
      • The gait (walk, trot, canter, gallop) of the horse also influences the speed (just like you can walk, jog, run, or sprint).
  • The mechanics matter too!
    • Obviously falling off while trail riding from a calm and serene horse is different then being flung from a rowdy and rambunctious mustang during a steeplechase. Physics just matter.
      • The former may be considered similar to toppling off of a ladder.
      • The latter is more akin to losing control of a motorcycle and being launched over a small building.
        • Cross-Country riding (which involves speed and jumps) has been associated with greatest percentage of injuries (~40%). [Bixby-Hammett, 1985]
        • Jumping also associated with high percentage of injuries (~22%). [Bixby-Hammett, 1985]
    • Being near a horse is hazardous too!
      • Non-riding activities like grooming, feeding, handling, shoeing, and saddling can still place a young child in harms way of an unpredictable horse.
      • 15-17% of injuries in one study were due to kicks. [Zoetsch, 2013; Barone, 1989]
      • Injuries to non-riders account for ~27% of horse related injuries. [Lang, 2014]
      • Non-riders frequently sustain injuries that require surgery. [Lang, 2014]

 

Horse Related Injuries in Children

  • Of farm related injuries, ~37.5% due to horses. [Smith, 2004]
  • Over 2 million children engage in Equestrian sports. [McCrory, 2005; Bixby-Hammett, 1985]
  • Inexperienced riders are ~5 times more likely to be seriously injured. [Cuenca, 2009]
  • Unfortunately, accidents occur and injuries can be significant. [Lang, 2014; Zoetsch, 2013; Cuenca, 2009; Smith, 2004; Barone, 1989; Bixby-Hammett, 1985]
    • Head Injuries and Maxillofacial Trauma are the most common injuries.
    • Orthopedic Injuries are the second most common set of injuries.
    • Abdominal Injury 
    • Chest Trauma
      • Pulmonary Contusion 
      • Pneumothorax
      • One case of Traumatic injury to the Tricuspid Heart Valve from a kick to the chest that ruptured the chordae. [Loar, 2016]
    • Polytrauma
  • For those that sustain an injury that requires evaluation in the ED, many will require hospitalization: more than 50% in one study. [Cuenca, 2009]
    • 18% required surgery
    • 27% required ICU level care
    • Average length of stay was 3.7 days.

 

Horse Related Injuries: Injury Prevention

  • Helmets are often underutilized and lack of helmet use is associated with more serious injuries. [Short, 2017; Cuenca, 2009]
  • Since facial and head injuries can occur even when not riding the horse (ex, kick to the face), some advocate for children wearing helmets with facial shields any time they are near horses. [Lang, 2014]
  • Novice riders and young children should be closely supervised when working around horses in the barns, fields, and show areas. [AAP, 1992; Barone, 1989]
  • Some advocate for protective vests, although clear evidence of their advantage is lacking. [Hessler, 2012]

 

Moral of the Morsel

  • Physics matters and Force = Mass x Acceleration. Horses have a lot of mass and can accelerate quickly! They may not mean to cause harm, but sometimes that doesn’t matter.
  • Details matter. Determine whether this was more like a 2,000 lb motorcycle becoming airborne or a slip off a 5 foot ladder.
  • Also take the time to educate. “Well, we can fix the broken arm… but now let’s talk about wearing that helmet!”

 

References

Short SS1, Fenton SJ2, Scaife ER3, Bucher BT4. Helmet under-utilization by children during equestrian events is associated with increased traumatic brain injury. J Pediatr Surg. 2018 Mar;53(3):545-547. PMID: 28365105. [PubMed] [Read by QxMD]

Loar RW1, Maskatia SA2, McLaughlin ES2, Mott AR2, Adachi I3, Fraser CD3. Complex Surgical Repair of a Flail Tricuspid Valve After Chest Wall Trauma in a Pediatric Patient. Ann Thorac Surg. 2016 Mar;101(3):e65-7. PMID: 26897232. [PubMed] [Read by QxMD]

Lang J1, Sathivelu M, Tetsworth K, Pollard C, Harvey K, Bellamy N. The epidemiology of horse-related injuries for different horse exposures, activities, and age groups in Queensland, Australia. J Trauma Acute Care Surg. 2014 Jan;76(1):205-12. PMID: 24368381. [PubMed] [Read by QxMD]

Hessler C1, Eckert V, Vettorazzi E, Meenen N, Jürgens C, Schult M, Flamme C, Herberhold HJ, Madert J, Ekkernkamp A, Lockemann U, Püschel K, Pohlenz P. Effectiveness of safety vests in pediatric horseback riding. Klin Padiatr. 2012 Nov;224(7):443-7. PMID: 23070863. [PubMed] [Read by QxMD]

Cuenca AG1, Wiggins A, Chen MK, Kays DW, Islam S, Beierle EA. Equestrian injuries in children. J Pediatr Surg. 2009 Jan;44(1):148-50. PMID: 19159733. [PubMed] [Read by QxMD]

McCrory P1, Turner M. Equestrian injuries. Med Sport Sci. 2005;48:8-17. PMID: 16247251. [PubMed] [Read by QxMD]

Smith GA1, Scherzer DJ, Buckley JW, Haley KJ, Shields BJ. Pediatric farm-related injuries: a series of 96 hospitalized patients. Clin Pediatr (Phila). 2004 May;43(4):335-42. PMID: 15118776. [PubMed] [Read by QxMD]

Ghosh A1, Di Scala C, Drew C, Lessin M, Feins N. Horse-related injuries in pediatric patients. J Pediatr Surg. 2000 Dec;35(12):1766-70. PMID: 11101733. [PubMed] [Read by QxMD]

Barone GW1, Rodgers BM. Pediatric equestrian injuries: a 14-year review. J Trauma. 1989 Feb;29(2):245-7. PMID: 2918566. [PubMed] [Read by QxMD]
Bixby-Hammett DM. Youth Accidents With Horses. Phys Sportsmed. 1985 Sep;13(9):105-17. PMID: 27410703. [PubMed] [Read by QxMD]

Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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