Trampoline Injuries in a Statewide Trauma System

Key Takeaways

This study examined trauma patients who presented to Pennsylvania Trauma Centers between 2016 and 2018 and compared trampoline-related injuries to the general trauma population.

Introduction

Every year in the United States, trampoline use results in a multitude of traumatic injuries. Of these traumas, many injured patients are under 18 years of age. In 2017, the leading cause of death in children was found to be unintentional injuries. ¹ On average, there were over 88,000 trampoline-related injury emergency department (ED) visits annually (2000-2005) in the United States for pediatric patients (0-18 years). ² Between 2002 and 2011, there were even more ED visits for trampoline-related injuries, which was estimated to be over 1,000,000 visits; as a result, trampoline injuries have led to over 288,000 fractures annually between 2002 and 2011. The average patient presenting with a trampoline injury was found to be 9.5 years old, with 92.7% of patients aged 16 years or younger. ³

Along with these astounding numbers, the incidence of trampoline-related injuries appears to be increasing.^3,4 A study done at the Children’s Hospital of Colorado found the annual incidence of trampoline-related injuries increased about 3.85% per year between 2008 and 2017. ⁴ This rate is alarming, especially given the population age.

The current American standards set forth by the American Academy of Orthopaedic Surgeons (AAOS) and the American Academy of Pediatrics (AAP) state that no child under the age of 6 years should use a trampoline, that all trampoline jumpers should be supervised at all times, and regular checks should be performed on safety equipment surrounding the trampoline.^5,6 It is well known that trampolines can be a particular source of danger, especially in children. We sought to examine the profile of those patients with trampoline injuries in the Pennsylvania Trauma System and evaluate if changes should be made to these professional standards. We hypothesized there would be certain injury patterns predicative of trampoline injuries, including increased incidence of long bone injuries among pediatric patients.

Methods

Following review and approval by the institutional review board, the Pennsylvania Trauma Outcome Study (PTOS) database was retrospectively queried from the years of 2016-2018. Pennsylvania Trauma Outcome Study is a statewide trauma registry managed by the Pennsylvania Trauma Systems Foundation (PTSF). The PTSF, established in 1984 as part of the Emergency Medical Services Act, is a private, nonprofit organization that serves as the accrediting body for all trauma centers, both adult and pediatric alike, located in the Commonwealth of Pennsylvania. Trauma centers are granted accreditation according to the standards set forth by the American College of Surgeons Committee on Trauma Resources for Optimal Care of the Injured Patient. ⁷ In order to maintain trauma center accreditation, all trauma centers in PA must submit de-identified patient data to PTOS for all patients meeting one or more of the following criteria:

⁃ Intensive care unit admission,

Any trauma patient admitted to a Pennsylvania trauma center between the years of 2016-2018 with a trampoline-related injury (ICD-10 activity code Y93.44) was included in this analysis. Patients presenting dead on arrival were excluded from the study. Variables of interest included age, sex, race, ethnicity, injury type, systolic blood pressure (SBP), pulse, shock index, Injury Severity Score (ISS), abbreviated injury scale (AIS) body regions injured (head, face, neck, thorax, abdomen, spine, upper extremity, and lower extremity), hospital length of stay in days, and mortality.

Injury patterns in the form of AIS body regions were examined in the trampoline-injured patients. Within the trampoline injury group, pediatric patients (age <15 years) were subsequently compared to adult (age ≥15 years) patients injured on a trampoline. Patient demographics and clinical variables were compared between those with trampoline injury vs those without. Univariate analysis in the form of t-tests and chi-squared tests were used to analyze trampoline injury patterns and assess the differences between those with a trampoline injury vs those who did not have a trampoline injury. All data manipulation and statistical analyses were performed using Stata/IC, version 16.0. Significance was defined by a confidence level of 95% and a p of <.05.

Results

From the PTOS query, 107 trauma patients had at least one trampoline injury from 2016 to 2018, resulting in 122 body regions affected overall. All of these patients were discharged alive and had a blunt mechanism of injury. Of the 107 patients, the most common injury type was injury to the extremities (90/107 patients [84.1%]) with 54 (50.5%) patients having upper extremity injury and 36 (33.6%) patients having lower extremity injury. Ten (9.35%) patients had injuries to the spine, five (4.67%) had a head injury, and five (4.67%) had an injury to the face. One patient (.93%) had an injury to the chest and one patient (.93%) had an injury to the abdomen. When comparing pediatric (age <15 years) trampoline injuries (n = 81, 75.7%) to adult (age ≥15 years) trampoline injuries (n = 26, 24.3%), pediatric patients made up 76/90 patients (84.4%) who sustained injury to an extremity. Of those with an injury to an upper extremity, all but one patient was considered pediatric (53/54 patients, 98.1%). Pediatric patients also made up the majority of patients with injury to a lower extremity (23/36 patients, 63.9%). Adults made up most of the injuries to the spine (8/10, 80%).

When comparing patients with trampoline injuries to the greater trauma population who did not have trampoline injuries, those with trampoline injuries were significantly younger (mean age: 13 years vs 49 years, P < .001). Almost half of the patients injured on a trampoline (49.5%) were under 10 years of age. There was no difference in sex between the groups (P = .428). Patients with trampoline injuries had significantly lower Injury Severity Scores (4 vs 9, P<.001). Trampoline-injured patients had a lower median length of stay in the hospital (1 day vs 3 days, P<.001) compared to the greater trauma population who did not suffer a trampoline injury (Table 1).

OPEN IN VIEWER

Table 1.

Patient Demographic and Clinical Variables from the PTOS Database of Trampoline vs Non-Trampoline Injuries.

	Trampoline n=107	Non-trampoline n=602,943	P-value
Age, mean (±SD)	13.04 (±11.87)	48.58 (±26.68)	<.001
Age <10 years n (%)	53 (49.53)	45,501 (7.55)	<.001
Male sex n (%)	61 (57.01)	366,245 (60.75)	.428
Race n (%) White Black Asian Other	78 (77.23) 8 (7.92) 1 (.99) 14 (13.86)	467,793 (81.19) 85,396 (14.82) 5,842 (1.01) 17,129 (2.97)	<.001
Hispanic ethnicity n (%)	16 (15.09)	21,260 (4.85)	<.001
ISS, median (IQR)	4 (4-5)	9 (4-14)	<.001
SBP (mmHg), mean (±SD)	124 (±16.20)	137 (±31.03)	<.001
Pulse (bpm), mean (±SD)	99 (±21.71)	90 (±23.78)	<.001
Shock index, median (IQR)	.79 (.67-.89)	.64 (.44-.78)	.018
Hospital days, median (IQR)	1 (1-2)	3 (2-6)	<.001

Discussion

This study evaluating trampoline injuries in the Pennsylvania Trauma System found that those who sustained injuries from a trampoline were younger than the general trauma population. Additionally, we found that upper and lower extremities were the most common body regions injured in trampoline trauma patients, and most often, pediatric patients suffered extremity injuries. These findings support our initial hypothesis that there would be an increased incidence of long bone injuries in the pediatric population of patients presenting with trampoline injuries.

In this cohort of patients, we found that the mean age of those with trampoline-related injuries was significantly younger than patients with all other traumatic injuries. The average age of patients with a trampoline-related injury was 13 years old, whereas all other trauma patients were older, with an average age of 48.6 years old. This was a significant finding because we believe this can help shape new policies around the use of trampolines. Both the American Academy of Pediatrics (AAP) and American Academy of Orthopaedic Surgeons (AAOS) recommend in their guidelines on trampoline use that children younger than 6 years of age should not use trampolines.^5,6 The US Consumer Product Safety Commission (CPSP) Safety Alert for Trampoline Safety also advised that children under 6 years old should not use trampolines.^8,9 A study done by Karkenny et al analyzed pediatric orthopedic injuries following AAOS and AAP statements. Patient behavior and compliance with safety recommendations can be highly variable, and these are some of the most important contributing factors to injury patterns. This group found related decreases in injury rates in the years following safety statements made by these professional organizations. ¹⁰ Our data suggest the age restrictions suggested by professional organizations, such as AAOS and AAP, should be updated to help decrease the number of injuries in pediatric patients. By updating these policies and statements to include that no one under the age of 10 years old should be using a trampoline, we predict we will see fewer pediatric injuries from this mechanism. If the age recommendation we proposed, restricted trampoline use under 10 years of age, was followed before the onset of this study, the trampoline-related injuries in the Pennsylvania Trauma System could have decreased by 49.5%.

Trampoline use is not unique to the United States of America; some of the locations in which trampoline-related injuries have been studied are Australia, ¹¹ Singapore, ¹² France, ¹³ and Austria. ¹⁴ Several studies in areas worldwide show similar trends in injury presentation from trampoline use, with extremity injuries being most prevalent.^11-13,15 These results indicate the danger of trampoline use in children and highlight the most frequent injuries seen in this population. The majority of patients in our cohort with trampoline injuries presented with injury to an extremity (84.1%), while the remaining 15.9% of patients had an injury classified as “other.” Lim et al ¹² conducted a study that showed 80.3% of patients in their cohort sustained injuries to the limbs. A study done by Sandler et al from 1999 to 2008 looked at children 16 years of age or younger in Australia and found similar results to our patient cohort in Pennsylvania. This group found that upper extremity injuries accounted for the majority of injuries sustained by trampoline users (64.2%), followed by lower limb injuries (10.7%), with other injuries such as head, neck, facial, spinal, and dental, among others, accounting for the remaining 25.1% in total. ¹¹ Another study completed through the emergency department at Primary Children’s Medical Center in Salt Lake City, Utah, showed that the majority of pediatric patients presenting with trampoline injuries (55%) had an injury to an extremity. The average age in this study was 8 years old. ¹⁵ These injury patterns are consistent with our findings in this study both in terms of age and injury type.

The AAP and AAOS guidelines recommend that no more than one supervised jumper over the age of 6 years old should be on the trampoline at a time with proper padded safety equipment surrounding the trampoline. However, even with these precautions, injuries can still ensue.^8,9 Lim et al evaluated the mechanism of injury associated with trampoline injuries and found that only 25.5% of these injuries were associated with a fall from the trampoline but the vast majority (61.3%) of injuries occurred inside the trampoline. The remaining injures occurred from the patient hitting the frame of the trampoline. ¹² Another study demonstrated that nearly 77% of injuries occurred when the patient was jumping on a trampoline alone. ¹¹ While the mechanism of jumping leading to the trampoline injury was not investigated in our cohort of patients, it is essential to note that injuries may still occur even when taking precautions suggested by professional organizations.

Children are at significant risk for musculoskeletal injuries, spinal cord injuries, head injuries, or other severe injuries while using potentially dangerous equipment such as trampolines. ¹ Musculoskeletal injuries, such as fractures, can be insidious in a trauma patient, so it is important to highlight ways to improve safety measures to keep children safe from complications. Between 1961 and 1984, there were at least 114 cervical spine injuries resulting in quadriplegia from trampoline-related injuries and minitrampoline use. ¹⁶ Trampolines have been found to be unsafe for use for decades, yet we still see an increasing rate of injuries from these devices.^2,4 The US Consumer Product Safety Commission reported being aware of a total of 22 deaths related to trampoline-related injuries in a 10-year period (2000-2009). ⁹

There are limitations to this study. This study was retrospective and only used data from the PTOS database, which may make the findings inapplicable to greater trauma population outside of Pennsylvania. By using this trauma registry, data are limited to patients admitted to an accredited trauma center, excluding those who were not taken to a trauma center. In addition, only 3 years of data were used. More studies should be conducted to evaluate the trends of trampoline injuries and evaluate if the age of patients stays consistent. This study also does not allow us to understand the details surrounding the injuries in regard to other jumpers on the trampoline, supervision while using a trampoline, safety equipment in place, etc. This information could be helpful in the future to identify additional ways to keep the pediatric population safe if using trampolines.

Conclusion

These results help us better understand the demographic, physiologic, and anatomic patterns surrounding trampoline injuries. Current government standards recommend that no child under age six should use a full-sized trampoline; however, based on the study results, we advise that this age be increased to ten. While trampoline users as a whole have a lower ISS and hospital length of stay compared to all other trauma patients, by adjusting the age recommendations for trampoline use, many of these injuries could be prevented altogether. We believe raising the age of trampoline jumpers to 10 years old, as opposed to current guidelines, may help mitigate some of these musculoskeletal injuries that are being seen in the literature and in our cohort of patients in Pennsylvania.