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 References 1. US Consumer Product Safety Commis- sion: NEISS Coding Manual, 2000: National Electronic Injury Surveillance System. Washington, DC: US Consum- er Product Safety Commission, 2000. 2. US Consumer Product Safety Commis- sion, Directorate for Economic An- alysis: Injury Cost Model Description. Washington, DC: US Consumer Pro- duct Safety Commission, March 2001. 3. Sullivan JA, Anderson SJ (eds): Care of the Young Athlete. Rosemont, Ill: American Academy of Orthopaedic Surgeons and American Academy of Pediatrics, 2000. 4. 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