1. Pediatric Musculoskeletal Injuries Associated with Recreational Motorized Vehicle Use: Do More Wheels Mean a Safer Ride?
Authors: Grant D. HOGUE, MD; Ryan ROSE, MD; Robert L. WIMBERLY, MD; Anthony I. RICCIO,MD
Conflicts of Interest: None Declared

2. Introduction
All Terrain Vehicles (ATVs) and off-road Motor-Bikes (MBs) are popular in the state of Texas
This is likely secondary to the abundance of open space for riding, minimal regulation, and the general inability to enforce regulation at the state level
In addition to off-road leisure, these motorized vehicles are used in the pediatric population in ATV and Motocross racing events

3. What do the pediatricians think?
The American Academy of Pediatrics recommends that no children under the age of 16 make use of ATVs or motorbikes as they do not have the motor coordination, strength, or judgment to operate these devices
A representative Pediatrician
“My son will never have an ATV or Dirtbike. Mostly because I don’t want him to die, but not all parents feel that way”

4. It’s not just pediatricians…
The American Academy of Orthopaedic Surgeons (AAOS) considers ATVs to be a significant public health risk.
To help reduce the numbers of injuries and deaths, particularly among young people, the AAOS along with the Orthopaedic Trauma Association, and the Pediatric Orthopaedic Society of North America recommends that:
All ATV operators should be licensed and undergo a hands-on training course.
ATVs should never be driven by a child younger than age of 12. Younger children do not have adequate physical size and strength to control these vehicles. Nor do they have the motor skills and coordination to operate a vehicle safely.
Children between the age of 12 and 16 should have limitations on their use of ATVs. They should be supervised by a responsible adult. Children under 16 years of age should not operate ATVs that have an engine size of 90 cc or greater.
Always wear protective gear. Helmets are especially important in reducing the risk of head injury. Protective gloves and heavy boots can also help reduce injuries.
ATVs should be used during daylight hours only.
Only one person should ride vehicles intended for single person use.
Do not operate an ATV if you have taken drugs or alcohol.

5. What are the Texas Laws? ATV
All ATV owners must apply for a title before selling or disposing of their ATV.
All ATVs operated on public property must be registered, renewing registration once every year.
No passengers are allowed at any time while the ATV is on public lands, unless the ATV is designed to carry a passenger.
ATV use on public streets is prohibited, except to cross these roads or for agricultural purposes.
All operators under 14 must be accompanied by a parent or guardian.
While on public lands, all operators must have a safety certificate or be with an adult who has obtained a safety certificate.
ATVs shall not be operated from ½ hour after sunset to ½ hour before sunrise without a lighted taillight and headlight.

6. What are the Texas Laws? Motor-Bike
Off road motorbike laws:
Helmets, eye protection, rider education certification required by law
Direct supervision required if operator under 14 years of age
No license required

7. ATV and MB Racing Events
Engine Class
Age
50cc
4yr-9yr
65cc
7yr-9yr
85cc
9yr-13yr
Remember, medical associations recommend against use by individuals under years of age

8. What are We Looking at/for?
Many peer reviewed articles have demonstrated injury/fracture patterns in the adult and pediatric population of ATV riders
There has been only one study reviewing injuries associated with motorbikes in the pediatric population
No study to date has compared the two groups

9. ATV vs MB
PURPOSE: To identify differences in musculoskeletal injury location and severity between pediatric operators of 4 wheel all-terrain (ATV) and motorized two-wheel (motor-bike / MB) vehicles

10. ATV vs MB
Methods:
Retrospective Review: Single Pediatric Level 1 Trauma Center ( )
All ER Visits for ATV and Motorbike Injuries:
Characteristics of Osseous Musculoskeletal Injuries and Associated Injuries
Protective Equipment Use
Injury Severity Score (ISS) and Length of Hospital Stay (LOS)
Study Parameters Compared Between Cohorts (Student’s t-test and nonparametric testing)

11. RESULTS-Demographics
504 ED encounters Identified
334 ATV Related ER Visits
170 MB Related ER Visits
Mean Age:
ATV: 8.7 years (range 1-17 yrs)
MB: 10.2 years (range 3-16 yrs)
p<0.001
Gender
ATV: 67% male
MB: 83% male
p<0.002

12. PROTECTIVE EQUIPMENT USE
ATV (n=334)
MB (n=170)
P value
Any
51 (16%)
95 (60%)
<0.0001
Helmet
48 (14%)
74 (44%)
Protective Clothing
2 (0.6%)
9 (5%)
<0.001
Helmet and Protective Clothing
1 (0.3%)
12 (7%)
No difference in ISS, LOS, or Rate of Associated Head/Visceral Injury despite higher rate of protective equipment use among motor bike riders
But…

13. RESULTS
Incidence of Musculoskeletal Injury:
ATV: 156/334 patient visits (46%)
MB: 123/170 patient visits (72%)
p<0.001
DESPITE SIGNIFICANTLY MORE USE OF PROTECTIVE EQUIPMENT, CHILDREN ARE MORE LIKELY TO SUSTAIN ORTHOPAEDIC INJURY WHILE RIDING A MOTORBIKE THAN WHEN ON AN ATV

14. Fractures ATV n = 156 Motorbike n = 123 9 4 25 10 11 3 30 5 23 2 7 1 54 25 10 11 3 30 5 23 2 7 1 5 14 6 4 24 22 10

15. Comparison of Orthopaedic Injuries
ATV (N=344)
MB (N=170)
p value
Upper Extremity Injury
68 (20%)
47 (28%)
0.07
Shoulder Girdle
9 (3%)
7 (4%)
0.42
Arm
4 (1%)
5 (3%)
0.17
Elbow
25 (7%)
Forearm
10 (3%)
0.60
Wrist
11 (3%)
14 (8%)
0.03
Hand

16. Comparison of Orthopaedic Injuries
ATV (N=344)
MB (N=170)
p value
Lower Extremity Injury
80 (24%)
68 (40%)
0.0003
Hip
3 (1%)
4 (2%)
0.23
Femur
30 (9%)
24 (14%)
0.09
Knee
5 (1%)
5 (3%)
0.31
Tibia/Fibula
23 (7%)
22 (13%)
0.03
Ankle
9 (3%)
10 (6%)
Foot
10 (3%)
3 (2%)
0.55

17. Comparison of Orthopaedic Injuries
ATV (N=344)
MB (N=170)
p value
Spine Injury
5 (1%)
2 (1%) 1
Cervical
1 (1%)
0.33
Thoracic
2 (2%)
Lumbar
3 (1%)
0.55

18. Comparison of Orthopaedic Injuries
ATV (N=344)
MB (N=170)
p value
Open Fracture
33 (9%)
15 (9%)
0.7508
Multiple Injuries
21 (6%)
23 (14%)
0.0114
Required Surgery
85 (25%)
46 (27%)
0.7474

19. Comparison of Non-Orthopaedic Injuries
ATV (N=344)
MB (N=170)
p value
Intracranial
30 (9%)
24 (14%)
0.0935
Skull Fracture
55 (16%)
14 (8%)
0.0131
Intrathoracic
19 (6%)
7 (4%)
0.5279
Intra-abdominal
25 (7%)
0.1772

20. Discussion Points
No differentiation between recreational and organized riders
Presumed all riders in sanctioned events would have protective equipment
More common sanctioned motorbike events than ATV events
Unlikely to account for such disparity
Difficult to assess motorbike injuries off and on-road
Attempted to characterize injuries between drivers / operators and passengers

21. ATV Riders Have a Significantly Higher Risk of Skull Fracture
Conclusions
Despite Significantly Higher Rates of Protective Equipment Use, Children Injured Riding Motor Bikes are More Likely to Sustain a Musculoskeletal Injury Than Those Injured Riding an ATV
Motor Bike Riders Sustain a Significantly Higher Number of Lower Extremity Injuries, Wrist Fractures and Tibia/Fibula Shaft Fractures than ATV Riders
Motor Bike Riders have a Significantly Higher Rate of Multiple Orthopaedic Injury
ATV Riders Have a Significantly Higher Risk of Skull Fracture

22. CONCLUSION
Musculoskeletal Trauma is Common in Children Injured while Operating Recreational Motorized Vehicles
Understanding the Differences in Injury Patterns Associated with ATV and Motor-Bike Trauma Can Help Guide Orthopaedic and Emergency Department Providers Assess Patients for Secondary Injuries
Critical for the industry to understand the medical community and strive to improve rider safety