All-terrain vehicle injuries in children and adolescents

Injuries among children

A disproportionately high rate of ATV accidents occurs in use by children compared with adults. In the United States, children and adolescents account for only 14% to 18% of ATV riders, but they are more frequently injured in ATV-related accidents (representing 26% to 57% of those injured).^2,4 Children aged 5 to 19 years account for more than one-third of ATV-related hospitalizations, and riders younger than 16 years old represent 15% to 23% of ATV fatalities.^4,5 Most ATV accidents occur in riders who are male (70% to 85%) and who are White (89% to 99%), and most happen in summer months (67%) and during recreational activity (83%) or organized racing (3.6%).^2-6

A US annual report of ATV-related deaths and injuries estimated that in 2018 as many as 21,000 children younger than 16 years old were involved in ATV accidents and required emergency department (ED) treatment.⁷ A retrospective review of 802 children involved in ATV accidents between 2005 and 2020 found that 23.8% of the children required intensive care unit (ICU) admission and that 7 children died (0.87%).² In addition, children with ATV-related injuries use substantial resources for diagnosis and treatment. In 2010 the annual economic burden of ED and hospital visits for ATV accidents (all ages) was estimated at more than $2 billion in the United States⁸ and at $507 million in Canada⁵ (includes ATV and snowmobile injuries).

Types of injuries

The most common types of ATV injuries sustained by children and adolescents are orthopedic in nature; particularly, injuries to the extremities, intra-abdominal or intrathoracic injuries, and injuries to the head or face, chest, and abdomen.^2,4

Older children are more likely to sustain body or extremity fractures and multiple fractures, specifically of the axial skeleton or lower extremities.² In a retrospective review of pediatric ATV-related trauma cases from 2005 to 2020 (802 patients), the most common fractures (open and closed) were in the forearm (21%), femur (8%), and spine (7%), whereas the most common open fractures represented were the tibia (1.5%), humerus (1%), and forearm (1%).² Overall, while musculoskeletal trauma accounted for a large percentage of injuries among young riders, the trauma registry at the University of Kentucky Chandler Medical Center in Lexington and a retrospective cohort population study of the Alberta Trauma Registry suggest that head trauma was the leading cause of death from ATV injuries.^9,10 Youth younger than 16 years of age in Canada were reported to be at an increased risk of head injuries compared with adults due to their lack of ATV riding knowledge and experience.^5,11

Reasons for injuries

When used by children and adolescents, ATVs are particularly dangerous, as the operators often lack the knowledge and skills to ride the vehicles safely.³ The most common causes for ATV injuries include not using a helmet, inexperience, inadequate physical size and muscle strength, poor judgment, loss of control, immature motor and cognitive development, and substance use in older children.^3,4 Children have underdeveloped frontal cortices, resulting in potentially skewed views of risky behaviour and perceived invincibility, and thus have an increased tendency to engage in risk-taking behaviour such as riding after dark, jumping with the ATV, high-speed racing, and driving under the influence of alcohol or other substances.^3,4

Furthermore, younger ATV riders (those 6 to 11 years of age) might also have a more restricted field of vision compared with adults.¹² These visual limitations hinder the operators’ ability to see ATV controls, potentially leading to loss of control and increased risk of being involved in a crash.¹² Additionally, body weight controls stability and maneuverability in ATVs, and since the size and the power of ATVs have increased substantially over time, children might find it difficult to safely control them due to their body size and strength.⁴ In 1 study, more than 90% of young riders used ATVs that were more powerful and larger than recommended for their size by safety guidelines.⁴ Even as passengers, children are likely to get injured, since most ATVs are designed for a single rider.⁵ The mechanisms of ATV-related injuries in children include vehicle rollover, collision with a stationary object, and ejection from the vehicle.^3,4

Helmet use

Failure to wear a helmet is a main reason for injury and fatality.⁴ Children younger than 16 years of age are at an increased risk of head injuries and fractures, and riding without a helmet increases the likelihood of traumatic brain injury, fatality, and injury to the face and neck.^2,11 A large Canadian study of ATV-related injuries reported that wearing a helmet can substantially reduce the chance of sustaining a moderate to severe head trauma by approximately 50%.^4,5

However, despite proposed legislation requiring helmet use, there does not currently seem to be sufficient compliance.² In cases where the helmet status of the injured individual was reported, it was found that roughly 45% of riders had been wearing a helmet.^2,5 Severe head injuries can be partially prevented by helmet use.^11,13

Medical practitioner education

Injuries related to ATV use appear to be underestimated in medical practice. In a 2016 survey of pediatricians and pediatric subspecialists participating in the Canadian Paediatric Surveillance Program, which aimed to evaluate practitioners’ knowledge of ATV-related legislation and safety recommendations, only 67.5% of the respondents knew that ATVs should not carry passengers and 42.2% never discussed ATV safety with their patients.⁵