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Fig. 1 A, Clinical photograph and B, intraoperative fluoroscopic image of a 2-year-old boy with a history of factor VIII deficiency who was riding an all-terrain vehicle with his mother when his foot was caught in the chain, amputating his first through fourth toes. Reprinted from Sawyer JR, Kelly DM, Kellum E, Warner WC Jr: Orthopaedic aspects of all-terrain vehicle–related Injury. J Am Acad Orthop Surg 2011;19(4):219-225.


Published 4/1/2011
Terry Stanton

ATVs: Injuries are part of the terrain

Children account for a disturbing proportion of four-wheeler accidents

Since all-terrain vehicles (ATVs) were introduced in the United States in the 1970s, their popularity and use have risen almost exponentially. Just as dramatic as the increase in use has been the number of injuries associated with ATV accidents.

The number of annual ATV-related injuries has increased from 10,100 in 1982 to 58,200 by 1992, and to more than 150,000 in 2007. The number of fatalities per year has also increased—from 29 in 1982 to 766 in 2007. More than a quarter of the total 10,281 deaths reported from 1982 to 2009 were children younger than 16 years.

These unsettling statistics are reported and reviewed in an article in the April 2011 issue of the Journal of the AAOS (JAAOS) by Jeffrey R. Sawyer, MD, and his colleagues at the Campbell Clinic, University of Tennessee.

The alarming increase in injury and mortality from the use of ATVs is attributable not just to increased use but to the production of larger, faster, and more powerful ATVs. The first ATVs typically had a 7-horsepower, 89 cc engine and weighed between 160 and 200 pounds; some modern vehicles have engines of more than 600 cc and 50 horsepower, weigh more than 400 pounds, and reach top speeds of more than 100 miles per hour.

The original ATVs were three-wheeled vehicles designed for farm use. In 1988, however, the U.S. Consumer Product Safety Commission imposed a 10-year ban on their use due to their dramatic injury rates. This was followed by a directive limiting the sale of adult-sized vehicles for use by children and providing for safety awareness and education programs. Since the development of four-wheeled vehicles and the expiration of the ban, the vehicles have became more powerful, with a corresponding rise in ATV-associated injuries in all age groups, especially in young riders.

Who’s at risk?
ATV injuries are most common in white men aged 18 to 30 years; they usually occur in rural areas, and 80 percent of injuries are to the driver rather than to a passenger. Although ATVs are used for work activities, injuries occur more frequently during recreational riding. Although only 15 percent of ATV riders are children, they account for 27 percent of ATV injuries, and 28 percent of deaths.

Injuries are also increasing in persons older than 50 years. When older riders are injured, they have more frequent and more severe thoracic injuries, with longer hospital stays and more complications.

All 50 states have ATV-related legislation, with considerable variation in scope; 31 states require helmet use; and 28 have minimum age laws. However, legislation has been ineffective in preventing ATV-related death and injury.

To further explore the issues covered in the JAAOS article and to gain the clinical perspective of a surgeon who sees patients with ATV injuries, AAOS Now spoke to Dr. Sawyer.

AAOS Now: In addition to this review article, you are conducting research on ATV injuries. What brought you to this subject?

Dr. Sawyer: This work all started when I came to Tennessee. I was struck by the prevalence of ATV-related injuries in children that I was seeing. What struck me was how common these injuries are, and how young the children are, and how little awareness parents have about the dangers of ATV use by children (Fig. 1). We’ve looked at this both locally and nationally over the past 4 years, which prompted the JAAOS article.

Our referral area in Memphis has about a 300-mile radius, and includes several rural communities. ATVs are more prevalent in the culture, and kids are outdoors more. So for a variety of reasons, more ATV injuries occur in the South.

The biggest factor is the power of the vehicles. They are much bigger and faster than initially. Now, they’re really motor vehicles, but they don’t have the safety features of automobiles. Nor are people required to take any kind of formal training to drive an ATV. It’s the worst of both worlds.

AAOS Now: You note that the mechanism of injury is revealing in regard to children.

Dr. Sawyer: The way the accidents occur was interesting, and we are studying this prospectively. The majority of accidents occur in rollover, where the vehicle starts to roll and either ejects or pins the rider. That raised the concept of vehicle-rider mismatch, which may be why so many children are injured. The vehicle can weigh hundreds of pounds, and once it starts to roll, children don’t have the body mass or the muscular strength to correct the rollover.

One of our studies found the mean age of riders to be 12.8 years. That’s below the age in the AAOS guidelines, which is 16 years (Table 1). Children just don’t have the cognitive abilities, the depth perception, or the emotional maturity and judgment to operate these vehicles.

Medical societies have education programs, but the message really isn’t getting to the parents or the kids. So we are working to raise awareness of the problem.

I’ve done seminars with Kevin Shea, MD, who is in Boise, Idaho. He rides ATVs with his kids, and they do it safely. My kids are too young, and they don’t ride. Our take-home message is we don’t want to ban four-wheelers, but we want to show how we do it right and how we do it safely. We are working with the Pediatric Orthopaedic Society of North America to develop recommendations on ATV use.

AAOS Now: What are some other factors?

Dr. Sawyer: There is the Generation X effect, where kids see these highly trained professional riders on TV, and go out and try to imitate them. Also, these vehicles are not designed for on-road use. We see kids getting hurt on-road, which is usually more recreational use than utility use—such as hunting and fishing.

Intoxication in accidents is probably underreported. In adolescents, marijuana and other drugs are also a problem.

Orthopaedic surgeons need to think about intoxication and secondary injuries. The statistics surprised me.

We’ve prepared an educational campaign for nurses, emergency department physicians, and orthopaedic surgeons. We are also working for legislation in Tennessee on some of these issues, in regard to safety classes and other steps. That’s been difficult because the ATV industry has a powerful lobby here.

These are high-energy injuries; of children with ATV injuries, a fourth to a third of them will have an intra-abdominal, an intrathoracic, or a head injury. As orthopaedic surgeons, we might see a kid with a femur fracture, but we need to look at his belly and his head to make sure there aren’t other injuries. And we should look for intoxication.

AAOS Now: What should orthopaedic surgeons do to counsel patients?

Dr. Sawyer: This is a great time to educate because the family is now sensitized to the situation. Use the opportunity.

Our review of the literature found that ATV use after the first accident didn’t change. Even more concerning, after an accident, helmet use didn’t change. The bottom line is that injuries don’t really change behavior. The parents don’t always understand that ATVs can be dangerous and riders need to wear helmets. The message may be out there, but doesn’t sink in, even when an accident occurs. We’re looking for suggestions, for something other than education or legislation.

Counseling patients and families on this is no different than counseling elderly patients about osteoporosis or fall prevention. We can all be educators. We have the family and their attention, with an obvious emotional attachment because of the accident. One injury has already happened, but maybe we can prevent a second injury or protect a sister or brother from injury.

Even when ATV use results in a head injury, it doesn’t usually change helmet use. It makes you wonder what it will take for people to realize that they need to change their behavior. I tell families that I can fix a broken bone, but I can’t fix a head injury.

Not even legislation changes behavior. A lot of these accidents occur on private land. Enforcement of helmet laws is a big problem, which is why education is so important.

The age issue is a tough one. It’s hard to come out with policy statements. Even with an age guideline, kids will ride anyway. So maybe age is tied to the size of the vehicle, 16 or older for adult-sized vehicles, with age- and weight-appropriate vehicles for younger children. Also, adult supervision plays a role.

AAOS Now: What is your clinical advice to surgeons treating injured riders?

I tell my colleagues to look for that second injury. The femur fracture won’t kill a child, but the missed abdominal injury or the missed head injury will. Treat ATV accident cases as high-energy injuries.

I am also concerned about the child who is taken to a community hospital that doesn’t have an in-house thoracic surgeon or in-house neurosurgeon. So, emergency department physicians need to look for that secondary injury and refer the child if they find it.

Coauthors of “Orthopaedic Aspects of All-terrain Vehicle–related Injury” are Derek M. Kelly, MD; Ethan Kellum, MD; and William C. Warner Jr., MD.

Disclosure information: Dr. Sawyer—Medtronic, Smith & Nephew, Wright Medical Technology; Dr. Warner—Saunders/Mosby-Elsevier, Medtronic Sofamor Danek. Drs. Kellum and Kelly report no conflicts.

Terry Stanton is senior science writer for AAOS Now. He can be reached at tstanton@aaos.org

AAOS spreads the word on ATV safety
The AAOS has played an active role in promoting ATV safety and preventing accidents and injury. The Academy has a position statement on ATV use, which calls for driver training, safety equipment, and age limits on driving. In addition, the AAOS has been involved in efforts to enact state legislation and to educate the public about safe riding. In 2007, in partnership with the Orthopaedic Trauma Association (OTA), the Academy embarked on a public awareness campaign, including radio and print ads and various educational materials.

Craig S. Roberts, MD, of the University of Louisville, proposed the campaign after he compiled and reviewed databases on ATV injuries around Kentucky. “I was shocked,” he said. “We had to get the message out.”

The campaign was quite effective, both with the public and with elected officials. “It had an incredible impact on legislators,” he said.

In North Dakota, the campaign was enlisted to successfully oppose legislation to lower the minimum age for ATV driving. It was also cited in a recent report to Congress.

In many parts of the country, enacting regulation on activities such as ATV use can be a delicate matter. “It can become a civil liberties issue over risky behavior,” said Dr. Roberts. “The person in the country has a different perspective. It’s a highly charged, emotional issue for many people. ATVs are not intrinsically evil; it’s how people operate them.”

Frank B. Kelly, MD, was chair of the AAOS Communications Cabinet when the campaign was launched. He notes that the Academy “has made injury prevention a cornerstone of our public relations campaigns.” He urges members to avail themselves of Academy resources to educate patients, including the current campaign against distracted driving.

“Whether you put posters in your office, give a presentation to a local civic group, or write a letter about injury prevention to your local newspaper, you can spread the message of injury prevention,” he says. To learn more about the AAOS injury prevention campaign and available resources, visit AAOS Public Relations online or e-mail publicrelations@aaos.org

Additional Resources:
AAOS position statement on ATVs

Adult-Sized ATVs Are Not Safe for Kids; Statistics Startling

ATV and Motocross Sports – High Velocity Toys Merit Caution

ATV and Motocross Sports – High Velocity Toys Merit Caution

Trends in ATV-related Spine Injuries in Children in the US: 1997-2006 KIDS Database