Pediatrics

Pediatric all-terrain vehicle (ATV) related head injury rates and patterns: A 10-year nationwide analysis

a b s t r a c t

Introduction: The use of all-terrain vehicles (ATVs) carries significant risk of permanent injury and death, disproportionately affecting children. These injuries commonly affect the head and are especially severe among children as they are often unhelmeted and more likely than adults to experience rollover injuries. Many studies examining patients with ATV-related injuries are single-center cohort studies, with few focusing specifically on head injuries. In the present study, we aimed to characterize the annual incidence of ATV- related head injuries between 2012 and 2021, classify and compare head injury types, and identify descriptive characteristics of ATV-related head injury victims.

Methods: Using the US Consumer Product Safety Commission’s National Electronic Injury surveillance System (NEISS) database, we queried all head injuries associated with operating or riding an ATV in children under 18 years-old from over 100 emergency departments (EDs). Patient information regarding age, race, sex, location of incident, diagnoses, and sequelae were analyzed. We also collected the estimated number of ATV-related head injuries from all US EDs using the NEISS algorithm provided by the database.

Results: Using the NEISS algorithm we identified 67,957 (95% CI: 43,608 – 92,305) total pediatric ATV-related head injuries between 2012 and 2021. The annual incidence of ATV-related head injury was similar throughout this study period except for a 20% increase during the COVID-19 pandemic period of 2019-2021 (2019: 6382 in- juries, 2020: 6757 injuries, 2021: 7600 injuries). A subset of 1890 cases from approximately 100 EDs were then analyzed. Unspecified Closed head injuries were the prevailing type of injury (38%, 900/1890), followed by concussions (27%, 510/1890). More severe injuries included intracranial hemorrhages in 91 children (3.8%, 91/ 1890). Injuries of all types were predominantly seen in 14-17 year-old’s (780/1890, 41%) and in males (64.1%, 1211/1890). In addition, ATV-Associated injuries were significantly more common in those coded as white (58.0%, 1096/1890) than any other racial group. ATV-associated accidents among children younger than 9 more commonly occurred at the home compared to accidents involving children older than 9 (57% vs. 32%, p < 0.0001).

Conclusion: ATV-related head injuries cause a significant annual burden among children, with growing incidence in recent years. Further research may wish to explore potential benefits of helmet use and supervision of Younger children in possible prevention of these accidents and their associated economic and non-economic costs.

(C) 2023 Published by Elsevier Inc.

  1. Introduction

Abbreviations: ATV, all-terrain vehicle; ED, emergency department; NEISS, National Electronic Injury Surveillance System.

* Corresponding author at: Department of neurosurgery, Rhode Island Hospital, 593 Eddy St, Providence, RI 02903, United States of America.

E-mail address: [email protected] (P.Z. Sullivan).

The use of both recreational and commercial all-terrain vehicles (ATVs) carries a significant risk of injury and death, disproportionately affecting children [1]. These injuries in children are severe, as children are often unhelmeted and more likely than adults to experience rollover injuries caused by ATVs without crush protection devices (CPDs) such as metal cages [2-4]. ATV-related injuries in children may even be more severe than injuries associated with motor vehicles, dirt bikes,

https://doi.org/10.1016/j.ajem.2023.02.007 0735-6757/(C) 2023 Published by Elsevier Inc.

and snowmobiles possibly due to ATVs’ higher center of gravity and increased weight [5-7]. Emergency department (ED) visits for ATV- related injuries are increasing and are estimated to account for 3.4% of all ED admissions with over 30,000 visits annually [8-10]. Additionally, the costs associated with ATV-related injuries are possibly as high as

$1 billion per year in the United States [8,11,12]. Regarding fatalities, ATV-related deaths affect 0.32 persons per 100,000 in the United States [11]. Between 1982 and 2010, the US Consumer Product Safety Commission reported 11,001 ATV-related fatalities, with 25% of these involving children under the age of 16 [13].

The mechanisms of ATV injuries are most frequently entrapment due to ATV rollover, loss of control when moving at high speeds, and collision with stationary or moving objects, with the latter two mechanisms, frequently causing ejection from the vehicle [1,14]. These injuries com- monly involve the head and spine [6]. Among all types of ATV-related injuries, those involving the brain and spine are most commonly associ- ated with death and frequently result in permanent neurologic deficit [8,15].

To better understand the nature of ATV-related head injuries and inform potential policy solutions, we sought to comprehensively review the types, incidence, and patterns of these injuries that presented to EDs across the United States using the US Consumer Product Safety Commis- sion’s National Electronic Injury Surveillance System database. Given that ATV injuries disproportionately affect children and children are more likely to incur severe injury, we focused our search on patients under the age of 18 [3,16,17]. Furthermore, many studies examining pa- tients with ATV-related injuries are single-center cohort studies with few focusing specifically on head injuries, which are more commonly associated with mortality [1,4,15,18-23]. Therefore, we sought to query a nationally representative database to more accurately and broadly track and classify ATV-related head injuries. Furthermore, pre- vious studies have focused on limited years of incidence and/or utilized data from single states. In this study, we therefore analyze injury pat- terns over a ten-year period using data from EDs across the country [24-26]. Using our findings, we hope to increase the knowledge regard- ing ATV-related injuries, raise patient and parent awareness and inform potential policy interventions to curb preventable injuries among children.

  1. Methods
    1. Information regarding the NEISS database

Patient records were collected from the NEISS database, a national database that collects consumer product-related injuries, organized by the United States Consumer Product and Safety Commission. There are about 100 EDs nationwide that contribute patient data to this database, and from this data, nationally representative probability samples can be estimated for the over 5000 EDs in the United States [27]. Numerous studies have utilized this database for research purposes, and the con- tents of this database have been extensively described and shown to be reliable [28-34].

The NEISS database allows users to construct queries for specific injuries that can be organized by the body parts injured, age of the patients, the year the injury occurred, and causes of injury. For this study, the authors investigated all ATV-related head injuries from operating an ATV (i.e., collisions and falls from ATV) between the years 2012-2021 in pediatric patients aged 0-17 years old (Product Codes: 3296, 3287, 3286, 3285; Body Part Code: 75). These product codes include the following types of ATVs: more than four wheels, exclusively off-road; number of wheels unspecified/off-road; four wheels/off-road only; and three wheels/off-road only. Age was stratified into four age groups: 0-3-year-olds, 4-8-year-olds, 9-13- year-olds, and 14-17-year-olds. The mechanisms of injury included were operator or passenger falls/rollovers from ATVs, or operator or passenger collisions with stationary or moving objects. All other

mechanisms of injuries involving ATVs were excluded such as other conditions that may have developed while riding the ATV unrelated to the ATV itself. Provided case narratives were used to determine the spe- cific mechanism of injury. We also collected the estimated number of ATV-related head injuries from all US EDs using the NEISS algorithm provided by the database.

    1. Location of incident, diagnoses, and sequelae

Before data collection, two reviewers (AG and EK) convened to input data for the first 50 patients to elucidate and refine the methodology for determining the specific diagnoses and sequelae for each patient. Although the primary Diagnosis codes are available and provided by NEISS, the accuracy of these codes was shown to be around 70% in a previous study [35]. Therefore, the accompanying narrative for each patient was reviewed and the diagnoses for each patient were assigned based on the narratives only, as they provide a greater wealth of information and patients may have had more than just one di- agnosis and/or sequelae. Patients were assigned to at least one of the following diagnoses: (1) closed head injury, (2) Skull fracture, (3) con- cussion, (4) laceration, (5) abrasion, (6) contusion, (7) intra-axial bleed- ing (e.g., Intraparenchymal hemorrhage), (8) extra-axial bleeding (e.g., epidural, subdural, or Subarachnoid hemorrhages), and (9) hema- toma. Closed head injuries included unspecified closed head injuries, unspecified Traumatic brain injuries, and any descriptions of blunt force trauma to the head that resulted in non-specific head injuries. Diagnoses were coded in this manner to allow for rarer injuries (i.e., subarachnoid hemorrhages) to be subsumed into larger categories. If present, post-traumatic sequelae were noted as follows: (1) loss of consciousness, (2) vomiting, (3) and seizures. Analysis regarding the location of the incident was conducted based on the location codes provided for each patient case. The category of “other” location encom- passed farms, ranches, and schools. Helmet use, when available in provided case narratives, was also collected for each patient.

    1. Statistical analysis

Pearson’s Chi-squared test was used to compare frequencies between groups. Simple linear Regression modeling was utilized to investigate any changes over time in the volume of head injuries associated with ATV operation. Statistical significance was defined as p < 0.05. Analysis was conducted using Microsoft Excel (version 2016; Microsoft, Redmond, WA, USA) and GraphPad Prism (version 8.0.0 for Windows, GraphPad Software, San Diego, California USA, www. graphpad.com).

  1. Results
    1. National estimates and characteristics of analyzed sample

Using the provided NEISS algorithm to estimate the national incidence of ATV-related injuries, a total of 67,957 (95% CI: 43,608- 92,305) head injuries were estimated in children under 18 between 2012 and 2021. During this study period, there was no significant trend regarding the volume of ATV-related head injuries (Fig. 1). The national incidence of ATV-related head injury remained stagnant from 2012 to 2015 and then fluctuated from 2016 to 2021. National estimates of Injury incidence are listed in Table 1. There was a significant trend across the entire study period, however, incidence did increase by 19% from 2019 (pre-COVID-19) to 2021 (2019: 6382 injuries; 2020: 6757

injuries; 2021: 7600 injuries).

Upon conducting the NEISS query for a subset of specific cases from approximately 100 hospitals, a total of 1894 head injuries associated with ATVs were available for detailed analysis. Four of these cases were excluded from the analysis given their mechanisms not being directly related to ATV use. Two excluded cases involved insect bites

Image of Fig. 1

Fig. 1. Trends in pediatric ATV-related head injuries from 2012 to 2021.

that occurred while operating the ATV, one described headache after rid- ing an ATV without any collisions or falls that could have produced acute injury, and one involved a patient conducting repairs underneath an ATV and subsequently hitting their head on the ATV when standing up.

The cases that were included for analysis were relatively diverse in terms of age (Table 1). ATV-related head injuries were predominantly seen in males (64.1%, 1211/1890), and head injuries were more com- mon in males in every age group. ATV-related injuries were significantly more common in those coded as White (58.0%, 1096/1890) than any other racial group.

Table 3 describes the types of head injuries that followed reported ATV accidents. Of the 1890 total cases, 479 had at least two of the diag- noses listed in Table 3. Almost half of the cases suffered a non-specific closed head injury (47.6%, 900/1890). Closed head injuries were the prevailing injury in all four age groups. Concussions, a type of closed head injury, were the second-most common head injury after an ATV accident, occurring in 27% (510/1890) of all individuals. Lacerations (18.4%, 348/1890), abrasions (7.1%, 134/1890), contusions (8.9%, 168/ 1890), and Skull fractures (8.8%, 166/1890) were also prevalent among the studied cohort. Hematomas were one of the least commonly seen head injuries associated with ATVs (3.3%, 79/1890). Intra-axial bleeding (1.1%, 27/1890) and extra-axial bleeding (2.7%, 64/1890) were also observed. The relative distribution of head injuries in different age groups also tended to mirror that of the overall cohort, with closed head injuries being the most common across groups.

Around 1 in 10 (11.2%, 213/1890) individuals were reported to have lost consciousness immediately after the ATV accident, representing the most common acute neurological, post-traumatic sequelae associated

Table 1

National ATV-related head Injury estimates by year.

Year

National Estimate

95% CI lower bound

95% CI Upper Bound

2012

6883

4227

9539

2013

6894

4828

8961

2014

6942

3793

10,090

2015

7096

4147

10,045

2016

6013

3470

8556

2017

8144

5039

11,249

2018

5246

3069

7423

2019

6382

4070

8693

2020

6757

4137

9377

2021

7600

3654

11,546

with ATV-related head injury. Although rare, some cases were reported to have emesis episodes following the trauma (1.4%, 26/1890). Seizures were rarely seen following head injury among the study sample (0.4%, 8/1890). Table 2. Regarding helmet use, relevant data was available in case narratives for only 673 (35.6%) patients. Of these, 422 (62.7%) were reported not to be wearing helmets at the time of the accident.

    1. Location of incident and disposition from the emergency department

Of the 1890 total cases, 994 (52.6%) cases were not assigned a code describing the location of the incident. Among the known 896 (47.4%) cases, most injuries occurred at home. Overall, second to ATV-related head injuries at home, ATV-related head injuries occurred at places of recreation (242, 12.8%). A majority of patients (72.4%, 1368/1890) were released following examination and treatment in the ED. Many patients (21.3%, 403/1890) were admitted to the hospital and subse- quently treated. Less commonly, patients were treated and transferred (3.7%, 69/1890), held for observation but not admitted (1.9%, 35/ 1890), or left the emergency department without being seen (0.4%, 9/ 1890). Six patients (0.3%, 6/1890) died either upon arrival at the ED or during their clinical course.

  1. Discussion

The main purpose of this study was to classify and track the inci- dence of ATV-related head injuries among children under 18 in the United States using data provided by the US Consumer Product Safety Commission from 2012 to 2021. The present study aims to fill gaps in the literature, as many studies examining ATV-related head injuries are limited to single-center cohorts without a specific focus on head injuries. Additionally, as ATVs become heavier and faster, with some models capable of reaching over 65 miles per hour and weighing over 750 pounds, understanding injury patterns to improve safety is paramount [11,20,36].

We found that ATV-related head injuries occurred most commonly in 14-17 year-olds and among males, with both of these findings mir- rored in similar studies [23,37-39]. Regarding yearly national estimates of head injuries associated with operating ATVs, we found no consistent trend between 2012 and 2021. This result was surprising, as overall injuries seen in EDs associated with ATVs have been increasing, likely indicating an increase in overall usage of ATVs [8-10]. The factors con- tributing to this finding are unclear. Perhaps more individuals are wear- ing helmets or employing safer riding practices, offsetting the increase in overall usage of ATVs and the concomitant increases in ATV-related head injuries. There was no generalizable trend observed from 2012 to 2021. However, the incidence of head injuries increased by approxi- mately 20% from 2019 to 2021, during the COVID-19 pandemic. This may be due to the socially distanced nature of ATV riding coupled with an increased desire for outdoor activity caused by fears surround- ing the pandemic. This increase in ATV-related head injuries during COVID-19 was also described by advocacy groups, state governments, and health systems, who additionally reported increased sales and use of ATVs [40-42]. The Consumer Federation of America, a non-profit col- lective comprised of over 300 groups, also noted that 16 states reported increased ATV injuries between 2020 and 2021 [43].

In our studied cohort, head injuries were predominantly observed in males. This finding is consistent with other similar studies investigating the epidemiology of other sports- and recreation-related head injuries beyond just those associated with ATV use [44,45]. The most common types of head injury were closed head injuries/concussions (58%), followed by lacerations, contusions, and abrasions (27%), with more se- vere injuries of extra- and intra-axial hemorrhages comprising only a small fraction (4%) of the cohort. Despite this low incidence of intracra- nial hemorrhages, they bring to light the possible severity of ATV accidents. Other studies that have investigated head injuries in ATV crashes in single-center cohorts identified similar patterns [4,20,46-49].

Table 2

Patient Demographics and Disposition.

Total

14-17 years-olds

9-13 years-old

4-8 years-old

0-3 years-old

n (%)

n (%)

n (%)

n (%)

n (%)

Sex

Male

1211 (64.1)

472 (60.5)

412 (66.1)

257 (68.2)

70 (63.6)

Female

679 (35.9)

308 (39.5)

211 (33.9)

120 (31.8)

40 (36.4)

Race

White

1096 (58.0)

455 (58.3)

361 (57.9)

215 (57.0)

65 (59.1)

Black

101 (5.3)

31 (4.0)

34 (5.5)

31 (8.2)

5 (4.5)

Asian

7 (0.3)

3 (0.4)

3 (0.5)

0

1 (0.9)

American Indian/Alaska Native

10 (0.5)

2 (0.3)

6 (1.0)

1 (0.3)

1 (0.9)

Native Hawaiian/Pacific Islander

1 (0.1)

1 (0.1)

0

0

0

Other

170 (9.0)

85 (10.9)

55 (8.8)

23 (6.1)

7 (6.4)

Not Stated

505

203 (26.0)

164 (26.3)

107 (28.4)

31 (28.2)

Location of Incident

Home

344 (18.2)

94 (12.1)

119 (19.1)

93 (24.7)

38 (34.5)

Street or Highway

147 (7.8)

77 (9.9)

48 (7.7)

17 (4.5)

5 (4.5)

Other Public Property

149 (7.9)

79 (10.1)

47 (7.5)

20 (5.3)

3 (2.7)

Place of Recreation

242 (12.8)

121 (15.5)

68 (10.9)

45 (11.9)

8 (7.3)

Other

14 (0.7)

5 (0.6)

8 (1.3)

0

1 (0.9)

Unknown

994 (52.6)

404 (51.8)

333 (53.5)

202 (53.6)

55 (50.0)

Disposition

Released Following Examination and Treatment

1368 (72.4)

557 (71.4)

434 (69.7)

291 (77.2)

86 (78.2)

Treated and Transferred

69 (3.7)

22 (2.8)

29 (4.7)

14 (3.7)

4 (3.6)

Treated and Admitted

403 (21.3)

182 (23.3)

141 (22.6)

64 (17.0)

16 (14.5)

Held For Observation

35 (1.9)

12 (1.5)

15 (2.4)

6 (1.6)

2 (1.8)

Left without being seen/Left Against Medical Advice

9 (0.4)

4 (0.5)

1 (0.2)

2 (0.5)

2 (1.8)

Died

6 (0.3)

3 (0.4)

3 (0.5)

0

0

Total

1890

780

623

377

110

Unfortunately, the NEISS database did not contain consistent data on helmet wearing during the reported injuries thus precluding further analysis. However, of the cases with included helmet information, we found that about two-thirds of cases involved unhelmeted riders. Nevertheless, significant evidence shows that helmets can decrease the incidence of head injuries, injury severity, and hospital stays, with one study estimating that helmets lower the risk of mortality by 42% and the risk that an injury involves the head by 64% [20,50-54]. Helmet use has also been shown to correlate with a decreased incidence of con- cussions, which was the most common injury in the present cohort [46,50,55]. Given the social and economic impacts of concussion in children, understanding the utility of helmet use may be a potentially important area of future research aimed at reducing ATV-related head injury. The financial healthcare-related cost related to concussion is es- timated to be around $800 per Pediatric concussion, with significant non-economic costs as well including missed days of school, extended cognitive Recovery times, transportation to medical appointments,

parents missing work, and the possibility of long-term sequelae such as post-concussion syndrome [56-59].

Despite the efficacy of helmets in reducing rates of Traumatic brain injury , compliance with helmet use remains low, and even people with previous injuries ATV-related are still unlikely to use a helmet [1,60]. Some states mandate helmet use for ATVs in state codes, but hel- met laws vary widely between states and helmet usage has previously been reported to only be between 10 and 30% [1,61-65]. These helmet laws are effective, as a recent study demonstrated children in Pennsyl- vania, a state with helmet laws, had decreased risk factors for injury when compared to children in North Carolina, a state without helmet laws [66]. Helmet use has also been shown to vary with factors such as poverty, education level, and parental attitudes towards helmets [61,67]. Given the demonstrated risk reduction for injury and death of helmet legislation and helmets themselves, increasing helmet use may be one way to reduce the 68,000 ATV-related head injuries presenting to EDs identified in this study.

Table 3

ATV Associated Head Injuries and Post-Trauma Sequelae.

Total

14-17 years-olds

9-13 years-old

4-8 years-old

0-3 years-old

Closed Head Injury

n (%)

n (%)

n (%)

n (%)

n (%)

Diagnoses

Closed Head Injury

900 (37.6)

344 (35.4)

296 (37.3)

193 (39.7)

67 (46.9)

Skull Fracture

166 (6.9)

64 (6.6)

59 (7.4)

35 (7.2)

8 (5.6)

Concussion

510 (21.3)

260 (26.7)

171 (21.5)

70 (14.4)

9 (6.3)

Laceration

348 (14.5)

116 (11.9)

105 (13.2)

99 (20.4)

28 (19.6)

Abrasions

134 (5.6)

51 (5.2)

45 (5.7)

28 (5.8)

10 (7.0)

Contusions

168 (7.0)

69 (7.1)

58 (7.3)

30 (6.2)

11 (7.7)

Intra-axial Bleeding

27 (1.1)

13 (1.3)

11 (1.4)

2 (0.4)

1 (0.7)

Extra-axial Bleeding

64 (2.7)

32 (3.3)

23 (2.9)

7 (1.4)

2 (1.4)

Hematoma

79 (3.3)

24 (2.5)

26 (3.3)

22 (4.5)

7 (4.9)

Total

Post-Traumatic Sequelae Loss of Consciousness

2396

213 (86.2)

973

115 (88.5)

794

80 (90.9)

486

17 (65.4)

143

1 (33.3)

Vomiting

26 (10.5)

11 (8.5)

7 (8.0)

7 (26.9)

1 (33.3)

Seizures

8 (3.2)

4 (3.1)

1 (1.1)

2 (7.7)

1 (33.3)

Total

247

130

88

26

3

While helmet use has been well studied in the literature concerning ATV-related injuries, there are additional factors that may drive injury incidence. A common mechanism of ATV-related head injuries are rollover injuries, which McIntosh et al. showed occurred in up to 55% of recreational ATV fatalities and which NEISS identified as the primary hazard in roughly 40% of ATV fatalities [14,68]. Rollover injuries are an increasingly significant concern due to ATVs becoming heavier with more powerful engines [48]. Forward and backward rollover are com- mon while traversing steep inclines and may also result from high rates of speed and certain terrain such as gravel [68]. One factor to re- duce the incidence of rollover injuries is rollover protective structures (ROPS) and/or crush protection devices (CPDs) including roll-bar struc- tures, cages, lifeguards, and quadbars [69]. Therefore, in addition to pro- moting helmet use, specific interventions aimed at decreasing rollover injuries such as the implementation of these devices may be indicated. Additionally, interventions such as improved the handling of ATVs, horsepower limitations, better shock-absorbability of wheels to decrease loss-of-control events, and education programs encouraging safe riding may also be warranted, but literature evaluating these inter- ventions as risk mitigation strategies is severely limited and was not possible with the available data. However, regarding education pro- grams specifically, previous literature has demonstrated that safety education courses significantly increased helmet use, awareness of best practices, and knowledge of relevant ATV laws [70-73]. Regarding current guidelines on ATV use among children, the American Associa- tion of Pediatrics actually recommends that no child under 16 years old operate or ride as a passenger on an ATV. For children who do, the guidelines suggest Department of Transportation approved helmets, recommend children only use youth-approved models, and go on to en- courage promotion of laws that require safety training and prohibit the use of full-sized ATVs by children [74].

    1. Limitations

There were several limitations to the NEISS database and the present study. Because the patient population derived from the NEISS queries is limited to only those seen in the EDs and not those seen in other care settings such as urgent care, the rates of mild TBI injuries may be underestimated, as many of these milder cases may not present to the ED or present in an Outpatient setting. In addition, NEISS patient narratives are not standardized, and due to incomplete reporting, useful information such as helmet status before injury was not always avail- able. Therefore, we were not able to provide additional analysis regard- ing helmet status. We also did not perform a sub-analysis of injuries according to the Type of ATV, however over 97% of the cases involved product code 3286 (four wheels/off road only) or product code 3287 (# of wheels unspecified/off road). The NEISS database also does not receive follow-up data from participating EDs, and thus long-term sequelae were not available to the reviewers. Therefore, the incidence of sequelae that have a propensity to manifest later was not captured, and sequelae that may have appeared shortly after the patient was re- leased from or left the hospital was also not captured. In the present study, post-traumatic sequelae, namely loss of consciousness, seizures, and vomiting, were reported in 247 (13%) patients, while loss of con- sciousness at the time of injury was the most common post-traumatic sequelae, transpiring in 86% of the 247 patients. However, these findings regarding sequelae were likely underestimated due to inconsistent reporting. And regarding primary diagnoses, our review of case narra- tives may have created bias and/or inaccuracies. More standardized diagnostic tools such as ICD-9-CM codes or the Abbreviated Injury Scale may have been superior but were unable to be used due to limita- tions of the database.

There are also many other, important factors involved in ATV- related head injuries not included in the NEISS database. Firstly, the size of the ATV and whether it is marketed/designed for children may play a role in each injury as smaller ATVs have less powerful engines

and therefore accelerate slower and travel at lower speeds. Additionally, the use of full-sized, adult ATVs by children may drive significant inju- ries but was unable to be studied due to the database only reporting four product codes with no further details of ATV size. Factors such as adult supervision, passenger status and positioning, riding on roadways versus off road, and the use of speed limit settings also potentially play an important role in accident epidemiology but were unable to be included due to lack of information in the database.

  1. Conclusion

ATV-related Pediatric injuries exert a significant burden on the United States healthcare system, with an estimated 68,000 injuries occurring over a ten-year period. ATV use can lead to debilitating injuries such as concussions and in extreme cases Brain hemorrhages. While this study was limited by the inability to conduct further analysis based on helmet status or ATV characteristics such as roll cages, the positive impacts of helmet use and stricter legislation on manufacturing requirements have been supported in other studies and may be indicated.

Funding

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

CRediT authorship contribution statement

Arjun Ganga: Writing – review & editing, Writing – original draft, Methodology, Investigation, Formal analysis, Data curation, Conceptual- ization. Eric J. Kim: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Project administration, Method- ology, Investigation, Data curation, Conceptualization. Ermias S. Araia: Writing – review & editing, Writing – original draft, Validation, Method- ology. Matthew Hagan: Writing – review & editing, Writing – original draft, Validation, Methodology. Belinda Shao: Writing – review & editing, Writing – original draft, Methodology, Investigation, Data curation. Konstantina Svokos: Writing – review & editing, Writing – original draft, Methodology, Investigation, Data curation. Petra M. Klinge: Writing – review & editing, Writing – original draft. Deus J. Cielo: Writing – review & editing, Writing – original draft, Visualization, Supervision, Project administration. Jared S. Fridley: Writing – review & editing, Writing – original draft, Supervision, Project administration. Ziya L. Gokaslan: Writing – review & editing, Writing – original draft, Supervision, Project administration. Steven A. Toms: Writing – original draft, Supervision, Project administration. Patricia Zadnik Sullivan: Writing – review & editing, Writing – original draft, Visualization, Vali- dation, Supervision, Project administration, Methodology, Investigation, Data curation, Conceptualization.

Declaration of Competing Interest

The authors of “All-terrain vehicle (ATV) related head injury rates and patterns in children: a 10-year nationwide analysis ” declare no competing interests.

Acknowledgments

None.

References

  1. Adil MT, Konstantinou C, Porter DJ, Dolan S. All-terrain vehicle(ATV) injuries – an in- stitutional review over 6 years. Ulster Med J. 2017;86:103-7.
  2. Allen JH, Yengo-Kahn AM, Vittetoe KL, Greeno A, Owais Abdul Ghani M, Unni P, et al. The impact of helmet use on neurosurgical care and outcomes after pediatric

all-terrain vehicle and dirt bike crashes: a 10-year single-center experience. J Neurosurg Pediatr. 2022;29:106-14. https://doi.org/10.3171/2021.6.PEDS21225.

  1. Ross RT, Stuart LK, Davis FE. All-terrain vehicle injuries in children: industry- regulated failure. Am Surg. 1999;65:870-3.
  2. Brandenburg MA, Brown SJ, Archer P, Brandt EN. All-terrain vehicle crash factors and associated injuries in patients presenting to a regional trauma center. J Trauma. 2007;63:994-9. https://doi.org/10.1097/TA.0b013e31814b91fe.
  3. Siman-Tov M, Marom-Trabelsi I, Radomislensky I, Bodas M, Peleg K, Israeli Trauma Group. Injuries among all-terrain vehicle users: a population-based study. Inj Prev. 2020;26:540-5. https://doi.org/10.1136/injuryprev-2019-043425.
  4. Larson AN, McIntosh AL. The epidemiology of injury in ATV and motocross sports. Med Sport Sci. 2012;58:158-72. https://doi.org/10.1159/000338728.
  5. Shannon SF, Hernandez NM, Sems SA, Larson AN, Milbrandt TA. Pediatric Orthopae- dic trauma and associated injuries of snowmobile, ATV, and Dirtbike accidents: a 19- year experience at a level 1 pediatric trauma center. J Pediatr Orthop. 2018;38: 403-9. https://doi.org/10.1097/BPO.0000000000000838.
  6. Denning GM, Jennissen CA. Pediatric and adolescent injury in all-terrain vehicles. Res Sports Med. 2018;26:38-56. https://doi.org/10.1080/15438627.2018.1438279.
  7. Breslau J, Stranges E, Gladden M, Wong H. Emergency department visits and inpa- tient hospital stays for all-terrain-vehicle-related injuries, 2009: Statistical brief #130. Healthcare cost and utilization project (HCUP) statistical briefs. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006.
  8. Nabaweesi R, Robbins JM, Goudie A, Onukwube JI, Bowman SM, Aitken ME. A cross- sectional study of emergency department visits by children after all-terrain vehicle crashes, motor vehicle crashes, and sports activities. Pediatr Emerg Care. 2018;34: 479-83. https://doi.org/10.1097/PEC.0000000000000776.
  9. Helmkamp JC, Aitken ME, Lawrence BA. ATV and bicycle deaths and associated costs in the United States, 2000-2005. Public Health Rep. 2009;124:409-18.
  10. Strohecker KA, Gaffney CJ, Graham J, Irgit K, Smith WR, Bowen TR. Pediatric all- terrain vehicle (ATV) injuries: an epidemic of cost and grief. Acta Orthop Traumatol Turc. 2017;51:416-9. https://doi.org/10.1016/j.aott.2017.06.003.
  11. Garland S. Annual report of ATV-related deaths and injuries. U.S. Consumer Product Safety Commission; 2010. n.d.
  12. Mcintosh AS, Patton DA, Rechnitzer G, Grzebieta R. injury mechanisms in fatal Australian quad bike incidents. Traffic Inj Prev. 2016;17:386-90. https://doi.org/ 10.1080/15389588.2015.1091073.
  13. Vasilakis A, Vargish T, Apelgren KN, Moran WH. All terrain vehicles (ATVs). A recre- ational gamble. Am Surg. 1989;55:142-4.
  14. Doud AN, Moro R, Wallace SG, Smith MD, McCall M, Veach LJ, et al. All-terrain vehi- cle injury in children and youth: examining current knowledge and future needs. J Emerg Med. 2017;53:222-31. https://doi.org/10.1016/j.jemermed.2016.12.035.
  15. Nolan HR, Ashley DW, Stokes NA, Christie DB. Increasing incidence of all-terrain ve- hicle trauma admissions in the pediatric and adult populations: an evaluation of in- jury types and severity. Int J Orthop Trauma Nurs. 2018;28:33-6. https://doi.org/10. 1016/j.ijotn.2017.10.001.
  16. Kirkpatrick R, Puffinbarger W, Sullivan JA. All-terrain vehicle injuries in children. J Pediatr Orthop. 2007;27:725-8. https://doi.org/10.1097/BPO.0b013e3181558856.
  17. Fonseca AH, Ochsner MG, Bromberg WJ, Gantt D. All-terrain vehicle injuries: are they dangerous? A 6-year experience at a level I trauma center after legislative reg- ulations expired. Am Surg. 2005;71:937-40. discussion 940-941.
  18. Benham EC, Ross SW, Mavilia M, Fischer PE, Christmas AB, Sing RF. Injuries from all- terrain vehicles: an opportunity for injury prevention. Am J Surg. 2017;214:211-6. https://doi.org/10.1016/j.amjsurg.2016.11.017.
  19. Reid CM, Rivera-Barrios A, Tapp M, Hassanein AH, Herrera FA. Upper extremity inju- ries associated with all terrain vehicle accidents: a multicenter experience and case review. Injury. 2018;49:1805-9. https://doi.org/10.1016/j.injury.2018.08.018.
  20. Gill PJ, McLaughlin T, Rosenfield D, Moore Hepburn C, Yanchar NL, Beno S. All-terrain vehicle Serious injuries and death in children and youth: a national survey of Cana- dian paediatricians. Paediatr Child Health. 2019;24:e13-8. https://doi.org/10.1093/ pch/pxy059.
  21. Brown RL, Koepplinger ME, Mehlman CT, Gittelman M, Garcia VF. All-terrain vehicle and bicycle crashes in children: epidemiology and comparison of injury severity. J Pediatr Surg. 2002;37:375-80. https://doi.org/10.1053/jpsu.2002.30826.
  22. Garay M, Hess J, Armstrong D, Hennrikus W. Pediatric ATV injuries in a statewide sample: 2004 to 2014. Pediatrics. 2017;140:e20170945. https://doi.org/10.1542/ peds.2017-0945.
  23. Wiener RC, Waters C, Harper M, Shockey AKT, Bhandari R. All-terrain vehicle-related emergency department visits: interaction of sex and age, NEISS, 2019. J Emerg Med. 2022. https://doi.org/10.1016/j.jemermed.2022.02.005. S0736-4679(22)00162-7.
  24. Shults RA, West BA. ATV riding and helmet use among youth aged 12-17 years, USA, 2011: results from the YouthStyles survey. Inj Prev. 2015;21:10-4. https://doi.org/ 10.1136/injuryprev-2013-041138.
  25. Armstrong G, Chen A, Linakis J, Mello M, Greenberg P. Motor vehicle crash- associated eye injuries presenting to U.S Emergency Departments. WestJEM. 2014; 15:693-700. https://doi.org/10.5811/westjem.2014.5.20623.
  26. DeFroda SF, Lemme N, Kleiner J, Gil J, Owens BD. Incidence and mechanism of injury of clavicle fractures in the NEISS database: athletic and non athletic injuries. J Clin Orthop Trauma. 2019;10:954-8. https://doi.org/10.1016/j.jcot.2019.01.019.
  27. Xiang H, Sinclair SA, Yu S, Smith GA, Kelleher K. Case ascertainment in pediatric trau- matic brain injury: challenges in using the NEISS. Brain Inj. 2007;21:293-9. https:// doi.org/10.1080/02699050701311034.
  28. Pollard KA, Xiang H, Smith GA. Pediatric eye injuries treated in US emergency de- partments, 1990-2009. Clin Pediatr (Phila). 2012;51:374-81. https://doi.org/10. 1177/0009922811427583.
  29. Thiels CA, Hernandez MC, Zielinski MD, Aho JM. Injury patterns and outcomes of ice- fishing in the United States. Am J Emerg Med. 2016;34:1258-61. https://doi.org/10. 1016/j.ajem.2016.02.078.
  30. Etzel CM, Wang KH, Li LT, Nadeem M, Owens BD. Epidemiology of rugby-related fractures in high school- and college-aged players in the United States: an analysis of the 1999-2018 NEISS database. Phys Sportsmed. 2021:1-6. https://doi.org/10. 1080/00913847.2021.1962204.
  31. Baugh TP, Hadley JB, Chang CWD. Epidemiology of wire-bristle grill brush injury in the United States, 2002-2014. Otolaryngol Head Neck Surg. 2016;154:645-9. https://doi.org/10.1177/0194599815627794.
  32. Khurana B, Loder RT. Injury patterns and associated demographics of intimate part- ner violence in older adults presenting to U.S. emergency departments. J Interpers Viol. 2021. https://doi.org/10.1177/08862605211022060. 8862605211022060.
  33. Thompson MC, Wheeler KK, Shi J, Smith GA, Groner JI, Haley KJ, et al. Surveillance of paediatric traumatic brain injuries using the NEISS: choosing an appropriate case definition. Brain Inj. 2014;28:431-7. https://doi.org/10.3109/02699052.2014. 887146.
  34. Kelleher CM, Metze SL, Dillon PA, Mychaliska GB, Keshen TH, Foglia RP. Unsafe at any speed-kids riding all-terrain vehicles. J Pediatr Surg. 2005;40:929-34. discus- sion 934-935. https://doi.org/10.1016/j.jpedsurg.2005.03.007.
  35. McLean L, Russell K, McFaull S, Warda L, Tenenbein M, McGavock J. Age and the risk of all-terrain vehicle-related injuries in children and adolescents: a Cross sectional study. BMC Pediatr. 2017;17:81. https://doi.org/10.1186/s12887-017-0807-y.
  36. Kleiner JE, Johnson J, Cruz AI. Trends in all-terrain vehicle injuries from 2000 to 2015 and the effect of targeted public safety campaigns. J Am Acad Orthop Surg. 2018;26: 663-8. https://doi.org/10.5435/JAAOS-D-17-00041.
  37. Abdelrahman H, Khan NA, El-Menyar A, Consunji R, Asim M, Alani M, et al. All- terrain vehicle (ATV)-related injuries among different age groups: insights from a 9-year observational study. Eur J Trauma Emerg Surg. 2022. https://doi.org/10. 1007/s00068-022-01984-1.
  38. umash. Upper Midwest Agricultural Safety and Health Center – SPOTLIGHT: ATV’s and the Pandemic. http://umash.umn.edu/spotlight-atvs-and-the-pandemic/; 2020.
  39. ATV Injury Cases Triple Prompting Safety Warning. The University of Vermont Health Network. https://www.uvmhealth.org/coronavirus/staying-healthy/atv- injury-cases-triple-prompting-safety-warning; 2020.
  40. New Mexico Department of Game and Fish. States See Increase in OHV Sales, Use and Injuries During Pandemic; 2020.
  41. CFA Warns: OHV Injuries Have Increased in At Least Sixteen States Since a State of Emergency Was Declared Due to Covid-19. Consumer Federation of America. Consumer Federation of America; 2021. https://consumerfed.org/press_release/cfa- warns-ohv-injuries-have-increased-in-at-least-sixteen-states-since-a-state-of- emergency-was-declared-due-to-covid-19/ (accessed July 22, 2022).
  42. Coronado VG, Haileyesus T, Cheng TA, Bell JM, Haarbauer-Krupa J, Lionbarger MR, et al. Trends in sports- and recreation-related traumatic brain injuries treated in US emergency departments: the National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) 2001-2012. J Head Trauma Rehabil. 2015;30:185-97. https://doi.org/10.1097/HTR.0000000000000156.
  43. Sarmiento K, Thomas KE, Daugherty J, Waltzman D, Haarbauer-Krupa JK, Peterson AB, et al. Emergency department visits for sports- and recreation-related traumatic brain injuries among children — United States, 2010-2016. MMWR Morb Mortal Wkly Rep. 2019;68:237-42. https://doi.org/10.15585/mmwr.mm6810a2.
  44. Bowman SM, Aitken ME, Helmkamp JC, Maham SA, Graham CJ. Impact of helmets on injuries to riders of all-terrain vehicles. Inj Prev. 2009;15:3-7. https://doi.org/10. 1136/ip.2008.019372.
  45. Li D, Jatana KR, Kistamgari S, Smith GA. Nonfatal all-terrain vehicle-related head and neck injuries to children treated in US emergency departments. Clin Pediatr (Phila). 2020;59:1141-9. https://doi.org/10.1177/0009922819901011.
  46. Butts CC, Rostas JW, Lee YL, Gonzalez RP, Brevard SB, Frotan MA, et al. Larger ATV en- gine size correlates with an increased rate of traumatic brain injury. Injury. 2015;46: 625-8. https://doi.org/10.1016/j.injury.2014.11.007.
  47. Gibbs L, Lawrence D, Reilley B. ATV-related central nervous system injuries in Loui- siana. J La State Med Soc. 1997;149:276-8.
  48. Rattan R, Joseph DK, Dente CJ, Klein EN, Kimbrough MK, Nguyen J, et al. Prevention of all-terrain vehicle injuries: a systematic review from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2018;84:1017-26. https://doi. org/10.1097/TA.0000000000001828.
  49. Rodgers GB. The effectiveness of helmets in reducing all-terrain vehicle injuries and deaths. Accid Anal Prev. 1990;22:47-58. https://doi.org/10.1016/0001-4575(90) 90006-7.
  50. Bethea A, Samanta D, Willis JA, Lucente FC, Chumbe JT. Substance exposure and hel- met use in all-terrain vehicle accidents: nine years of experience at a level 1 trauma center. J Saf Res. 2016;59:61-7. https://doi.org/10.1016/j.jsr.2016.09.006.
  51. Miller M, Davidov D, Tillotson R, Whiteman C, Marshall T, Lander O. Injury preven- tion and recreational all-terrain vehicle use: the impact of helmet use in West Vir- ginia. W V Med J. 2012;108:96-101.
  52. Ganti L, Bodhit AN, Daneshvar Y, Patel PS, Pulvino C, Hatchitt K, et al. Impact of hel- met use in traumatic brain injuries associated with recreational vehicles. Adv Prev Med. 2013;2013:450195. https://doi.org/10.1155/2013/450195.
  53. Sone JY, Kondziolka D, Huang JH, Samadani U. Helmet efficacy against concussion and traumatic brain injury: a review. J Neurosurg. 2017;126:768-81. https://doi. org/10.3171/2016.2.JNS151972.
  54. Yengo-Kahn AM, Kelly PD, Liles DC, McKeithan LJ, Grisham CJ, Khan MS, et al. The cost of a single concussion in American high school football: a retrospective cohort study. Concussion. 2020;5:CNC81. https://doi.org/10.2217/cnc-2020-0012.
  55. Graves JM, Whitehill JM, Hagel BE, Rivara FP. Making the most of injury surveillance data: using narrative text to identify exposure information in Case-control studies. Injury. 2015;46:891-7. https://doi.org/10.1016/j.injury.2014.11.012.
  56. Fu TS, Jing R, McFaull SR, Cusimano MD. Health & Economic burden of traumatic brain injury in the emergency department. Can J Neurol Sci. 2016;43:238-47. https://doi.org/10.1017/cjn.2015.320.
  57. Morgan CD, Zuckerman SL, King LE, Beaird SE, Sills AK, Solomon GS. Post-concussion syndrome (PCS) in a youth population: defining the diagnostic value and cost-utility of brain imaging. Childs Nerv Syst. 2015;31:2305-9. https://doi.org/10.1007/ s00381-015-2916-y.
  58. Mangus RS, Simons CJ, Jacobson LE, Streib EW, Gomez GA. Current helmet and pro- tective equipment usage among previously injured ATV and motorcycle riders. Inj Prev. 2004;10:56-8. https://doi.org/10.1136/ip.2003.002626.
  59. Vittetoe KL, Allen JH, Unni P, McKay KG, Yengo-Kahn AM, Ghani O, et al. Socioeco- nomic factors associated with helmet use in pediatric ATV and dirt bike trauma. Trauma Surg Acute Care Open. 2022;7:e000876. https://doi.org/10.1136/tsaco- 2021-000876.
  60. Sec. 84.928 MN Statutes. https://www.revisor.mn.gov/statutes/cite/84.928; 2022.

(accessed July 3, 2022).

  1. Low Speed Vehicles. Florida Department of Highway Safety and Motor Vehicles; 2022. https://www.flhsmv.gov/safety-center/consumer-education/low-speed-

vehicles/ (accessed July 3, 2022).

  1. Connecticut All-Terrain Vehicle Laws. https://www.cga.ct.gov/2002/rpt/2002-R-080

7.htm; 2022. accessed July 3, 2022.

  1. Laws & Rules: All-Terrain Vehicles: ATV & Snowmobile. Maine Dept of Inland Fisheries and Wildlife; 2022. https://www.maine.gov/ifw/atv-snowmobile/atv/ laws-rules.html accessed July 3, 2022.
  2. Keenan HT, Bratton SL. All-terrain vehicle legislation for children: a comparison of a state with and a state without a helmet law. Pediatrics. 2004;113:e330-4. https:// doi.org/10.1542/peds.113.4.e330.
  3. Wymore C, Denning G, Hoogerwerf P, Wetjen K, Jennissen C. Parental attitudes and family helmet use for all-terrain vehicles and bicycles. Inj Epidemiol. 2020;7:23. https://doi.org/10.1186/s40621-020-00253-2.
  4. Topping J. Report of deaths and injuries involving off-highway vehicles with more than two wheels; 2021; 21.
  5. Van Ee CA, Toomey DE, Moroski-Browne BA, Vander Roest M, Wilson A. ATV roll- over, rider response, and determinants of injury: in-depth analysis of video- documented ATV rollover events. Traffic Inj Prev. 2014;15(Suppl. 1):S190-6. https://doi.org/10.1080/15389588.2014.935940.
  6. Jeffries K, Burks AR, Nichols M, Farmer J, Shah N, Jennissen CA, et al. Using a resident- led school outreach program to improve knowledge of all-terrain vehicle safety. South Med J. 2021;114:106-10. https://doi.org/10.14423/SMJ.0000000000001201.
  7. Novak JA, Hafner JW, Aldag JC, Getz MA. Evaluation of a standardized all-terrain ve- hicle safety education intervention for youth in rural Central Illinois. J Prim Care Community Health. 2013;4:8-13. https://doi.org/10.1177/2150131912446374.
  8. Jennissen CA, Peck J, Wetjen K, Hoogerwerf P, Harland KK, Denning GM. The safety tips for ATV riders (STARs) programme: short-term impact of a school-based educa- tional intervention. Inj Prev. 2015;21:166-72. https://doi.org/10.1136/injuryprev- 2014-041408.
  9. Williams RS, Graham J, Helmkamp JC, Dick R, Thompson T, Aitken ME. A trial of an all-terrain vehicle safety education video in a community-based hunter education program. J Rural Health. 2011;27:255-62. https://doi.org/10.1111/j.1748-0361. 2010.00327.x.
  10. Jennissen CA, Denning GM, Aitken ME, Council On Injury, Violence, and Poison Prevention, Council on Injury, Violence, and Poison Prevention, 2019-2020, Hoff- man B, et al. American academy of pediatrics recommendations for the prevention of pediatric ATV-related deaths and injuries. Pediatrics. 2022;150:e2022059279. https://doi.org/10.1542/peds.2022-059279.