No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Fractures in New Zealand Elementary School Settings
Abstract
There is a need for greater international understanding of student safety in schools. This New Zealand study investigated the causes and school location of fractures sustained by students attending elementary school, with special emphasis on the types of fractures sustained following falls from playground equipment of various heights.
Over a 1-year period, 76 participating schools (with a combined roll of over 25,000 students) completed a questionnaire about the nature and circumstances of student fractures sustained during regular school hours.
Some 118 students sustained a total of 131 fractures. Injuries from playground equipment were no more frequent than those from general activities at school, and most were sustained in falls from heights less than 59 inches. Most fractures were to the upper limbs. Fractures were found to vary by gender and school size.
The results are discussed in terms of the conditions and policies present in local schools, and the tension that exists in maintaining safety while offering appropriate challenges to students. Improvements in school safety may be more likely to result from a greater focus on the way that students interact at school, rather than on modifications to playground equipment.
... r The magnitude of the number of included studies is small (N = 1). [89]; a Observational studies include 1 longitudinal study [89]; Indirectness Imprecision Other Considerations Social competence (age range between 42 months and 11.2 years, data collected over a single session up to 2 years, aspects of social competence were measured using teacher-report questionnaire, peer nominations of popularity and rejection, social cognitive problem solving task, observer rated) 5 Observational studies a [90][91][92][93][94][95][96]; a Observational studies include 1 longitudinal study [90] and 4 cross sectional studies [91][92][93][94][95][96]. Dewolf [91] was an unpublished graduate thesis; b It is unclear if participants were blinded to the outcomes assessed, and likely that their behaviour was affected by being observed. ...
... r The magnitude of the number of included studies is small (N = 1). [89]; a Observational studies include 1 longitudinal study [89]; Indirectness Imprecision Other Considerations Social competence (age range between 42 months and 11.2 years, data collected over a single session up to 2 years, aspects of social competence were measured using teacher-report questionnaire, peer nominations of popularity and rejection, social cognitive problem solving task, observer rated) 5 Observational studies a [90][91][92][93][94][95][96]; a Observational studies include 1 longitudinal study [90] and 4 cross sectional studies [91][92][93][94][95][96]. Dewolf [91] was an unpublished graduate thesis; b It is unclear if participants were blinded to the outcomes assessed, and likely that their behaviour was affected by being observed. ...
... RTP rough was negatively correlated with peer nominations of likes most, but was not related to peer nominations of likes least, social impact, or social preference [90]; i RTP flexibility was correlated with interpersonal cognitive problem solving (positive and negative solutions respectively). Popularity was not correlated with any aspect of RTP; RTP relative frequency negatively predicted popularity; RTP flexibility accounted for unique variance in the model to predict negative, and positive solutions to an interpersonal cognitive problem, respectively [96]; j For boys, RTP correlated with social preference and interpersonal cognitive problem solving, respectively, but not social impact, likes most or likes least peer ratings; For girls, RTP did not correlate with social preference, social impact, likes most, likes least, interpersonal cognitive problem solving [94]; k For popular children, RTP correlated with interpersonal cognitive problem solving [89]; Antisocial behaviour: 0 Randomized trials; 2 Observational studies [90,93,94]; l Includes 1 longitudinal study [90] and 1 cross sectional study [93,94]; m Pellegrini [90] is a longitudinal study, however only data from year 1 are included. Children in year 2 met age-based exclusion criteria; n It was not possible to blind assessors to outcomes, however assessors were blinded to children's sociometric and dominance status [90,93,94]; The probability of RTP leading to observer rated aggression for popular children was not significant; For popular children, RTP was not correlated with anti-social behavior [93]; RTP frequency was not correlated with aggression frequency for boys or girls. ...
... r The magnitude of the number of included studies is small (N = 1). [89]; a Observational studies include 1 longitudinal study [89]; Indirectness Imprecision Other Considerations Social competence (age range between 42 months and 11.2 years, data collected over a single session up to 2 years, aspects of social competence were measured using teacher-report questionnaire, peer nominations of popularity and rejection, social cognitive problem solving task, observer rated) 5 Observational studies a [90][91][92][93][94][95][96]; a Observational studies include 1 longitudinal study [90] and 4 cross sectional studies [91][92][93][94][95][96]. Dewolf [91] was an unpublished graduate thesis; b It is unclear if participants were blinded to the outcomes assessed, and likely that their behaviour was affected by being observed. ...
... r The magnitude of the number of included studies is small (N = 1). [89]; a Observational studies include 1 longitudinal study [89]; Indirectness Imprecision Other Considerations Social competence (age range between 42 months and 11.2 years, data collected over a single session up to 2 years, aspects of social competence were measured using teacher-report questionnaire, peer nominations of popularity and rejection, social cognitive problem solving task, observer rated) 5 Observational studies a [90][91][92][93][94][95][96]; a Observational studies include 1 longitudinal study [90] and 4 cross sectional studies [91][92][93][94][95][96]. Dewolf [91] was an unpublished graduate thesis; b It is unclear if participants were blinded to the outcomes assessed, and likely that their behaviour was affected by being observed. ...
... RTP rough was negatively correlated with peer nominations of likes most, but was not related to peer nominations of likes least, social impact, or social preference [90]; i RTP flexibility was correlated with interpersonal cognitive problem solving (positive and negative solutions respectively). Popularity was not correlated with any aspect of RTP; RTP relative frequency negatively predicted popularity; RTP flexibility accounted for unique variance in the model to predict negative, and positive solutions to an interpersonal cognitive problem, respectively [96]; j For boys, RTP correlated with social preference and interpersonal cognitive problem solving, respectively, but not social impact, likes most or likes least peer ratings; For girls, RTP did not correlate with social preference, social impact, likes most, likes least, interpersonal cognitive problem solving [94]; k For popular children, RTP correlated with interpersonal cognitive problem solving [89]; Antisocial behaviour: 0 Randomized trials; 2 Observational studies [90,93,94]; l Includes 1 longitudinal study [90] and 1 cross sectional study [93,94]; m Pellegrini [90] is a longitudinal study, however only data from year 1 are included. Children in year 2 met age-based exclusion criteria; n It was not possible to blind assessors to outcomes, however assessors were blinded to children's sociometric and dominance status [90,93,94]; The probability of RTP leading to observer rated aggression for popular children was not significant; For popular children, RTP was not correlated with anti-social behavior [93]; RTP frequency was not correlated with aggression frequency for boys or girls. ...
Risky outdoor play has been associated with promoting children’s health and development, but also with injury and death. Risky outdoor play has diminished over time, concurrent with increasing concerns regarding child safety and emphasis on injury prevention. We sought to conduct a systematic review to examine the relationship between risky outdoor play and health in children, in order to inform the debate regarding its benefits and harms. We identified and evaluated 21 relevant papers for quality using the GRADE framework. Included articles addressed the effect on health indicators and behaviours from three types of risky play, as well as risky play supportive environments. The systematic review revealed overall positive effects of risky outdoor play on a variety of health indicators and behaviours, most commonly physical activity, but also social health and behaviours, injuries, and aggression. The review indicated the need for additional “good quality” studies; however, we note that even in the face of the generally exclusionary systematic review process, our findings support the promotion of risky outdoor play for healthy child development. These positive results with the marked reduction in risky outdoor play opportunities in recent generations indicate the need to encourage action to support children’s risky outdoor play opportunities. Policy and practice precedents and recommendations for action are discussed.
... As a result of efforts by the injury prevention community to reduce hazards where children play, these are now extremely rare [33,83]. The vast majority of injuries that do happen are very minor (e.g., sprains and strains, bumps and bruises) [84][85][86][87][88]. Nevertheless, less minor injuries do occur as a result of normal and healthy active play, and these tend to be fractures to the upper limbs. ...
... The vast majority of injuries that do happen are very minor (e.g., sprains and strains, bumps and bruises) [84][85][86][87][88]. Nevertheless, less minor injuries do occur as a result of normal and healthy active play, and these tend to be fractures to the upper limbs. Two large studies that included all children in a school district (15,074 Canadian students [89]; 25,782 New Zealand students [84]) reported there were no fractures to the head or spine as a result of a fall from playground equipment over the course of the 1 year and 2.5 year assessment periods respectively. Furthermore, findings from a recent systematic review by Nauta and colleagues [85] indicated that while the total number of reported injuries during children's unstructured play (identified as mainly climbing frames, monkey bars and trampolines) was high compared with sport and active transportation, the incidence rate of medically treated injuries per 1000 hours of unstructured physical activity was lower than for sports and active transportation. ...
A diverse, cross-sectorial group of partners, stakeholders and researchers, collaborated to develop an evidence-informed Position Statement on active outdoor play for children aged 3–12 years. The Position Statement was created in response to practitioner, academic, legal, insurance and public debate, dialogue and disagreement on the relative benefits and harms of active (including risky) outdoor play. The Position Statement development process was informed by two systematic reviews, a critical appraisal of the current literature and existing position statements, engagement of research experts (N = 9) and cross-sectorial individuals/organizations (N = 17), and an extensive stakeholder consultation process (N = 1908). More than 95% of the stakeholders consulted strongly agreed or somewhat agreed with the Position Statement; 14/17 participating individuals/organizations endorsed it; and over 1000 additional individuals and organizations requested their name be listed as a supporter. The final Position Statement on Active Outdoor Play states: “Access to active play in nature and outdoors—with its risks— is essential for healthy child development. We recommend increasing children’s opportunities for self-directed play outdoors in all settings—at home, at school, in child care, the community and nature.” The full Position Statement provides context for the statement, evidence supporting it, and a series of recommendations to increase active outdoor play opportunities to promote healthy child development.
... As a result of efforts by the injury prevention community to reduce hazards where children play, these are now extremely rare [33,83]. The vast majority of injuries that do happen are very minor (e.g., sprains and strains, bumps and bruises) [84][85][86][87][88]. Nevertheless, less minor injuries do occur as a result of normal and healthy active play, and these tend to be fractures to the upper limbs. ...
... The vast majority of injuries that do happen are very minor (e.g., sprains and strains, bumps and bruises) [84][85][86][87][88]. Nevertheless, less minor injuries do occur as a result of normal and healthy active play, and these tend to be fractures to the upper limbs. Two large studies that included all children in a school district (15,074 Canadian students [89]; 25,782 New Zealand students [84]) reported there were no fractures to the head or spine as a result of a fall from playground equipment over the course of the 1 year and 2.5 year assessment periods respectively. Furthermore, findings from a recent systematic review by Nauta and colleagues [85] indicated that while the total number of reported injuries during children's unstructured play (identified as mainly climbing frames, monkey bars and trampolines) was high compared with sport and active transportation, the incidence rate of medically treated injuries per 1000 hours of unstructured physical activity was lower than for sports and active transportation. ...
A diverse, cross-sectorial group of partners, stakeholders and researchers, collaborated to develop an evidence-informed Position Statement on active outdoor play
for children aged 3–12 years. The Position Statement was created in response to
practitioner, academic, legal, insurance and public debate, dialogue and disagreement on
the relative benefits and harms of active (including risky) outdoor play. The Position
Statement development process was informed by two systematic reviews, a critical
appraisal of the current literature and existing position statements, engagement of research
experts (N = 9) and cross-sectorial individuals/organizations (N = 17), and an extensive
stakeholder consultation process (N = 1908). More than 95% of the stakeholders consulted
strongly agreed or somewhat agreed with the Position Statement; 14/17 participating
individuals/organizations endorsed it; and over 1000 additional individuals and
organizations requested their name be listed as a supporter. The final Position Statement on
Active Outdoor Play states: “Access to active play in nature and outdoors—with its
risks— is essential for healthy child development. We recommend increasing children’s
opportunities for self-directed play outdoors in all settings—at home, at school, in child
care, the community and nature.” The full Position Statement provides context for the statement, evidence supporting it, and a series of recommendations to increase active
outdoor play opportunities to promote healthy child development.
... Vi beregnet en bruddrisiko på 8,5 brudd per 1 000 barn per år. I en studie fra New Zealand fant forfatterne 118 skolerelaterte brudd blant 25 000 elever i løpet av ett år (23). Det gir til sammenlikning en årlig bruddrisiko på 4,7 brudd per 1 000 barn. ...
... Dette samsvarer med tall fra Canada og Nederland, som viser at de fleste skolerelaterte bruddskader skjer i forbindelse med uorganisert aktivitet og fri lek (24,25). Også i New Zealand skjedde de fleste brudd utendørs ved fri lek, og bare 12 av 118 brudd (10,1 %) fant sted under organisert idrett (23). I en kanadisk studie fant man at de fleste idrettsrelaterte skader som inntraff i skoletiden, fant sted under organisert idrett og fysisk aktivitet utenom kroppsøvingstimene (26). ...
Background:
Introduction of daily PE classes has been proposed as a measure to reduce childhood obesity. At the same time, the prevalence of activity-related fractures among children is increasing. Previously, we have found that the fracture rate per 10,000 hours of activity amounted to 1.9 for snowboarding, 0.79 for handball, 0.44 for football and 0.35 for trampolining. The purpose of the study is to describe the prevalence of school-related fractures, as well to investigate whether PE exposes schoolchildren aged 6-16 to a heightened risk of fractures when compared to other activities.
Material and method:
Fractures in children aged 6-16 resident in the catchment area of Akershus University Hospital were recorded over a 12-month period. Information on fractures sustained at school, defined as fractures that occurred during school hours, during supervised after-school activities (SFO) or on the way to or from school, was retrieved from the records. The fractures were classified according to activity, time of the school day when the injuries occurred and their anatomical location.
Results:
Of a total of 1,144 fractures registered among children aged 6-16, altogether 422 (37%) were school-related, equivalent to 8.5 per 1000 children. Of these, 257 (61%) were in boys. Altogether 276 (65.4%) fractures occurred outdoors, 135 (32%) occurred during breaks and 94 (22.3%) during PE classes. The fracture rate for PE amounted to 0.29 fractures per 10,000 hours (95% CI: 0.22-0.33).
Interpretation:
The fracture rate for PE classes is lower than for a number of other common leisure activities. As a measure to increase children's physical activity, the introduction of daily PE classes will be a beneficial alternative with a view to the risk of injury.
... Parent tolerance of injury during play was assessed using an 8-item questionnaire developed by the authors, based on relevant literature and expert opinion (Howard et al., 2009;Kvalnes et al., 2023;Nixon et al., 2003;Rubie-Davies et al., 2007;Stathakis and B.-, 2020). The 'Acceptability of School Play Injury' scale asks participants to select items they consider to be 'a normal part of child development and therefore, may sometimes occur during outdoor play at school'. ...
Background:
Children naturally seek risk in play and adventurous play outdoors confers many benefits, including the potential to increase moderate-to-vigorous physical activity (MVPA). This study aimed to investigate the relationship between parent attitudes to risk and injury, and their elementary school-aged child's daily adventurous play and MVPA.
Methods:
A panel sample of 645 Australian parents/guardians completed an online survey consisting of several validated measures of risk and injury attitudes, and physical activity and play behaviour. Data were analysed via descriptive statistics, univariate and multivariable regressions using Stata 17. A series of exploratory univariate logistic regressions were conducted, followed by a series of multivariable logistic regressions fitted to test the association between parent risk and injury attitudes and (i) children's MVPA, (ii) active play and (iii) adventurous play, while adjusting for socio-demographic factors.
Results:
Most adult participants (81%) were female. The mean age of the child participants (53% male) was 8.6 years (SD = 2.4). On average, parents were positive about children's engagement with risk, however, 78% of parents had low tolerance of risk when presented with specific play scenarios, and attitudes towards injuries varied, with mothers more concerned than fathers. After adjusting for confounders, children with parents who were tolerant of risk in play were more likely to meet the MVPA guideline of ≥60 min daily (OR 2.86, CI: 1.41, 5.82, p < 0.004) and spend more time playing adventurously (OR 3.03, CI: 1.82, 5.06, p < 0.001). Positive associations for MVPA and adventurous play were observed across all models examining parent attitudes to risk and injury. Younger children engaged in more play and physical activity, however, more positive parent attitudes appeared to moderate the age-related influences.
Conclusions:
We found a divergence between the outcomes parents desire for their children through engagement with risk and the play activities they are comfortable with in practice. Parent attitudes to risk and injury are potentially modifiable factors that may increase children's affordances for adventurous play and physical activity. Parent education interventions that provide practical approaches to address injury concerns and support children's risk-taking in play outdoors are recommended.
... The injury data are clear in indicating the rarity of head injuries. For example, studies that have collected playground injury statistics across entire school districts in Canada and New Zealand have not documented any head injuries (Howard, Macarthur, Rothman, Willan, & Macpherson, 2009;Rubie-Davies & Townsend, 2007). A US study of playground-related head injuries between 2001 and 2013 found rates indicating that an elementary school with 500 students would experience one emergency department visit every 5-6 years, and a city of 700,000 would experience one hospitalization every year (Cheng et al., 2016). ...
... The overall positive health effects secondary to risky outdoor play (eg. neuromuscular development, balance, agility, strength, etc.) may justify why children should not avoid this type of activity [14][15]. Nevertheless, educating parents on preventative behavior and considering the age and physical maturity of children when choosing playground activities may help reduce the number of serious injuries. ...
... Half of the arm fractures that we observed occurred from falls off play equipment onto the surfacing with the other half occurring as a result of standing height falls elsewhere on the playground. This is consistent with reports of school playground injuries from other countries [25]. If our data are representative, then the 160,000 annual emergency department visits in the US from playground falls might be reduced by 90,000 to 110,000 and the 5,900 playground fall fracture-related hospitalizations might be reduced by 3,900 to 4,700. ...
Background:
The risk of playground injuries, especially fractures, is prevalent in children, and can result in emergency room treatment and hospital admissions. Fall height and surface area are major determinants of playground fall injury risk. The primary objective was to determine if there was a difference in playground upper extremity fracture rates in school playgrounds with wood fibre surfacing versus granite sand surfacing. Secondary objectives were to determine if there were differences in overall playground injury rates or in head injury rates in school playgrounds with wood fibre surfacing compared to school playgrounds with granite sand surfacing.
Methods and findings:
The cluster randomized trial comprised 37 elementary schools in the Toronto District School Board in Toronto, Canada with a total of 15,074 students. Each school received qualified funding for installation of new playground equipment and surfacing. The risk of arm fracture from playground falls onto granitic sand versus onto engineered wood fibre surfaces was compared, with an outcome measure of estimated arm fracture rate per 100,000 student-months. Schools were randomly assigned by computer generated list to receive either a granitic sand or an engineered wood fibre playground surface (Fibar), and were not blinded. Schools were visited to ascertain details of the playground and surface actually installed and to observe the exposure to play and to periodically monitor the depth of the surfacing material. Injury data, including details of circumstance and diagnosis, were collected at each school by a prospective surveillance system with confirmation of injury details through a validated telephone interview with parents and also through collection (with consent) of medical reports regarding treated injuries. All schools were recruited together at the beginning of the trial, which is now closed after 2.5 years of injury data collection. Compliant schools included 12 schools randomized to Fibar that installed Fibar and seven schools randomized to sand that installed sand. Noncompliant schools were added to the analysis to complete a cohort type analysis by treatment received (two schools that were randomized to Fibar but installed sand and seven schools that were randomized to sand but installed Fibar). Among compliant schools, an arm fracture rate of 1.9 (95% confidence interval [CI] 0.04-6.9) per 100,000 student-months was observed for falls into sand, compared with an arm fracture rate of 9.4 (95% CI 3.7-21.4) for falls onto Fibar surfaces (p< or =0.04905). Among all schools, the arm fracture rate was 4.5 (95% CI 0.26-15.9) per 100,000 student-months for falls into sand compared with 12.9 (95% CI 5.1-30.1) for falls onto Fibar surfaces. No serious head injuries and no fatalities were observed in either group.
Conclusions:
Granitic sand playground surfaces reduce the risk of arm fractures from playground falls when compared with engineered wood fibre surfaces. Upgrading playground surfacing standards to reflect this information will prevent arm fractures.
Trial registration:
Current Controlled Trials ISRCTN02647424.
Aim
To examine the incidence and outcomes of paediatric playground and tree-related injuries in the Midland region of New Zealand.
Methods
A retrospective review of Midland Trauma Registry hospitalisation data between January 2012 and December 2018 was undertaken. Cases included children aged 0–14 years hospitalised for playground and tree-related injuries. Demographic and event information, injury severity and hospital-related outcomes were examined.
Results
Playground and tree-related hospitalisations (n = 1941) occurred with an age-standardised rate of 144.3/100 000 (confidence interval (CI) 127.3–161.3) and increased 1.4% (CI 1.3–4.2%) annually. The highest incidence was observed in 5–9-year olds (248.8/100 000) with 0–4 and 10–14-year olds at 86.0 and 89.2/100 000, respectively. Injuries most commonly occurred at home, school or pre-school (77.1%), 93.7% were due to falls and, the upper extremity was the most frequently injured body region (69.9%), particularly due to forearm (55.6%) and upper arm (34.7%) fractures. Tree-related incidents comprised 11.6% of all injuries and explained 57.1% of injuries classified as major severity. Fifty-eight percent of children were hospitalised for 1 day and 97.0% for less than 5 days. Estimated hospital costs were NZ$1.2 million annually with a median of NZ$3898 per incident. Injuries classified as minor severity accounted for 86.5% of the total estimated cost.
Conclusion
Children aged 5–9 years' experience high rates of costly hospitalisation for playground and tree-related injuries. Targeted injury prevention initiatives, particularly in the home and school environments, are imperative to reduce the incidence and burden of playground and tree-related injuries to affected children, their families and hospital resources.
Background:
Children's risky play is associated with a variety of positive developmental, physical and mental health outcomes, including greater physical activity, self-confidence and risk-management skills. Children's opportunities for risky play have eroded over time, limited by parents' fears and beliefs about risk, particularly among mothers. We developed a digital tool and in-person Risk-reframing (RR) workshop to reframe parents' perceptions of risk and change parenting behaviours. The purpose of this paper is to describe our RR intervention, rationale and protocol for a randomised controlled trial to examine whether it leads to increases in mothers' tolerance of risk in play and goal attainment relating to promoting their child's opportunities for risky play.
Methods:
We use a randomised controlled trial design and will recruit a total of 501 mothers of children aged 6-12 years. The RR digital tool is designed for a one-time visit and includes three chapters of self-reflection and experiential learning tasks. The RR in-person tool is a 2-h facilitated workshop in which participants are guided through discussion of the same tasks contained within the digital tool. The control condition consists of reading the Position Statement on Active Outdoor Play. Primary outcome is increased tolerance of risk in play, as measured by the Tolerance of Risk in Play Scale. Secondary outcome is self-reported attainment of a behaviour-change goal that participants set for themselves. We will test the hypothesis that there will be differences between the experimental and control conditions with respect to tolerance of risk in play using mixed-effects models. We will test the hypothesis that there will be differences between the experimental and control conditions with respect to goal attainment using logistic regression.
Discussion:
The results of this trial will have important implications for facilitating the widespread change in parents' risk perception that is necessary for promoting broad societal understanding of the importance of children's risky play. In addition, the findings may provide relevant information for the design of behaviour-change tools to increase parental tolerance of risk.
Trial registration:
ClinicalTrials.gov, ID: NCT03374683 . Retrospectively registered on 15 December 2017.
Numerous initiatives by private philanthropies and the US government have supported school size reduction policies as an educational reform intended to improve student outcomes. Empirical evidence to support these claims, however, is underdeveloped. In this article, we draw on information from a longitudinal dataset provided by the Northwest Evaluation Association covering more than 1 million students in 4 US states. Employing a student fixed effects strategy, we estimate how a student’s achievement changes as (s)he moves between schools of different sizes. We find evidence that students’ academic achievement in math and reading declines as school size increases. The negative effects of large schools appear to matter most in higher grades, which is also when schools tend to be the largest.
Outdoor play spaces can contribute to children’s healthy development and learning in important ways. However, changes in society
have increasingly limited the capacity of the outdoors to contribute to the educational experience of children. The following
describes four crucial aspects that should be addressed when designing outdoor play spaces at childcare centres and schools.
This review examined 57 post-1990 empirical studies of school size effects on a variety of student and organizational outcomes. The weight of evidence provided by this research clearly favors smaller schools. Students who traditionally struggle at school and students from disadvantaged social and economic backgrounds are the major benefactors of smaller schools. Elementary schools with large proportions of such students should be limited in size to not more than about 300 students; those serving economically and socially heterogeneous or relatively advantaged students should be limited in size to about 500 students. Secondary schools serving exclusively or largely diverse and/or disadvantaged students should be limited in size to about 600 students or fewer, while those secondary schools serving economically and socially heterogeneous or relatively advantaged students should be limited in size to about 1,000 students.
To determine the risk for injury associated with environmental hazards in public playgrounds.
One hundred and seventeen playgrounds operated by municipalities or school boards in and around Kingston, Ontario, Canada.
A regional surveillance database was used to identify children presenting to emergency departments who were injured on public playgrounds; each case was individually matched (by sex, age, and month of occurrence) with two controls--one non-playground injury control, and one child seen for non-injury emergency medical care. Exposure data were obtained from an audit of playgrounds conducted using Canadian and US safety guidelines. Exposure variables included the nature of playground hazards, number of hazards, frequency of play, and total family income. No difference in odds ratios (ORs) were found using the two sets of controls, which were therefore combined for subsequent analysis.
Multivariate analysis showed strong associations between injuries and the use of inappropriate surface materials under and around equipment (OR 21.0, 95% confidence interval (CI) 3.4 to 128.1), appropriate materials with insufficient depth (OR 18.2, 95% CI 3.3 to 99.9), and inadequate handrails or guardrails (OR 6.7, 95% CI 2.6 to 17.5).
This study confirms the validity of guidelines for playground safety relating to the type and depth of surface materials and the provision of handrails and guardrails. Compliance with these guidelines is an important means of preventing injury in childhood.
To measure the incidence of childhood fractures in a defined population.
Accident and emergency (A&E) departments covering the Swansea and Neath Port Talbot areas of South Wales in 1996.
Linkage of data from A&E departments with population data to produce fracture incidence rates by anatomical site and cause in children aged 0-14 years.
During 1996, 2463 new fractures occurred in 2399 residents yielding a fracture rate of 36.1/1000 children. Fractures were more common in boys than girls and increased with age in both groups. Sports and leisure activities accounted for 36% of fractures, assaults for 3.5%, and road traffic accidents 1.4%. Fractures of the radius/ulna were most frequent (36%).
The fracture rate in South Wales children is twice the rate reported in previous studies. Further research is required to elucidate the reasons behind this high rate. Many fractures could be prevented by the use of safer surfaces in school playgrounds, and wrist protection in in-line skaters and possibly in soccer players.
To evaluate whether surface characteristics (absorption level (g-max), material) and the height of play equipment are related to the occurrence and severity of injuries from falls.
During the summers of 1991 and 1995, conformity of play equipment to Canadian standards was assessed in a random sample (n = 102) of Montreal public playgrounds. Surface absorption (g-max) was tested using a Max Hic instrument and the height of equipment was measured. Concurrently, all injuries presenting at the emergency department of Montreal's two children's hospitals were recorded and parents were interviewed. Inspected equipment was implicated in 185 injuries. The g-max measurements (1995 only) were available for 110 of these playground accidents.
One third of falls (35 %) occurred on a surface exceeding 200 g and the risk of injury was three times greater than for g level lower than 150 (95% confidence interval (CI) 1.45 to 6.35). On surfaces having absorption levels between 150 g and 200 g, injuries were 1.8 times more likely (95% CI 0.91 to 3.57). Injuries were 2.56 times more likely to occur on equipment higher than 2 m compared with equipment lower than 1.5 m. Analysis of risk factors by severity of injury failed to show any positive relationships between the g-max or height and severity, whereas surface material was a good predictor of severity.
This study confirms the relationships between risk of injury, surface resilience, and height of equipment, as well as between type of material and severity of injury. Our data suggest that acceptable limits for surface resilience be set at less than 200 g, and perhaps even less than 150 g, and not exceed 2 m for equipment height. These findings reinforce the importance of installing recommended materials, such as sand, beneath play equipment.
To present the development of a novel multidisciplinary method to investigate physical risk factors for playground related arm fracture.
Previous playground injury research has been limited in its ability to determine risk factors for arm fractures, despite their common and costly occurrence. Biomechanical studies have focused exclusively on head injury. Few epidemiological studies have quantified surface impact attenuation and none have investigated specific injury outcomes such as arm fracture.
An unmatched case-control study design was developed. An instrumented child dummy and rig were designed to simulate real playground falls in situ. Validated output from the dummy was used to quantify arm load. Other field measurements included equipment height, fall height, surface depth, headform deceleration, and head injury criterion.
Validated methods of biomechanics and epidemiology were combined in a robust design. The principle strength of this method was the use of a multidisciplinary approach to identify and quantify risk and protective factors for arm fracture in falls from playground equipment. Application of this method will enable countermeasures for prevention of playground related arm fracture to be developed.
The purpose of this study was to determine the frequency of use of play equipment in public schools and parks in Brisbane, Australia, and to estimate an annual rate of injury per use of equipment, overall and for particular types of equipment.
Injury data on all children injured from playground equipment and seeking medical attention at the emergency department of either of the two children's hospitals in the City of Brisbane were obtained for the years 1996 and 1997. Children were observed at play on five different pieces of play equipment in a random sample of 16 parks and 16 schools in the City of Brisbane. Children injured in the 16 parks and schools were counted, and rates of injury and use were calculated.
The ranked order for equipment use in the 16 schools was climbing equipment (3762 uses), horizontal ladders (2309 uses), and slides (856 uses). Each horizontal ladder was used 2.6 times more often than each piece of climbing equipment. Each horizontal ladder was used 7.8 times more than each piece of climbing equipment in the sample of public parks. Slides were used 4.6 times more than climbing equipment in parks and 1.2 times more in public schools. The annual injury rate for the 16 schools and 16 parks under observation was 0.59/100 000 and 0.26/100 000 uses of equipment, respectively.
This study shows that annual number of injuries per standardized number of uses could be used to determine the relative risk of particular pieces of playground equipment. The low overall rate of injuries/100 000 uses of equipment in this study suggests that the benefit of further reduction of injury in this community may be marginal and outweigh the economic costs in addition to reducing challenging play opportunities.
The incidence of distal forearm fractures in children peaks around the time of the pubertal growth spurt, possibly because physical activity increases at the time of a transient deficit in cortical bone mass due to the increased calcium demand during maximal skeletal growth. Changes in physical activity or diet may therefore influence risk of forearm fracture.
To determine whether there has been a change in the incidence of distal forearm fractures in children in recent years.
Population-based study among Rochester, Minn, residents younger than 35 years with distal forearm fractures in 1969-1971, 1979-1981, 1989-1991, and 1999-2001.
Estimated incidence of distal forearm fractures in 4 time periods.
Comparably age- and sex-adjusted annual incidence rates per 100 000 increased from 263.3 (95% confidence interval [CI], 231.1-295.4) in 1969-1971 to 322.3 (95% CI, 285.3-359.4) in 1979-1981 and to 399.8 (95% CI, 361.0-438.6) in 1989-1991 before leveling off at 372.9 (95% CI, 339.1-406.7) in 1999-2001. Age-adjusted incidence rates per 100 000 were 32% greater among male residents in 1999-2001 compared with 1969-1971 (409.4 [95% CI, 359.9-459.0] vs 309.4 [95% CI, 259.3-359.5]; P =.01) and 56% greater among female residents in the same time periods (334.3 [95% CI, 288.6-380.1] vs 214.6 [95% CI, 174.9-254.4]; P<.001). The peak incidence and greatest increase occurred between ages 11 and 14 years in boys and 8 and 11 years in girls.
There has been a statistically significant increase in the incidence of distal forearm fractures in children and adolescents, but whether this is due to changing patterns of physical activity, decreased bone acquisition due to poor calcium intake, or both is unclear at present. Given the large number of childhood fractures, however, studies are needed to define the cause(s) of this increase.
This study examined the type of injury, fall heights and measures of impact attenuation of surfaces on which children fell from horizontal ladders and track rides.
All injured children who presented to two children's hospitals and received medical attention following a fall from a horizontal ladder or track ride in a public school or park during 1996--1997 were interviewed and the playground visited.
The number of children who fell from horizontal ladders and track rides and presented to hospitals with injury was 118. Of those children, 105 were injured when they hit the ground and data were available on 102 of those playground undersurfaces. Fractures to the arm or wrist were the most common injury. The median height fallen by children was 1930 mm, 73% of injuries were from falls greater than 1800mm. In 41% of sites, the surface was deficient in impact absorbing properties for the height of the equipment. Fractures were no more likely on loose surfaces than other surfaces, such as rubber matting (p = 0.556) but more prevalent on compliant than non-compliant surfaces. Relative to falls occurring on noncompliant surfaces, the odds of a fracture occurring on a compliant surface was 2.67 (95% CI 0.88-8.14).
Modification of the height of horizontal ladders and track rides to 1800mm is preferable to removal of such equipment. The prevalence of fractures on compliant surfaces suggests that the threshold of 200g or 1000 head injury criteria (HIC) needs to be revisited, or additional test criteria added to take account of change in momentum that is not presently accounted for with either g-max on HIC calculations.
Objectives —To evaluate whether surface characteristics (absorption level (g-max), material) and the height of play equipment are related to the occurrence and severity of injuries from falls.
Setting and methods —During the summers of 1991 and 1995, conformity of play equipment to Canadian standards was assessed in a random sample (n=102) of Montreal public playgrounds. Surface absorption (g-max) was tested using a Max Hic instrument and the height of equipment was measured. Concurrently, all injuries presenting at the emergency department of Montreal's two children's hospitals were recorded and parents were interviewed. Inspected equipment was implicated in 185 injuries. The g-max measurements (1995 only) were available for 110 of these playground accidents.
Results —One third of falls (35 %) occurred on a surface exceeding 200 g and the risk of injury was three times greater than for g level lower than 150 (95% confidence interval (CI) 1.45 to 6.35). On surfaces having absorption levels between 150 g and 200 g, injuries were 1.8 times more likely (95% CI 0.91 to 3.57). Injuries were 2.56 times more likely to occur on equipment higher than 2 m compared with equipment lower than 1.5 m. Analysis of risk factors by severity of injury failed to show any positive relationships between the g-max or height and severity, whereas surface material was a good predictor of severity.
Conclusions —This study confirms the relationships between risk of injury, surface resilience, and height of equipment, as well as between type of material and severity of injury. Our data suggest that acceptable limits for surface resilience be set at less than 200 g, and perhaps even less than 150 g, and not exceed 2 m for equipment height. These findings reinforce the importance of installing recommended materials, such as sand, beneath play equipment.
General Guidelines for New and Existing Playgrounds Equipment Surfacing, NZS 5828, Parts 2 and 3. Wellington, New Zealand: Standards Association of New Zealand
- Standards Association
Standards Association of New Zealand. General Guidelines for New and Existing Playgrounds Equipment Surfacing, NZS 5828, Parts 2 and 3. Wellington, New Zealand: Standards Association of New Zealand; 1997. 40 d Journal of School Health d January 2007, Vol. 77, No. 1 d ª 2007, American School Health Association
Playground Guide to Setting and to Installation and Maintenance of Equipment, Austra-lian Standard 2155, Parts 1 and 2. Sydney, Australia: Standards Association of Australia
- Standards Association
- Australia
Standards Association of Australia. Playground Guide to Setting and to Installation and Maintenance of Equipment, Austra-lian Standard 2155, Parts 1 and 2. Sydney, Australia: Standards Association of Australia; 1997.
Rockwood and Wilkins' Fractures in Children
- K Wilkins
Wilkins K. Incidence of fractures in children. In: Beaty J,
Kosser J, eds. Rockwood and Wilkins' Fractures in Children. 5th
ed. Philadelphia, Pa: Lippincott, Williams & Wilkins; 2006:
chapter 1, 3-20.
Playground injuries: recent attempts to begin to address what we don't know
- M Mackay
MacKay M. Playground injuries: recent attempts to begin to
address what we don't know. Inj Prev. 2003;9:194-196.
Children's Playspaces and Equipment, CAN/CSA-Z614-03
Canadian Standards Association. Children's Playspaces and
Equipment, CAN/CSA-Z614-03. Toronto, Ontario: Association
canadienne de normalisation; 2003.
British Standards Institution. Play Equipment Intended for Permanent Installation Outdoors
British Standards Institution. Play Equipment Intended for Permanent Installation Outdoors, BS 5696, Parts 2 and 3. London:
British Standards Institution; 1979.
General Guidelines for New and Existing Playgrounds Equipment Surfacing
Standards Association of New Zealand. General Guidelines for
New and Existing Playgrounds Equipment Surfacing, NZS 5828,
Parts 2 and 3. Wellington, New Zealand: Standards Association
of New Zealand; 1997.