Thương tích ở trẻ em: Tỷ lệ mắc và Phòng ngừa potx

Vol 9, No 6, November/December 2001
365
Recreational activities are important
for the normal healthy development
of children. The number of children
and adolescents participating in
sports and play activities continues to
increase each year. In the year 2000,
the eight recreational activities that
most commonly led to injury in chil-
dren aged 5 to 14 years accounted for
an estimated 2.24 million medically
treated musculoskeletal injuries, at a
cost to society of over $33 billion
1
(Fig. 1). Although many of these
injuries are minor and heal unevent-
fully, some can lead to permanent
impairment. Even minor injuries
cause anxiety and pain for both the
child and the parents, incur costs in
terms of time and money, and may
lead to functional restrictions.
Orthopaedic surgeons are fre-
quently involved in the diagnosis
and treatment of these injuries, but
less often in their prevention.
Parents consider their physicians to
be an important source of safety
education; therefore, orthopaedic
surgeons have a unique opportunity

to provide injury prevention advice.
Analysis of the frequency and cir-
cumstances of injuries related to
recreational activities has identified
areas for research and has led to in-
terventions that reduce and prevent
injuries in children. Such informa-
tion can provide physicians with
valuable resource materials for
patient education about the recre-
ational activities with the highest
number of injuries, detailing specific
hazards and emphasizing preven-
tion efforts.
Methodology
The most comprehensive statistics
on children’s recreational injuries are
available from the United States
Consumer Product Safety Commis-
sion (CPSC).
1
Since 1978, it has oper-
ated a statistically valid injury and
review system known as the Na-
tional Electronic Injury Surveillance
System (NEISS). The NEISS injury
data are gathered from a carefully se-
lected sample of 100 hospital emer-
gency departments in the United
States. Empirically derived relation-

ships between the number of injuries
evaluated in emergency departments
and those treated in other settings
(e.g., doctors’ offices and clinics) are
used to estimate the number of in-
juries treated outside hospital emer-
gency departments. The “Injury
Cost Model,” a computerized analyt-
ical tool designed to measure the
direct and indirect costs associated
with the reported injuries, is used to
estimate the four basic categories of
injury costs: medical, parental work
losses, pain and suffering, and prod-
uct liability and legal costs.
2
For the purpose of this article, the
term “child” is defined as an individ-
Dr. Purvis is Clinical Assistant Professor, De-
partment of Orthopaedic Surgery and Rehabili-
tation, University of Mississippi Medical School,
Jackson. Dr. Burke is Clinical Instructor, De-
partment of Orthopaedic Surgery and Rehabili-
tation, University of Mississippi Medical School.
Reprint requests: Dr. Purvis, Pediatric Ortho-
paedic Specialists of Mississippi, Suite 204,
1190 North State Street, Jackson, MS 39202.
Copyright 2001 by the American Academy of
Orthopaedic Surgeons.
Abstract

Participation in eight common types of recreational activities leads annually to
more than 2 million medically treated musculoskeletal injuries in children aged
5 to 14 years. Many of these injuries could have been prevented if current safety
guidelines and protective equipment had been used. Studies have demonstrated
the value of safety education programs in preventing injuries. Parents consider
their child’s physician an important source of safety education, and orthopaedic
surgeons have a unique opportunity to provide injury prevention counseling.
The American Academy of Orthopaedic Surgeons recognizes the importance of
injury prevention and has developed advocacy programs that are readily avail-
able to physicians and the public. Individual orthopaedists should be involved
in injury prevention through patient education, research, community programs,
and regulatory efforts that promote safe play for children.
J Am Acad Orthop Surg 2001;9:365-374
Recreational Injuries in Children:
Incidence and Prevention
John M. Purvis, MD, and Ronald G. Burke, MD
ual between the ages of 5 and 14
years. Unless otherwise noted, the
injury statistics are from the 2000
NEISS survey
1
and are an estimate of
the overall number of injuries treated
in hospitals, doctors’ offices, clinics,
ambulatory centers, and hospital
emergency rooms. The recreational
activities discussed specifically are
the eight with the highest total num-
ber of reported injuries but not nec-
essarily the highest rates of injuries.

Data on injuries sustained in both or-
ganized and unorganized sports,
team and individual sports, and in-
formal play activities have been ana-
lyzed. The injuries included are the
nonfatal, medically treated contu-
sions and abrasions, sprains and
strains, fractures, and dislocations
involving the extremities, neck, and
trunk that resulted from participa-
tion in a given activity in the year
2000 (Fig. 2).
General Strategies
Although the number of injuries for
certain activities, such as cheerlead-
ing, gymnastics, and winter sports,
may be relatively small, the risk of
injury may be quite high. For exam-
ple, boys’ and girls’ gymnastics
have the highest rate of catastrophic
injuries compared with all other
sports (Fig. 3).
3(p14)
It is recognized
that children and adolescents sus-
tain more injuries from free play
than from organized sports.
4
Also,
children are at risk for injury while

just attending sporting events (e.g.,
falling from bleachers), as well as
while traveling to and from such
events.
Injury-prevention strategies de-
veloped for the immature athlete
should consider the physical, men-
tal, and emotional differences be-
tween young athletes and their
adult counterparts. The prepartici-
pation physical examination for
organized sports is the first step in
injury prevention.
5
A task force of
several medical organizations has
developed a standardized form to
aid in administering a thorough
examination.
3(p56)
An accurate med-
ical history will identify any preex-
isting medical problems and should
serve as the cornerstone of the
examination. It is extremely impor-
tant that parents contribute to the
medical history. The American
Academy of Pediatrics (AAP) has
suggested guidelines for sports par-
Recreational Injuries in Children

Journal of the American Academy of Orthopaedic Surgeons
366
$4,500
$4,000
$3,500
$3,000
$2,500
$2,000
$1,500
$1,000
$500
$0
Total Cost, millions of dollars
Baseball/
softball
Basketball
Bicycling
Football
Play-
grounds
Roller
sports
Soccer
Trampo-
lines
Sprains/strains
Contusions/
abrasions
Fractures
Dislocations

Figure 1 Costs by type of musculoskeletal injuries to the extremities, neck, and trunk sus-
tained by children aged 5 to 14 years from the eight recreational activities with the highest
numbers of injuries during calendar year 2000. Data were obtained from Consumer
Product Safety Commission estimates of medically treated injuries. Cost estimates include
medical, parents’ work losses, pain and suffering, product liability, and legal. Roller
sports include those involving in-line skates, skateboards, scooters, and roller skates.
250,000
200,000
150,000
100,000
50,000
0
Number of Injuries
Baseball/
softball
Basketball
Bicycling
Football
Play-
grounds
Roller
sports
Soccer
Trampo-
lines
Sprains/strains
Contusions/
abrasions
Fractures
Dislocations

Figure 2 Incidence and type of musculoskeletal injuries to the extremities, neck, and
trunk sustained by children aged 5 to 14 years from the eight recreational activities with
the highest numbers of injuries during calendar year 2000. Data were obtained from the
NEISS report of the CPSC. Roller sports include those involving in-line skates, skate-
boards, scooters, and roller skates.
ticipation for children with certain
medical conditions.
3(pp448-453)
Head injuries and cardiac events
are the two most frequent causes of
sports fatalities. Therefore, cardio-
vascular screening should be em-
phasized during the preparticipa-
tion physical examination. Heart
auscultation during provocative
maneuvers (e.g., Valsalva) may fa-
cilitate the diagnosis of hyper-
trophic cardiomyopathy, the most
common cause of cardiovascular
system–related deaths on the play-
ing field. Improper strength train-
ing
6
and use of anabolic steroids
7
are other potential causes of injury.
Heat stroke is the third most
common cause of exercise-related
death among high school ath-
letes.

3(p65)
Children are especially
prone to heat-related illnesses be-
cause their thermoregulatory mech-
anisms are less efficient, they have
lower sweating rates, and they accli-
matize more slowly than adults. If
certain commonsense guidelines for
preventing heat illness
8
(Table 1) are
followed, the occurrence of heat-
related illnesses can be decreased.
General strategies to prevent
injury in all sports include proper
warm-up, stretching, conditioning,
and use of protective equipment.
Following guidelines based on age,
weight, and playing ability is partic-
ularly important for children who
are participating in team sports.
Although the use of braces or taping
can decrease ankle injuries, no con-
clusive studies demonstrate the
effectiveness of functional braces in
preventing noncontact anterior cru-
ciate ligament (ACL) injuries in the
knee.
9(p18)
It is also important that

parents and coaches have realistic
expectations of children’s perfor-
mance to avoid early burnout and
to prevent injuries that arise when
young athletes attempt to perform
beyond their limitations.
Basketball
Basketball is the most popular team
sport in high schools and is the
leading cause of sports-related in-
juries in the United States, based on
the total number of injuries sus-
tained. The NEISS statistics con-
firm that among children aged 5 to
14 years, basketball is second only
to bicycle riding in recreational in-
juries. Children playing basketball
suffered 407,000 medically treated
musculoskeletal injuries in the year
2000. The most common injury
sites were the ankles, hands, and
John M. Purvis, MD, and Ronald G. Burke, MD
Vol 9, No 6, November/December 2001
367
500,000
400,000
300,000
200,000
100,000
0

600,000
700,000
800,000
Number of Injuries
Bicycle
Musculoskeletal
injuries
All injuries
Basketball
Football
Roller sports
Playground
Baseball/softball
Soccer
Trampolines
Gymnastics
Snowboarding
Wrestling
Exercise activity
Snow skiing
Volleyball
Horseback riding
Cheerleading
Track and field
Swimming
Weight lifting
Diving
Figure 3 Incidence of musculoskeletal injuries compared with all injuries sustained by children aged 5 to 14 years from all recreational
activities during calendar year 2000. Data were obtained from the NEISS report of the CPSC. The musculoskeletal injuries included are
contusions/abrasions, sprains/strains, fractures, and dislocations to the extremities, neck, and trunk. Roller sports include those involv-

ing in-line skates, skateboards, scooters, and roller skates.
knees. Fractures were most fre-
quent in the fingers and ankles.
The total rates of injury for girls
and boys playing basketball were
equal for this age group.
3(p11)
How-
ever, young women aged 15 to 25
were 2.4 to 9.5 times more likely to
sustain a noncontact ACL injury
than young men in the same age
group.
9(p7)
Girls and young women
are also more likely to have ankle
sprains than boys and young men
are.
Key pieces of protective equip-
ment for basketball that have been
shown to reduce injury rates are
mouth guards, eye protection, and
ankle braces.
10
Functional knee
braces have not been shown to
reduce the incidence of noncontact
ACL injuries. Prevention is pri-
marily based on the development
of training programs aimed at

reducing ACL injuries. These pro-
grams emphasize training regi-
mens that target neuromuscular,
proprioceptive, and motor control
factors associated with ACL in-
jury.
9(p115)
Football
The collision sport most commonly
played by children in the United
States is football. In the year 2000,
an estimated 389,000 medically
treated musculoskeletal injuries
occurred in children playing both
organized and sandlot football.
1
As
in other contact sports, most mus-
culoskeletal injuries are sprains,
strains, and contusions.
11
This high-intensity, high-impact
sport also entails the risk of serious
head and neck injuries. Concus-
sions, which result in a transient
disruption of cognitive function,
occur frequently. Any athlete who
exhibits the signs and symptoms of
a concussion (Table 2) should be
removed from the playing field and

closely monitored. Return to play
can be considered for the athlete
with a first-time concussion and no
loss of consciousness. After 15 min-
utes of observation, if the player has
no signs or symptoms of a concus-
sion, he should be instructed to per-
form an activity that increases in-
tracranial pressure (e.g., sit-ups,
push-ups, Valsalva maneuver); if
asymptomatic during that activity,
the athlete can then return to com-
petition. Return to play should be
prohibited if there is any history of
loss of consciousness, recurrent con-
cussion, or signs and symptoms that
last for more than 15 minutes. The
“Standardized Assessment of Con-
cussion”
3(p175)
is a useful sideline
examination to help on-field med-
ical personnel evaluate for con-
cussion.
Recognizing head injuries in
young athletes is extremely impor-
tant because they are more suscep-
tible to the rare, but potentially
lethal, “second impact” syndrome.
This may develop if a second head

injury occurs before full recovery
from an initial head trauma. The
rapid onset of cerebral edema can
lead to death in seconds or min-
utes.
3(p172)
“Burners” (“stingers”) result
from a brachial plexus traction
injury or from cervical root com-
pression at the intervertebral fora-
men. Typically, a blow to the head
that depresses the shoulder and
flexes the neck to the opposite side
causes the injury. A transient, pain-
ful, burning sensation radiates from
the neck into the arm and hand of
the injured player. If the pain re-
solves without weakness or neuro-
logic deficit, the athlete can return
to play. If there are recurrent epi-
sodes or persistent symptoms, the
athlete should undergo further eval-
uation for cervical stenosis and de-
generative disk disease before re-
turning to the playing field.
12
Transient quadriparesis is a
spinal cord neurapraxia that leads
to paralysis followed by rapid re-
turn to normal function. The mech-

anism of injury is usually an axial
load on the cervical spine with a
component of hyperflexion or hyper-
extension. The athlete should be
removed from sports participation
until a thorough neurologic and
Recreational Injuries in Children
Journal of the American Academy of Orthopaedic Surgeons
368
Table 1
Guidelines for Preventing Heat Illness
*
Ensure proper acclimatization at the beginning of the workout session
Evaluate weather conditions for temperature, humidity, and sunlight
Schedule rest in the shade
Identify participants at particular risk
Hydrate before practice and competition
Have chilled fluids readily available at the practice site
Enforce periodic drinking
Never use water restriction as a form of discipline
Discourage deliberate dehydration for weight loss
Make appropriate clothing adjustments
Schedule events to avoid peak hours of heat and sun
Educate players and parents
Record daily weights to ensure adequate rehydration between practices
*
Reproduced with permission from Busch MT: Sports medicine in children and adoles-
cents, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics,
5th ed. Philadelphia: Lippincott Williams & Wilkins, 2001, vol 2, p 1275.
radiographic examination has been

performed.
12
Although organized football is a
hazardous sport, rule changes and
better equipment have made it safer.
New helmet design has led to a
decrease in head injuries and deaths.
Teaching proper tackling techniques
that avoid “spearing” can decrease
the incidence of spinal injuries.
Better education, supervision, and
coaching may also decrease the
number of injuries.
Baseball and Softball
Although the exact number of chil-
dren who participate in organized
and pickup games of baseball and
softball each year is unknown,
these are obviously extremely pop-
ular activities with wide participa-
tion. An estimated 160,000 med-
ically treated musculoskeletal in-
juries occurred in children in the
year 2000. Injuries in younger chil-
dren are most often due to impact
by the ball; older children incur
more acute injuries while sliding.
13
Young children (aged 5 to 10 years)
more commonly sustain acute

injuries to the head and neck re-
gion, whereas older children (aged
11 to 14 years) are more likely to
have injuries to their extremities.
Girls who play high school softball
have a higher injury rate than boys
who play high school baseball.
3(p11)
The most frequent anatomic loca-
tion for overuse injuries in children
who play baseball is the elbow.
14
“Little League elbow” is associated
with repetitive throwing and im-
proper technique. Sidearm throw-
ing by Little League pitchers is three
times more likely to cause elbow
symptoms than overhand throw-
ing.
15
Curveballs produce more
forces on the medial epicondyle and
joint area than overhand throw-
ing.
14
Whether throwing a curve-
ball at a young age has a detrimen-
tal effect on the elbow later in a
pitcher’s career is still controversial.
In general, however, young children

should avoid throwing sidearm and
throwing curveballs. At age 13 or
14, throwing a limited number of
curveballs is not harmful if there
has been adequate training in the
correct mechanics. By age 18, throw-
ing a curveball with regularity does
not seem to be associated with an
increased rate of injury. The associ-
ation between pitching frequency
and elbow symptoms is well docu-
mented. Although there are no con-
crete guidelines for the number of
pitches allowed, a general rule is to
limit the number of pitches thrown
at home and in practice and compe-
tition each week to 200 or fewer
(Table 3).
In 1995, the CPSC collected and
analyzed data on 162,100 children
treated in hospital emergency rooms
for baseball-related injuries.
16
Re-
view of these data identified three
types of safety equipment that
would reduce injuries. Face guards
on batting helmets and softer balls
can help reduce impact injuries, the
most common form of injury in chil-

dren. Use of breakaway bases can
reduce the number of base-sliding
injuries. Based on a study by Janda
et al,
13
the Centers for Disease Con-
trol and Prevention estimated that
as many as 1.7 million injuries for
all age groups could be prevented
each year, at a saving of $2 billion,
by using breakaway bases.
Although uncommon, baseball-
related deaths do occur in children.
From 1973 to 1995, the CPSC re-
ceived reports of the baseball-related
deaths of 88 children aged 5 to 14
years.
16
Thirty-eight deaths (43%)
resulted when ball impact to the
chest caused a sudden cardiac ar-
rest. This condition, known as com-
motio cordis, occurs with sudden
ventricular fibrillation.
17
Rapid rec-
ognition and immediate cardiopul-
monary resuscitation are necessary
to prevent a fatal outcome.
John M. Purvis, MD, and Ronald G. Burke, MD

Vol 9, No 6, November/December 2001
369
Table 2
Signs and Symptoms of
Concussion
*
Headache
Sleep disturbance
Dizziness
Confusion
Unsteadiness
Difficulty in concentrating
Disorientation
Loss of consciousness
Irritability
Amnesia (posttraumatic or
retrograde)
Hyperexcitability
Vomiting
Nausea
Visual disturbances
Tinnitus
Light-headedness
Fatigue
*
Reproduced with permission from
Smith BH: Head injuries, in Sullivan
JA, Anderson SJ (eds): Care of the
Young Athlete. Rosemont, Ill: Amer-
ican Academy of Orthopaedic Sur-

geons and American Academy of
Pediatrics, 2000, p 172.
Table 3
Pitching Recommendations for
Young Baseball Players
*
Maximum Maximum
Pitches Games
Age, yr per Game per Week
8-10 52 ± 15 2 ± 0.6
11-12 68 ± 18 2 ± 0.6
13-14 76 ± 16 2 ± 0.4
15-16 91 ± 16 2 ± 0.6
17-18 106 ± 16 2 ± 0.6
*
Reproduced with permission from
Pasque CB, McGinnis DW, Yurko-
Griffin L: Shoulder, in Sullivan JA,
Anderson SJ (eds): Care of the Young
Athlete. Rosemont, Ill: American
Academy of Orthopaedic Surgeons
and American Academy of Pediatrics,
2000, p 347.
Soccer
In the year 2000, soccer participation
resulted in an estimated 185,000
children’s musculoskeletal injuries,
1
with the most common diagnoses
being sprains and strains, followed

by contusions and fractures. Sprains
and strains frequently involve the
lower extremities, predominantly in
the ankle and knee. The upper
extremities are the site of most frac-
tures, with the majority occurring in
the wrists and fingers. Indoor soc-
cer players have higher injury rates
than outdoor soccer players.
18
Interestingly, female soccer play-
ers have higher injury rates than
male players,
19
with notably higher
rates of noncontact ACL injuries.
9(p5)
This is felt to be related to both dif-
ferences in anatomy and differences
in training. Boys’ and girls’ ACL
injuries occur more frequently in
soccer than in basketball.
3(p12)
Methods for decreasing soccer
injuries include the use of shin
guards, adequately secured and
padded goalposts, nonabsorbent
balls for wet playing fields, and
proper cleat selection. When young
athletes are playing in ideal weather

conditions, screw-in cleats are asso-
ciated with a higher risk of injury
compared with molded cleats or
ribbed soles. However, screw-in
cleats offer more traction on a wet
field with high grass.
The technique of “heading” the
ball has led to concerns about per-
manent cognitive impairment.
18
Further research is necessary before
a definitive recommendation can be
made about the safety of heading.
Coaches should minimize the use of
this technique in young athletes
until more information is available.
Fatalities from soccer-related
injuries are infrequent. When they
do occur, it is usually as a result of
player impact with a goalpost.
Falling goalposts accounted for 21
fatal injuries between 1979 and
1994.
18
Guidelines developed by
manufacturers and the CPSC should
be followed for properly securing
and padding goalposts.
Bicycling
Bicycle riding led to more muscu-

loskeletal injuries in children than
any other recreational activity in the
year 2000.
1
The CPSC estimated
that 415,000 musculoskeletal inju-
ries in children were associated with
bicycle riding. However, the actual
rate of participation is unknown;
thus, the rate of injury per partici-
pant or duration of participation
cannot be established. Boys had the
highest rate of injury. Contusions
were most common, followed by
fractures of the forearm and wrist.
A 1991 CPSC study of bicycle-
related injuries found that 17 of
every 1,000 riders aged 5 to 14 years
were treated in hospital emergency
rooms.
20
The most frequent hazard
patterns identified as being related
to injury were riding on uneven or
slippery surfaces, in nondaylight
hours, on city streets, and at exces-
sive speeds. Although most bicycle
injuries are related to falls, striking
fixed objects, and collisions with
other bicycles, 90% of deaths from

bicycle injuries are the result of col-
lisions with motor vehicles.
21
Most
injuries are attributable to rider
error due to lack of experience and
skill, rather than bicycle defects or
motorist error.
22
Community pro-
grams that emphasize bicycle safety,
teach riding skills, and increase hel-
met use can lower injury rates in
children.
23
Bicycle-related head trauma is an
important source of disability and
death. Helmets can decrease the
severity and incidence of head in-
juries. Studies show uniformly low
(1.4% to 16%) rates of helmet use
among children riding bicycles.
21,24
In states with mandatory helmet
laws, an association between a de-
cline in the proportion of severe
head injuries and increased helmet
use has been confirmed.
25
The Amer-

ican Academy of Orthopaedic Sur-
geons (AAOS) has issued a position
statement on bicycle and motorcycle
helmets, encouraging their utiliza-
tion and supporting laws that man-
date their use.
Playgrounds
Playgrounds developed from an
effort to keep children safely away
from city traffic. One of the first
public playgrounds was created in
1886 in Boston.
26
Current statistics
confirm that playgrounds are sec-
ond only to the home as the site
of unintentional injuries to chil-
dren.
26
In a study of playground
equipment–related injuries and
deaths, Tinsworth and McDonald,
27
of the Directorate for Epidemiology
at CPSC, estimated that of the
280,000 playground equipment–
related injuries treated in hospital
emergency rooms in 1999, 254,000
were musculoskeletal injuries. The
incidence was 34.8 injuries per

10,000 children. Fractures were the
most commonly reported injuries
(39% of the total number), with three
fourths involving the arm or hand.
Between 1990 and 2000, 147 deaths
associated with playground equip-
ment were reported to the CPSC.
27
The most frequent hazards were
hanging (82 deaths), falls (31), and
tip-over or collapse of equipment
(24). Seventy percent of the deaths oc-
curred at home while using back-
yard play equipment, not on public
playgrounds. The hanging deaths
involved entanglement in items
such as clothing drawstrings and
ropes that were not designed to be
part of the equipment.
Most injuries on public play-
grounds involve climbing equip-
ment; most of those at home loca-
tions involve swings. In the study
by Tinsworth and McDonald,
27
falls
were the most common mechanism
Recreational Injuries in Children
Journal of the American Academy of Orthopaedic Surgeons
370

of injury on both public equipment
(79%) and home equipment (81%).
In general, higher proportions of
arm and hand injuries occurred on
nonprotective surfaces than on
loose-fill surfaces or resilient mats.
The CPSC statistics point to the high
incidence of injuries from falls and
underscore the importance of pro-
tective surfacing beneath the equip-
ment.
In the past 20 to 30 years, there
has been greater emphasis on play-
ground safety. Several national or-
ganizations and agencies are actively
involved with investigating and pro-
moting playground safety (Table 4).
Trampolines
In the year 2000, children sustained
135,000 medically treated muscu-
loskeletal injuries while playing on
trampolines.
1
The overall usage of
trampolines is far lower than that of
all other recreational activities, but
the rate of injury is quite high. The
rates of injuries on large and small
trampolines were equal. Injuries
were most frequent on home tram-

polines. Sprains and strains occurred
predominantly in the lower extrem-
ities and were more frequent than
fractures, which had a higher inci-
dence in the upper extremities. In
general, lower-extremity injuries
were more common than upper-
extremity injuries.
The risk of serious injury to chil-
dren playing on trampolines has led
the AAP to recommend that tram-
polines never be used in the home
environment, in routine physical
education classes, or on outdoor
playgrounds.
28
The AAOS has
issued a position statement on tram-
polines and trampoline safety, rec-
ommending that trampolines should
be used only with parental super-
vision, that the jumping surface
should be at ground level, and that
all supporting bars and surrounding
landing surfaces should be padded.
Larson and Davis
29
recommend that
only one participant be on the tram-
poline at a time; that spotters should

be present when participants are
jumping; and that somersaults and
high-risk maneuvers should be
avoided unless there is proper su-
pervision and instruction.
John M. Purvis, MD, and Ronald G. Burke, MD
Vol 9, No 6, November/December 2001
371
Table 4
Sources of Information on Playground Safety
AAOS American Academy of Orthopaedic Surgeons
847-823-7186
www
.aaos.org
ASTM American Society for Testing and Materials
610-832-9585
www
.astm.org
Boundless Boundless Playgrounds
860-243-8315
www
.boundlessplaygr
ounds.org
CPSC Consumer Product Safety Commission
301-504-0990
800-638-2772 (toll-free)
800-638-8270 (TTY)
www
.cpsc.gov
IPEMA International Play Equipment Manufacturers Association

301-495-0240
800-395-5550 (toll-free)
www
.ipema.org
KaBOOM! KaBOOM!
312-360-9520
www
.kaboom.org
NPCA National Playground Contractors Association
888-908-9519 (toll-free)
www
.playground-contractors.org
NPPS National Program for Playground Safety
800-554-7529 (toll-free)
www
.uni.edu/playground/home.html
NRPA National Recreation and Park Association
National Playground Safety Institute
703-858-0784
www
.nrpa.org
NCIPC National Center for Injury Prevention and Control
Centers for Disease Control and Prevention
770-488-1506
www
.cdc.gov/ncipc
SAFE KIDS The National SAFE KIDS Campaign
Children’s National Medical Center
202-662-0600
www

.safekids.org
Roller Sports
Roller skates, in-line skates, skate-
boards, and scooters share many of
the same physical characteristics.
All have small-diameter wheels, can
achieve fairly high speeds, and are
propelled by the lower extremities.
In addition, their maneuverability
and stability depend a great deal on
operator experience and develop-
ment. Skateboards were first mar-
keted in the 1960s, and their utiliza-
tion and popularity have waxed
and waned since then, as have the
number of injuries.
30
In-line skating
was introduced in 1980 and has
become one of the fastest growing
recreational sports for children and
teenagers in the United States, with
a notable increase in related inju-
ries.
31
Foot-powered scooters were
first marketed in the 1960s. The
newer lightweight versions with
low-friction wheels have been asso-
ciated with a dramatic increase in

injuries for the year 2000.
32
The current NEISS data confirm
that 297,000 children sustained mus-
culoskeletal injuries from these four
activities in the year 2000.
1
The
highest number of injuries were due
to in-line skating. Of these, nearly
half were fractures, with most of
them occurring in the younger age
group (5 to 10 years). The most fre-
quent skateboard injuries were also
fractures, but these occurred more
frequently in the older age group
(11 to 14). Sprains and strains, con-
tusions, and fractures all had roughly
equal rates of occurrence for both
roller skating and riding on scooters.
The forearm and wrist were the most
common fracture locations for all
four activities, which emphasizes the
importance of wearing wrist guards.
Wrist guards have been proved
effective in protecting in-line skaters
in both case-control
31
and biome-
chanical studies.

33
Wearing helmets
that meet existing standards for
bicycle helmets has been recom-
mended for in-line skaters, as such
helmets have been proved to be
strongly protective against head
injuries in physical environments
quite similar to those of skaters.
31
Both the AAP
34
and the AAOS
advise the use of protective gear by
in-line skaters at all times, as well as
proper instruction, protected envi-
ronments for the novice, and avoid-
ance of traffic and road debris.
Scientific data about the efficacy
of safety equipment to protect
against scooter-related injuries are
lacking.
32
However, lessons learned
from similar activities, such as skat-
ing, suggest that reasonable safety
precautions should be observed,
such as wearing a helmet, using
protective knee and elbow pads,
riding on smooth surfaces without

traffic, and providing supervision
and training.
Summary
Play activities are important to the
healthy development of children.
However, injuries to children during
recreational activities frequently
result from their lack of physical
skills and cognitive development.
Therefore, their injury patterns are
different from those of adolescents
and adults. In general, children are
more likely to sustain upper-extremity
injuries, and lower-extremity inju-
ries are more frequent in adolescents
and adults. Children less than 10
years old incur more fractures and
catastrophic injuries (head injuries)
with individual recreational activi-
ties than they do with organized
sports.
3(p10)
Because their immaturity
limits their ability to learn the skills
that can help avoid accidents, fol-
lowing specific rules and using pro-
tective equipment are essential.
20
Epidemiologic studies have con-
firmed that injuries to children that

occur during recreational activities
can have marked consequences, and
that prevention methods can be suc-
cessful. Although the data from the
NEISS surveys are extremely valu-
able, they do not include direct
reporting from doctors’ offices and
urgent care centers, nor do they
include data on children who are
injured but do not seek medical
care. The NEISS data seldom in-
clude repetitive stress injuries and,
as is the case with other such sur-
veys, do not clearly identify injury
severity. Furthermore, comparable
data regarding numbers of partici-
pants in these activities are not read-
ily available to provide accurate rate
or incidence data. Therefore, the ex-
posure to risk for these injuries is
difficult to determine.
35
By assessing risks and trends that
impact children’s injuries, guide-
lines can be suggested that allow
parents, coaches, and physicians to
make informed choices about chil-
dren’s participation in sports. Safety
research as well as laboratory testing
of equipment could be most ef-

fectively guided by the analysis of
such data, particularly if there were
more extensive reporting and injury
severity classification. Intervention
in the form of equipment modifica-
tions, rule changes, safety guidelines,
product recalls, and legislation could
be based on such studies. The ulti-
mate benefit of these data is to reduce
and prevent injuries in children.
Estimates from the CPSC con-
cerning the total costs of children’s
recreational injuries are staggering
(Fig. 1). The projected amounts
(parents’ lost work, liability, pain
and suffering) beyond the medical
costs are frequently not appreciated
by treating physicians. As an exam-
ple, so-called “minor” sprains and
strains incurred by children playing
basketball in the year 2000 had an
estimated total cost of $2.2 billion.
1
Physicians can play a key role in
both the management and the pre-
vention of recreational injuries in
children. For the primary-care phy-
sician, it is important to promptly
determine the nature and extent of
the injury so that appropriate care

Recreational Injuries in Children
Journal of the American Academy of Orthopaedic Surgeons
372
can be given and the risk of perma-
nent disability can be lessened.
36
Even though primary-care physi-
cians and pediatricians are more fre-
quently in a position to provide
anticipatory counseling, orthopae-
dic surgeons should also be in-
volved in safety education, both at
the time of treatment and on a pro-
active basis. Furthermore, counsel-
ing about prevention of further in-
jury should be an integral part of
the treatment of the index injury.
Effective injury prevention pro-
grams for children’s recreational
activities should be based on com-
munity coalitions of physicians,
health-care organizations, public
and private agencies, manufacturers,
retail outlets, and the media.
37
Phy-
sicians can add validity to media
coverage by acknowledging the
importance of using protective gear
and other safety measures. Manu-

facturers and retailers can increase
the use of protective equipment by
lowering the cost and making it
more attractive and comfortable.
Prevention of injuries to children
is everyone’s responsibility and can
be achieved through a variety of
means, including patient education,
research, community programs, and
regulatory efforts, all of which pro-
mote safe play for children.
The AAOS recognizes the impor-
tance of injury prevention and has
developed advocacy programs that
are readily available to both physi-
cians and the public. The staff and
fellowship organize, sponsor, and
actually construct safe, accessible
playgrounds each year in host cities
of the AAOS Annual Meeting. The
AAOS also produces educational
materials that enable individual
orthopaedists to educate their com-
munity and patients.
John M. Purvis, MD, and Ronald G. Burke, MD
Vol 9, No 6, November/December 2001
373
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