Out on a limb: risk factors for arm fracture in playground equipment falls

Abstract

Objectives: To investigate and quantify fall height, surface depth, and surface impact attenuation as risk factors for arm fracture in children who fall from playground equipment. Design: Unmatched case control study. Setting: Five case hospitals and 78 randomly selected control schools. Participants: Children aged less than 13 years in Victoria, Australia who fell from school playground equipment and landed on their arm. Cases sustained an upper limb fracture and controls had minor or no injury. A total of 402 cases and 283 controls were included. Interventions: Children were interviewed in the playground as soon as possible after their fall. Main outcome measures: Falls were recreated on site using two validated impact test devices: a headform (measuring peak G and HIC) and a novel anthropometric arm load dummy. Equipment and fall heights, as well as surface depth and substrate were measured. Results: Arm fracture risk was greatest for critical equipment heights above 1.5 m (OR 2.39, 95% CI 1.49 to 3.84, p,0.01), and critical fall heights above 1.0 m (OR 2.96, 95% CI 1.71 to 5.15, p,0.01). Peak headform deceleration below 100G was protective (OR 0.67, 95% CI 0.45 to 0.99, p = 0.04). Compliance with 20 cm surface depth recommendation was poor for both cases and controls. Conclusions: Arm fracture-specific criteria should be considered for future standards. These include surface and height conditions where critical headform deceleration is less than 100G. Consideration should also be given to reducing maximum equipment height to 1.5 m. Improved surface depth compliance and, in particular, guidelines for surface maintenance are required. P lay is essential to child development; however playgrounds can also pose serious safety risks. Where contributing factors are known, falls from playground equipment are the leading cause of all child fall related hospitalization in Australia.1 Upper limb fracture is the most common playground injury, accounting for 43% of emergency department presentations and 74% of hospital admissions.2 3 Playground injury is moderately severe, with 22% of children presenting to emergency departments and 32% of those with arm fracture requiring hospitalization.

The Potential for Brain Injury on Selected Surfaces Used by Cheerleaders

“…These authors noted that fall heights higher than 2 ft (0.61 m) posed a significant risk for wrist fractures, 33 and the risk for arm fractures increased for fall heights above 3.3 ft (1.01 m) and peak deceleration above 100g. 11 However, none of these researchers presented conclusive data.…”

“…Using these critical heights as guidelines to select an appropriate cheerleading surface may not ensure protection from other types of injuries. Studies 8,10,11,33 have been conducted to determine the critical height for fractures. These authors noted that fall heights higher than 2 ft (0.61 m) posed a significant risk for wrist fractures, 33 and the risk for arm fractures increased for fall heights above 3.3 ft (1.01 m) and peak deceleration above 100g.…”

“…C onsiderable attention has been given to establishing safety thresholds for playground surfaces with respect to fall impact attenuation, [1][2][3][4][5][6][7][8][9][10][11][12] yet to date, nothing has been published regarding the impact attenuation of surfaces that cheerleaders use for practices and performances. Head impact injuries from a fall have the potential to be life threatening.…”

Epidemiology of Cheerleading Fall-Related Injuries in the United States

“…One forearm fracture was sustained in the present study, and it occurred at a height of 4 ft (1.22 m), which was above the fall height at which the risk for arm fractures is greatest (3.3 ft [1.01 m]) 14 and at the critical height for the surface upon which the cheerleader was performing. Although the critical height is specifically related to the risk for a serious head injury, 80% (12/15) of the most serious types of injuries sustained by cheerleaders in our study occurred at or above the critical height for the surface on which the cheerleader was performing at the time of injury: concussion or CHI (100%, 5/5), dislocation (67%, 4/6), fracture (50%, 1/2), and ACL tear (100%, 2/2).…”

“…The recommended maximum height for playground equipment ranges from 4.9 ft (1.5 m) 13,14 to 6.6 ft (2 m). 12 Fall heights of more than 2 ft (0.6 m) pose a significant risk for wrist fracture 15 ; arm fracture risk is greatest for fall heights above 3.3 ft (1 m) 14 ; and fall height is an important consideration when assessing the risk of sustaining a fatal head injury. 16 In the study by Boden et al, 9 the type of surface on which the injured cheerleader was performing was known for 74% (29/39) of the catastrophic injury cases described.…”