a b s t r a c t

Background: Although dog ownership may provide Health benefits, interactions with dogs and their leashes can result in injuries. The intent of this study was to describe dog leash-related injuries treated at United States (US) emergency departments (EDs).

Methods: Cases were dog leash-related injuries during 2001-2018 reported to the National Electronic Injury Sur- veillance System (NEISS), from which national estimates of dog leash-related injuries treated at US EDs were cal- culated. The distribution of the cases and estimated number of dog leash-related injuries was determined for selected variables, such as the circumstances of the injury, patient demographics, and diagnosis.

Results: A dog leash was involved in 8189 injuries, resulting in a national estimate of 356,746 injuries and an es- timated rate of 63.4 injuries per 1,000,000 population. Of these injuries, 193,483 resulted from a pull, 136,767 from a trip/tangle, and 26,496 from other or unknown circumstances. The total Injury rate per 1,000,000 popu- lation increased from 25.4 in 2001 to 105.5 in 2018. Adults accounted for 314,712 (88.2%) of the patients; 260,328 (73.0%) of the patients were female. The injury occurred at home in 133,549 (37.4%) cases. The most common injuries were 95,677 (26.8%) fracture, 92,644 (26.0%) strain or sprain, and 62,980 (17.7%) contusions or abra- sions.

Conclusion: The most common type of dog leash-related injuries resulted from a pull followed by a trip/tangle. The number of dog leash-related injuries increased during the time period. The majority of the persons sustaining such injuries were adults and female. Over one-third of the injuries occurred at home.

(C) 2020

Introduction

Various health and social benefits have been associated with pet ownership. These benefits include increased fitness and opportunities for socialization, lower stress, decreased blood pressure and cholesterol levels, and a reduction in feelings of loneliness [1,2]. According to the 2019-2020 American Pet Products Association (APPA) National Pet Owners Survey, 63.4 million households in the United States (US) owned a dog [3].

However, ownership of and interactions with dogs can result in inju- ries to humans. Dog bites account for an estimated average of 330,000 US emergency department (ED) visits annually [4]. Other dog-related injuries include tripping over or being pushed by a dog [5], dog- bicycle interactions [6], and falls resulting from dogs [7]. Moreover, there also may be injuries indirectly related to dogs, such as falling over a pet item or those from dog leashes [7-10]. A study of nonfatal un- intentional fall injuries relating to dogs and cats found that 9% of dog- related injuries occurred when the person fell over a pet item [7]. Dog

? This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

E-mail address: [email protected].

leashes can also cause Significant injuries, such as lacerations, burns, fractures, dislocations, and amputations [8-10].

Review of the published literature found one study that investigated injuries relating to walking leashed dogs; this study focused on fractures among elderly patients [11]. No published studies that examined inju- ries specifically associated with dog leashes under any circumstances were identified. The objective of this study was to use data from the Na- tional Electronic Injury surveillance System (NEISS) to describe dog leash-related injuries of any type among patients of all ages treated at hospital EDs. Several previous studies have examined dog-related inju- ries using NEISS data [6,7,11]; however, none of these studies specifi- cally examined injuries related to dog leashes.

Methods

This retrospective epidemiologic study utilized the NEISS, operated by the US Consumer Product Safety Commission (CPSC). The NEISS col- lects data on consumer product-related injuries in the US from the EDs of approximately 100 hospitals as a probabilistic sample of the N5000 hospitals with EDs in the US. The NEISS is a stratified sample based on ED size and geographic location. Information collected include the patient’s age, sex, race, ethnicity, injury diagnosis, body parts affected, and location where the injury occurred, among others [12]. Since the

https://doi.org/10.1016/j.ajem.2020.05.082

0735-6757/(C) 2020

data are publically available and de-identified, institutional review board approval was not needed.

The author downloaded NEISS data publically available at https:// www.cpsc.gov/cgibin/NEISSQuery/home.aspx for the years 2001-2018 and imported the data into a Microsoft Access database for case identi- fication. Cases were dog leash-related injuries included in the NEISS da- tabase during 2001-2018. Although the NEISS database includes two numeric fields for coding the product involved in the injury, there is no specific code for dog leashes. Code 1715 (Pet supplies) is not specific to dog leashes, and preliminary investigation indicated that dog leash- related injuries may be assigned other product codes. Thus, in order to identify cases, the author searched the Narrative_1 and Narrative_2 nar- rative text fields (fields that provide a brief summary of the circum- stances of the injury) of all records, including those not assigned product code 1715, for any mention of the word “leash.” For the resulting subset of records, the author individually reviewed the two narrative fields to determine whether the leash was described as a “dog leash” or a dog was otherwise mentioned. Records involving leashes for other types of animals or leashes not associated with a dog were excluded. Of the remaining records, those where the dog leash ap- peared to be directly involved in the injury were included in the study, whether or not the leash was attached to a dog, while records where the leash did not appear to be directly involved in the injury were excluded from the study. For example, records that stated the patient tripped over a leash, whether or not the leash was attached to a dog, were included while records that stated the patient tripped over a dog that just hap- pened to be on a leash were excluded.

The record narrative often provided a brief description of how the injury occurred. Upon initial review of the narratives of the records in- cluded in the study, the author found that these descriptions often contained similar or repeated terms or phrases that fell into several broad categories. As a result, the author grouped the injuries into these categories based on these terms or phrases:

Pull: The narrative included terms or phrases describing that the pa- tient was holding onto the leash and was pulled (jerked, yanked, dragged, etc.) by the dog or was pulling the dog. Included were in- stances where any part of the patient’s upper extremity was reported to be caught or wrapped in the leash whether or not being pulled was mentioned. Examples: “patient fell when pulled by dog leash,” “dog tugged on leash,” “sustained injury to finger after being wrapped and pulled in dog’s leash,” “leash got wrapped around her wrist.”

Trip/Tangle: The narrative included terms or phrases describing that the patient tripped over the leash or got caught or tangled in the leash (as long as the body part was not explicitly mentioned to be the upper extremity, in which case it was classified as a pull injury). Examples: “dog wrapped leash around patient’s leg, causing patient to fall down,” “tripped over dog leash,” “got legs tangled in dog leash and fell.”

Other/Unknown: The narrative included terms or phrases describing all other circumstances (being hit by the leash, strangled by the leash, the leash breaking, etc.). Examples: “struck in eye area by metal end of dog leash,” “hit in face by dog leash,” “patient fell when leash broke,” “patient was hit when retractable leash broke,” “patient was playing with dog leash and it got wrapped around neck.”

The author individually reviewed each record narrative and assigned each record into one of these three categories.

The variables examined were the circumstance of the injury, time of treatment (year, month, day of week), patient age and sex, location where the injury occurred, type of injury, body part affected, and patient disposition. For each variable, the national estimate of the number of in- juries was calculated for all records as well as for the pull and trip/tangle categories in the Microsoft Access database and exported to a Microsoft Excel file. The national estimate is based on a sample weight assigned to each case based on the inverse probability of the hospital being selected for the NEISS sample and is calculated by adding the numbers in the Weight numeric field for each record in the NEISS database. Using the Excel file functions, the distribution (percent of total) and 95%

confidence interval (CI) for the national estimate were calculated. The CPSC considers an estimate unstable and potentially unreliable when the number of records used is b20 or the estimate is b1200 [12]. Thus, the estimates for some of the variable subgroups may be unstable and potentially unreliable. For those variable subgroups where the estimate was b1200, no 95% CI was calculated.

For the analysis of treatment year, the estimated injury rate per 1,000,000 population was calculated for all records as well as for the pull and trip/tangle categories using the injury estimate by year and the total US population by year from the US Census.

Results

A total of 8189 dog leash-related injuries meeting the study criteria were identified during 2001-2018, resulting in a national estimate of 356,746 (95% CI 305,179-408,314) dog leash-related injuries, or an es- timated 63.4 dog leash-related injuries per 1,000,000 US population. Of the 356,746 injuries, 193,483 (95% CI 163,137-223,830) were classified as a pull, 136,767 (95% CI 114,229-159,304) as a trip/tangle, and 26,496 (95% CI 20,754-32,239) were for other or unknown reasons. The total injury rate per 1,000,000 population increased from 25.4 in 2001 to

105.5 in 2018. The pull injury rate increased from 11.5 in 2001 to 63.2

in 2018. The trip/tangle injury rate increased from 9.4 in 2001 to 36.5

in 2018 (Fig. 1).

When the patient demographics were examined (Table 1), the ma- jority of injuries were found to involve adults 20 years or older. The mean patient age of the total injuries was 49.6 years, pull injuries 47.6 years, and trip/tangle injuries 53.8 years. The majority of patients were female.

Table 2 presents various aspects of the time of treatment. The lowest proportion of injuries was reported during December-February. The highest proportion of injuries was treated on Saturday-Monday and the lowest proportion on Wednesday. These time patterns were ob- served for total injuries and for pull and trip/tangle injuries.

Of those cases where the location where the injury occurred was documented (Table 3), the majority occurred at home followed by a street or highway or other public property. The proportion of injuries that occurred at home was higher for trip/tangle injuries than for pull injuries. Table 4 shows the distribution of dog leash-related injuries by type of injury. The most common injuries in descending order among all injuries were fractures followed by sprains or strains and contusions or abrasions. The same was true for trip/tangle injuries while among pull injuries the most common injuries in descending order were sprains or strains followed by fractures and contusions or abrasions. The majority of pull injuries affected the upper extremity followed by the trunk and head and neck; roughly equal proportions of trip/tangle injuries affected the lower extremity and upper extremity while a lower proportion affected the head and neck.

Fig. 1. Annual estimated rate of dog leash-related injuries treated in United States emer- gency departments, National Electronic Injury Surveillance System (NEISS).

Table 1

Patient demographics of dog leash-related injuries treated at United States emergency departments, 2001-2018.

Variable	All injuries				Pull injuries				Trip/Tangle	injuries
	Est.	%	95% CI		Est.	%	95% CI		Est.	%	95% CI
Patient age (years)
00-05	10,373	2.9	7631-13,115		2531	1.3	1532-3530		5434	4.0	3742-7127
06-12	17,850	5.0	13,664-22,036		8067	4.2	5801-10,332		6903	5.0	4886-8920
13-19	13,812	3.9	10,390-17,233		8106	4.2	5832-10,380		4351	3.2	2907-5794
20-29	34,659	9.7	27,516-41,802		20,975	10.8	16,216-25,734		10,605	7.8	7816-13,394
30-39	42,278	11.9	33,870-50,687		25,998	13.4	20,343-31,653		12,884	9.4	9643-16,125
40-49	56,365	15.8	45,695-67,034		34,973	18.1	27,777-42,169		17,025	12.4	12,993-21,058
50-59	68,082	19.1	55,591-80,573		40,842	21.1	32,669-49,014		23,712	17.3	18,461-28,963
60-69	50,513	14.2	40,772-60,253		25,446	13.2	19,888-31,004		22,660	16.6	17,597-27,723
70-79	38,277	10.7	30,528-46,025		17,806	9.2	13,628-21,984		18,344	13.4	14,066-22,622
80+	24,539	6.9	19,141-29,937		8740	4.5	6334-11,147		14,849	10.9	11,228-18,470
50+	181,411	50.9	152,701-21,0121		92,834	48.0	76,619-109,050		79,565	58.2	65,327-93,802
Patient sex
Male	96,418	27.0	79,675-113,161		47,439	24.5	38,192-56,686		39,220	28.7	31,315-47,125
Female	260,328	73.0	221,115-299,542		146,045	75.5	122,207-169,882		97,547	71.3	80,638-114,455
Total	356,746		305,179-408,314		193,483		163,137-223,830		136,767		114,229-159,304

CI, confidence interval; Est., Weighted estimate - a national estimate based on a sample weight assigned to each case based on the inverse probability of the hospital being selected for the National Electronic Injury Surveillance System sample and calculated by adding the numbers in the Weight numeric field for each record in the NEISS database.

Table 2

Timing of treatment of dog leash-related injuries treated at United States emergency departments, 2001-2018.

Timing of treatment	All injuries				Pull injuries				Trip/Tangle	injuries
	Est.	%	95% CI		Est.	%	95% CI		Est.	%	95% CI
Season
December-February	69,304	19.4	56,625-81,983		39,017	20.2	31,146-46,888		26,110	19.1	20,435-31,785
March-May	95,341	26.7	78,756-111,925		48,913	25.3	39,429-58,397		39,247	28.7	31,338-47,156
June-August	97,627	27.4	80,706-114,547		53,259	27.5	43,081-63,437		35,824	26.2	28,485-43,163
September-November	94,475	26.5	78,018-110,933		52,295	27.0	42,270-62,320		35,585	26.0	28,286-42,884
Day of week
Sunday	54,723	15.3	44,313-65,133		30,273	15.6	23,875-36,670		20,387	14.9	15,734-25,039
Monday	53,452	15.0	43,243-63,660		30,367	15.7	23,954-36,781		20,012	14.6	15,428-24,597
Tuesday	48,044	13.5	38,699-57,388		25,710	13.3	20,105-31,314		18,041	13.2	13,819-22,262
Wednesday	46,744	13.1	37,609-55,878		25,468	13.2	19,906-31,030		17,551	12.8	13,420-21,681
Thursday	50,780	14.2	40,997-60,564		26,212	13.5	20,519-31,904		20,998	15.4	16,234-25,761
Friday	48,679	13.6	39,233-58,126		27,083	14.0	21,238-32,928		18,007	13.2	13,792-22,222
Saturday	54,325	15.2	43,978-64,672		28,371	14.7	22,302-34,440		21,771	15.9	16,868-26,675
Total	356,746		305,179-408,314		193,483		163,137-223,830		136,767		114,229-159,304

CI, confidence interval; Est., Weighted estimate - a national estimate based on a sample weight assigned to each case based on the inverse probability of the hospital being selected for the National Electronic Injury Surveillance System sample and calculated by adding the numbers in the Weight numeric field for each record in the NEISS database.

The majority of patients were treated or examined and released from the ED (Table 5). However, a higher proportion of patients with trip/tangle injuries than pull injuries were treated and admitted for hos- pitalization. Only one death was reported (for a national estimate of six). This was a person found hanging by a dog leash.

Discussion

This investigation using NEISS data found that over 350,000 dog leash-related injuries were estimated to have been treated at US EDs

during 2001-2018, resulting in over 60 estimated dog leash-related in- juries per 1,000,000 US population. Notably, the estimated rate of dog leash-related injuries increased during the time period. This was ob- served not only for total injuries but also for pull and trip/tangle injuries, although the rate was higher for pull injuries than for trip/tangle inju- ries. As a consequence, although the estimated rate of pull and trip/tan- gle injuries were similar in 2001, the estimated rate of pull injuries was 73% higher than the estimated rate of trip/tangle injuries in 2018. A study of fractures in elderly adults while walking leashed dogs using NEISS data found the estimated number of injuries increased from

Table 3

Location of dog leash-related injuries treated at United States emergency departments, 2001-2018.

Location All injuries Pull injuries Trip/Tangle injuries

	Est.	%	95% CI		Est.	%	95% CI		Est.	%	95% CI
Home	133,549	37.4	111,465-155,633		55,948	28.9	45,345-66,552		65,396	47.8	53,318-77,473
Street or highway	45,689	12.8	36,725-54,653		31,267	16.2	24,699-37,835		12,719	9.3	9510-15,928
Other public property	42,679	12.0	34,205-51,154		27,674	14.3	21,726-33,622		13,337	9.8	10,007-16,666
Place of recreation or sports	7994	2.2	5743-10,244		4686	2.4	3164-6208		2520	1.8	1524-3517
School	163	0.0	-		132	0.1	-		1	0.0	-
Not recorded	126,672	35.5	105,562-147,782		73,777	38.1	60,415-87,138		42,779	31.3	34,289-51,269
Total	356,746		305,179-408,314		193,483		163,137-223,830		136,767		114,229-159,304

CI, confidence interval; Est., Weighted estimate - a national estimate based on a sample weight assigned to each case based on the inverse probability of the hospital being selected for the National Electronic Injury Surveillance System sample and calculated by adding the numbers in the Weight numeric field for each record in the NEISS database.

The United States Consumer Product Safety Commission considers an estimate unstable and potentially unreliable when the estimate is b1200. For those estimates b1200, no 95% CI was calculated.

Table 4

injury type of dog leash-related injuries treated at United States emergency departments, 2001-2018.

Variable All injuries Pull injuries Trip/Tangle injuries

Est. % 95% CI Est. % 95% CI Est. % 95% CI

Type of injury

Fracture	95,677	26.8	79,043-112,311	52,600	27.2	42,527-62,674	39,942	29.2	31,918-47,966
Strain or Sprain	92,644	26.0	76,456-108,831	61,395	31.7	49,938-72,853	27,422	20.0	21,517-33,326
Contusions, Abrasions	62,980	17.7	51,276-74,683	26,631	13.8	20,865-32,397	29,956	21.9	23,613-36,299
Laceration	32,905	9.2	26,058-39,751	13,908	7.2	10,468-17,349	11,222	8.2	8309-14,134
Internal organ injury	15,644	4.4	11,872-19,417	5538	2.9	3822-7254	9589	7.0	7007-12,171
Dislocation	9471	2.7	6913-12,029	6801	3.5	4806-8796	2399	1.8	1434-3364
Concussions	3694	1.0	2406-4982	1199	0.6	-	2304	1.7	1364-3245
Avulsion	3390	1.0	2175-4604	2459	1.3	1478-3440	558	0.4	-
All other	40,343	11.3	32,252-48,433	22,952	11.9	17,836-28,067	13,375	9.8	10,038-16,712
Affected body part
Upper extremity	183,092	51.3	154,154-212,031	131,901	68.2	110,050-153,752	38,417	28.1	30,645-46,189
Lower extremity	61,809	17.3	50,288-73,331	15,624	8.1	11,856-19,392	41,382	30.3	33,120-49,643
Head/neck	60,233	16.9	48,957-71,509	22,057	11.4	17,102-27,012	31,280	22.9	24,710-37,850
Trunk	50,657	14.2	40,894-60,421	23,764	12.3	18,503-29,024	25,085	18.3	19,591-30,580
Other/unknown	955	0.3	-	138	0.1	-	603	0.4	-
Total	356,746		305,179-408,314	193,483		163,137-223,830	136,767		114,229-159,304

CI, confidence interval; Est., Weighted estimate - a national estimate based on a sample weight assigned to each case based on the inverse probability of the hospital being selected for the National Electronic Injury Surveillance System sample and calculated by adding the numbers in the Weight numeric field for each record in the NEISS database.

The United States Consumer Product Safety Commission considers an estimate unstable and potentially unreliable when the estimate is b1200. For those estimates b1200, no 95% CI was calculated.

1671 in 2004 to 4396 in 2017 [11]. As Americans try to lead healthier lifestyles, evidence of the health benefits of pet ownership might result in people walking dogs with leashes more, resulting in an increase in dog leash-related injuries. Also, people might have become more likely to own multiple dogs over the time period of the study; walking multi- ple dogs at the same time might increase the risk of dog leash injury. Further monitoring of NEISS data may prove useful for determining whether this annual trend continues.

Other temporal patterns were observed with the treatment of dog leash-related injuries. The injuries were seasonal, with injuries least likely to be reported during December-February. This might be ex- pected considering that people might be less likely to walk dogs during the colder winter weather. Moreover, injuries were more often treated on Saturday-Monday, possibly due to people having more free time on the weekends to walk their dogs, and thus become injured.

Relatively few of the patients were children and most were adults, particularly age 50 years or older. In contrast, a study of nonfatal unin- tentional fall injuries associated with dogs using NEISS data reported only 37% of the patients to be 55 years or older [7]. Because of the phys- ical requirements for walking dogs on leashes, particularly if the dogs are large, it might more likely for adults to walk dogs, consequently being the ones to sustain leash-related injuries. Of note, patients with trip/tangle injuries (mean age 53.8 years) were slightly older than pa- tients with pull injuries (mean age 47.6 years), suggesting that there may be an age component in the tendency to sustain the different types of dog leash-related injuries. older individuals might be more

likely to sustain injuries from tripping or tangling with a leash than being pulled by a leash.

In addition, the patients were more likely to be female, accounting for over 70% of all injuries. This was consistent with previous studies that examined dog-related injuries using NEISS data, which found the majority of patients to be female [7,11].

Since most of the dog leash-related injuries might be expected to occur while walking the dog, it might be expected for most of the inju- ries to occur away from home. However, the highest proportion oc- curred at home followed by a street or highway or other public property. Similarly, the study of nonfatal unintentional fall injuries asso- ciated with dogs found 62% of the injuries occurred at home [7]. The preponderance of injuries occurring at home may be related to the per- son being injured while setting out on or returning from a walk with the dog or occur while interacting with the dog at home or in their yard. This suggests that dog leash-related injury prevention activities might need to emphasize that such injuries are most likely to occur at home and not while out and about.

The pattern of injury differed by the circumstances of the injury. The most common pull injuries were sprains or strains followed by fractures and contusions or abrasions and most often affected the upper extrem- ity. In contrast, the most common trip/tangle injuries were fractures followed by contusions or abrasions and strains or sprains and most often affected the lower extremity followed by the upper extremity and head or neck, a pattern similar to that observed in the study of nonfatal unintentional fall injuries associated with dogs [7]. These

Table 5

Disposition of dog leash-related injuries treated at United States emergency departments, 2001-2018.

Disposition All injuries Pull injuries Trip/Tangle injuries

	Est.	%	95% CI		Est.	%	95% CI		Est.	%	95% CI
Treated or examined and released	331,918	93.0	283,492-380,345		183,929	95.1	154,876-212,981		122,523	89.6	102,004-143,043
Treated and admitted for hospitalization (within same facility)	19,213	5.4	14,775-23,651		7109	3.7	5048-9171		11,534	8.4	8559-14,509
Treated and transferred to another hospital	2817	0.8	1745-3890		962	0.5	-		1697	1.2	918-2476
Held for observation	1043	0.3	-		565	0.3	-		456	0.3	-
Left without being seen/Left against medical advice	1749	0.5	956-2542		918	0.5	-		557	0.4	-
Fatality	6	0.0	-		0	0.0	-		0	0.0	-
Total	356,746		305,179-408,314		193,483		163,137-223,830		136,767		114,229-159,304

CI, confidence interval; Est., Weighted estimate - a national estimate based on a sample weight assigned to each case based on the inverse probability of the hospital being selected for the National Electronic Injury Surveillance System sample and calculated by adding the numbers in the Weight numeric field for each record in the NEISS database.

The United States Consumer Product Safety Commission considers an estimate unstable and potentially unreliable when the estimate is b1200. For those estimates b1200, no 95% CI was calculated.

differences are most likely due to the manner in which these different circumstances of injury occur. A pull occurs while the person is holding onto or attached to the dog leash with their hand or arm. As a result, their upper extremity is most likely to be injured, and these injuries are most likely to be sprains or strains. Pull injuries might cause other types of injury and/or affect other parts of the body as the person strug- gles to maintain control of the dog or is pulled off their feet or dragged by the dog. A trip/or tangle is most likely to involve the legs or feet and result in such injuries as fractures or contusions or abrasions as the person falls or attempts to break their fall.

The majority of both pull and trip/tangle injuries were treated or ex- amined and released from the ED. The study of nonfatal unintentional fall injuries associated with dogs reported 92% of the patients to be treated and released from the ED [7]. However, in the present investiga- tion, a higher proportion of trip/tangle injuries (8.4%) than pull injuries (3.7%) were treated and admitted for hospitalization. This is likely re- lated to the observed differences in the types of injuries observed be- tween the two causes of injury.

The results of this study do not suggest ways to prevent dog leash- related injuries. However, precautions have been recommended by others to reduce or prevent dog leash-related injuries. Public awareness can be raised that certain activities involving dog leashes may lead to in- juries. Obedience training for dogs can be recommended to reduce be- haviors that may lead to leash injuries (e.g., pulling on the leash or running around the walker). People can be advised not to wrap the leash around their fingers or hand, use shorter leashes, not walk the dog while riding a bicycle, scooter, etc., wear appropriate shoes, and pay attention to their surroundings [7-9].

There are limitations to this study. Cases were identified by searching for “leash” in the electronic record narrative. Dog leash- related injuries where this term was not documented in the narrative would not be included in the investigation. In addition, the further se- lection of records to be included in the study and the sorting of them into the various circumstances of injury (pull, trip/tangle, other/un- known) was performed by a single person and based on the narrative, which contains a limited amount of information. Errors in the selection and classification of records may have resulted in records being in- cluded or excluded erroneously or misclassified. Only those dog leash- related injuries treated at EDs were included in the study. The number of such injuries not seen at EDs, i.e., managed at home or by a private physician, is unknown. Also, the estimates included in the study were based on a small subset of the EDs in the US. Furthermore, the NEISS da- tabase is a consumer product-related injuries database, so there may be some skepticism regarding its utility for analysis of dog leash-related in- juries. However, the NEISS database has been used extensively for other dog-related injury investigations [6,7,11]. Investigation of dog leash- related injuries from other data sources might prove useful to provide a more complete view of these injuries.

Conclusion

The most common type of dog leash-related injuries treated at EDs in the US was a pull followed by trip/tangle. The number of dog leash-

related injuries increased during the time period studied. The majority of the persons sustaining such injuries were adults, particularly adults 50 years or older, and female. The injuries most often occurred at home. The most common injuries were fractures followed by sprains or strains and contusions or abrasions and the most common Affected body parts were the upper extremity, head/neck, and lower extremity. The majority of patients were treated or examined and released from the ED. This information may be useful for targeting activities to reduce the risk of dog leash-related injuries.

CRediT authorship contribution statement

Mathias B. Forrester: Conceptualization, Methodology, Valida- tion, Formal analysis, Data curation, Writing - original draft, Writ- ing - review & editing.

Declaration of competing interest

None.

References

1. Centers for Disease Control and Prevention. About pets and people. April 15 https:// www.cdc.gov/healthypets/health-benefits/index.html; 2019. [Accessed 26 Septem-

   ber 2019].

   Dall PM, Ellis SL, Ellis BM, et al. The influence of dog ownership on objective mea- sures of free-living physical activity and sedentary behaviour in community- dwelling older adults: a longitudinal case-controlled study. BMC Public Health. 2017;17(1):496. https://doi.org/10.1186/s12889-017-4422-5.

2. American Pet Products Association. Pet industry market size and ownership statis- tics. http://www.americanpetproducts.org/press_industrytrends.asp. [Accessed 26 September 2019].
3. Loder RT. The demographics of dog bites in the United States. Heliyon. 2019;5(3): e01360. https://doi.org/10.1016/j.heliyon.2019.e01360.
4. Juang D, Sippey M, Zuckerbraun N, Rutkoski JD, Gaines BA. “Nonbite dog-related” in- juries: an overlooked injury mechanismin the pediatric population. J Trauma. 2011; 71(05):S531-3. https://doi.org/10.1097/TA.0b013e31823a4bb9 Suppl 2.
5. Loder RT, Yaacoub AP. Injuries to cyclists due to a dog-bicycle interaction. Vet Comp Orthop Traumatol. 2018;31(3):170-5. https://doi.org/10.1055/s-0038-1631879.
6. Stevens JA, Teh SL, Haileyesus T. Dogs and cats as environmental fall hazards. J Safety

   Res. 2010;41(1):69-73. https://doi.org/10.1016/j.jsr.2010.01.001.

   BBC News. Surgeons warn of serious hand injuries from dog leads and collars. https://www.bbc.com/news/health-48382570; 2019. [Accessed 26 September

   2019].

   Rush University Medical Center. Doggy danger. https://www.rush.edu/health- wellness/discover-health/preventing-dog-walking-injuries. [Accessed 26 Septem- ber 2019].

7. Consumer Reports News. Retractable leashes pose problems for people and their pets. https://www.consumerreports.org/cro/news/2009/03/retractable-leashes- pose-problems-for-people-and-their-pets/index.htm; 2009. [Accessed 26 Septem-

   ber 2019].

   Pirruccio K, Yoon YM, Ahn J. Fractures in elderly Americans associated with walking leashed dogs. JAMA Surg. 2019;154(5):458-9. https://doi.org/10.1001/jamasurg. 2019.0061.

8. United States Consumer Product Safety Commission. National Electronic Injury Sur- veillance System (NEISS). https://www.cpsc.gov/Safety-Education/Safety-Guides/ General-Information/National-Electronic-Injury-Surveillance-System-NEISS. [Accessed 1 October 2019].