Pediatric treadmill injuries: a public health issue

Journal of Pediatric Surgery (2007) 42, 2086–2089 www.elsevier.com/locate/jpedsurg Pediatric treadmill injuries: a public health issue April Wong a,⁎, Deborah Maze a , Eric La Hei a , Niall Jefferson b , Sean Nicklin b , Susan Adams b a The Children's Hospital at Westmead and The Children's Hospital at Westmead Burns Research Institute, Sydney NSW 2031, Australia b Sydney Children's Hospital Randwick, Sydney NSW 2031, Australia Received 8 August 2007; accepted 8 August 2007 Index words: Treadmill injuries; Friction burns; Hand injuries; Pediatric; Prevention strategy Abstract Background: Treadmill injuries in children tend to be severe and are becoming increasingly common. We present an overview of this problem to promote public awareness, education, and to advocate a prevention strategy for this preventable injury. Methods: Medical records of all children with treadmill-related injuries during a 6-year period (January 2001-November 2006) from 2 tertiary pediatric hospitals were reviewed. Data on patient demographics, injury related data, types of surgical procedure, and outcome of treatment were collected. Results: Forty-four children with treadmill-related injuries were admitted in a 6-year period (20012006). Each year, the incidence increased with 17 (39%) cases occurring in 2006 so far. The median age of injury at the time of incident was 2.8 years (range, 8 months-12 years). There was a higher incidence in males (55%) compared with females (45%). Most of these injuries were to the hand (75%), fullthickness burns (59%), b1% of total burn surface area (TBSA) (73%), and occurred while the treadmill was in use by an adult (34%). Twenty-one (47%) children required skin grafting surgery. Conclusion: Treadmill-related burn injuries in children are a serious public health issue and warrants considerable attention. Adult supervision is paramount, and prevention strategies should include child safety features in equipment designs. Crown Copyright © 2007 Published by Elsevier Inc. All rights reserved. Many of us have treadmills in our homes in a bid to become the ‘Biggest Loser’ in losing those extra pounds or just trying to stay fit and healthy. However, maybe, the biggest losers are our own children. Research has shown that there is an increase in number of injuries in children because Presented at the 40th annual meeting of the Pacific Association of Pediatric Surgeons, Queenstown, New Zealand, April 15-19, 2007. ⁎ Corresponding author. Department of Surgery, Children’s Hospital at Westmead, Westmead, NSW 2145, Australia. Tel.: +61 2 9845 2000; fax: +61 2 9804 1392. E-mail address: [email protected] (A. Wong). of contact with treadmills [1,2]. Treadmills can cause friction burns, abrasions, blunt trauma, or even amputations. These injuries are serious and often require surgical intervention and rehabilitation. We believe this is a health issue that needs to be addressed because treadmills are increasingly available in homes, and more children will be at risk of injuries. This study is an epidemiological overview of treadmill-related injuries in children. Our aim is to promote public awareness and to advocate the importance of a prevention strategy for this preventable injury. 0022-3468/$ – see front matter Crown Copyright © 2007 Published by Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2007.08.031 Pediatric treadmill injuries 2087 1. Methods Medical records of all children with treadmill-related injuries from 2 tertiary pediatric Hospitals during a 6-year period (January 2001 to November 2006) were reviewed. Data on patient demographics, mechanism of injury, burn site, degree and depth of burn, types of surgical procedure, and outcome of treatment were collected. 2. Results A total of 44 children with treadmill-related injuries were admitted, of which 20 (45%) were girls and 24 (55%) were boys. The median age of injury at the time of incident was 2.8 years (range, 8 months-12 years). Each year, the incidence increased with 17 (39%) cases occurring in 2006 so far (Table 1). Almost all injuries were friction burns because of contact with moving treadmill belts. There were more injuries to the right upper limb (52%) as compared with the left upper limb (34%). Thirty-three (75%) cases involved the hand including fingers. Finger injuries occurred most commonly to the third and fourth digits. There were more volar injuries (25 cases, 57%) compared with dorsal injuries (11 cases, 28%). Other associated burn sites were to the chest, back, chin, forehead, thigh, legs, and ankle. One patient had burn injuries to both hands. There were 2 cases of nonburn injury. There was a case of amputated right index finger, and 1 patient had laceration to the back of the head. Twenty-six (59%) patients had full thickness burns, 5 (11%) were partial thickness, and 10 (23%) were superficial. Most of the burns were b1% of TBSA (73%). One patient had TBSA of 8% from burn injuries to the anterior chest, right thigh, and left thigh. This child fell onto the treadmill. Table 1 Demographic data Fig. 1 Injury settings. , indicates adult using treadmill; , unsupervised children; , supervised children playing on treadmill; , unknown (*Nil documentation on event surrounding injury); □, other. All of these injuries occurred in the home. The most common mechanism of injury is when the treadmill was in use by an adult (15 cases, 34%). These patients were from the ages of 1 to 4 years (median age, 2.2 years). Eleven (25%) patients fell onto the treadmill. These patients were from the ages of 2 to 10 years (median age, 4.2 years). Three (7%) patients sustained injuries while playing on the treadmill under the supervision of an adult caretaker. Eighteen (41%) patients sustained injuries while playing in an unsupervised setting either at home (14 cases) or at a friend's (4 cases) house where the patient or friend turned on the treadmill. In 1 case, the treadmill fell on the child. This child sustained a laceration to the back of the head, as well as abrasions to the forehead and upper back. Seven cases of hand injuries did not have details of the mechanism of injury (Fig. 1). Of the 44 patients in our study, 21 (47%) patients required skin grafting surgery (Table 2). Other surgery includes a case of right fourth finger laceration repair and a case of reattachment of amputated right index finger. There were Age ≤12 mo 1-2 y 2-3 y 3-4 y 4-5 y N5 y Year of injury 2006 a 2005 2004 2003 2002 2001 Values in parentheses are in percentages. a Data only to November 2006. 1 (2) 9 (20) 17 (39) 6 (14) 8 (18) 3 (7) 17 (39) 11 (25) 6 (14) 5 (11) 2 (5) 3 (7) Table 2 Surgical procedure and morbidity Skin grafting surgery a Yes No Other surgery Complications Cellulitis Wound infection Wound dehiscence Scar contracture Reoperation Values in parentheses are in percentages. a ×2 missing surgery-related data. 21 (47) 19 (43) 2 (5) 3 2 1 3 3 2088 9 postoperative complications. There was a case of severe wound infection requiring readmission to hospital for intravenous antibiotics. This patient was not referred to a burns unit after discharge from the hospital. Three patients returned to theater for reoperation. One patient's skin graft failed with superimposed infection and required regrafting. There was a case of wound dehiscence and infection requiring further debridement and closure of wound. One patient underwent scar contracture release. The other 2 cases of scar contractures were managed conservatively by physiotherapy. 3. Discussion Treadmills are emerging as the dominant form of home exercise equipment. Statistics have shown that walking is the most popular form of exercise for both males (17.5%) and females (32.9%) [3]. As consumer demand increases, the increase in sales will inadvertently contribute to the continual rise in treadmill injuries. Four hundred cases of treadmill-related injury in children have been published worldwide since its first documentation [4]. Friction burns accounted for 1.4% of patients treated at our burns unit during this 6-year period, although many injuries may go unseen and therefore underreported. A review of Consumer Product Safety Commission data in the United States revealed that of the 1009 home treadmill injuries in infants and children in a 4-year period, only 12 incidents were formally reported and investigated [1]. All treadmills have a rotating belt that can entrap a child's hand causing severe friction burns, lacerations, and even amputations. More than half our patients sustained fullthickness burns, and close to half our patients required skin grafting surgery. Volar injuries were most common, and other studies have noted similar findings [2,5-8]. There were 2 common scenarios. The most commonly affected group was the curious toddler who is driven to explore the environment and sustained injuries when an adult was using the treadmill. Not surprisingly, all these injuries were to the hand including fingers, wrist, or forearm. Other studies also showed similar results [1,5,9,10]. The second commonest group was the older child who has the height to reach and activate treadmills while playing and sustained injuries when they fell. In our study, the median age in this group was 4.2 years. These patients were more likely to sustain burns to multiple areas and also have more severe injuries. Treadmills were designed for adults, not children. The International Organisation for Standardisation specified the need for roller guards on a treadmill, but children's fingers could still be trapped at the rear end of the machine where the belt is unguarded. There were no specific child safety features mentioned [11]. The International Organisation for Standardisation does recommend an “immobilization A. Wong et al. method” for power-driven treadmills to prevent uncontrolled usage by “third parties.” This may prevent the older child from harm but does not prevent young infants and toddler from injuries. Currently, there are no product safety guidelines regarding children in contact with treadmills [12]. In Australia, the Trade Practices Act 1974 states a Standard Safety Guideline for a product may be issued “as are reasonably necessary to prevent or reduce risk of injury to any person” [13]. Stationary bicycle hand injuries resulted in the Consumer Product Safety Commission data in the United States issuing a Consumer Product Safety Alert to the public to “keep children away from exercise equipment” and have since led to the modification of stationary bicycle design [14]. Should there be a safety alert for treadmills as more treadmills enter our homes? Until mandatory guidelines are set, ‘Prevention is the key.’ Warnings found in manuals may benefit first time users, but clear labeling to remind the user about the potential dangers to children would be a better prevention strategy. One study evaluated 55 treadmill models and found 95% of the treadmills had no labels or poorly located labels on the side rails or underneath the machine [9]. Previous studies have made recommendations for design modifications and child safety features to be incorporated in the making of treadmills [1,6-9]. These include installing guards to shield the belt at the rear end of the machine to prevent entrapment, childproof on/off switches or lockout codes, warning labels placed on the console of the treadmill, and sensor-activated mechanism to stop the belt on soft tissue contact; however, these features have not been tested. Lack of supervision accounted for most injuries in our study, whether the victim was playing on their own, with friends, or under the care of an adult. When the treadmill was in use, the child typically approached the treadmill from behind unbeknownst to the adult until injury has occurred [5,7,10]. Parents must know that supervision is paramount and should be responsible for preventing children coming in contact with treadmills. Prevention strategies include limit- Fig. 2 Practical recommendations to prevent treadmill injuries in children. Pediatric treadmill injuries ing children access by the use of gates or a locked room while the treadmill is in use, to position the treadmill facing the open room or use of a back wall mirror to watch for children coming behind the machine, to avoid the use of headsets and be aware of surroundings while using the machine, to store the treadmill away after use, or avoid the use of treadmill completely in the presence of children [6-9] (Fig. 2). Pediatric treadmill injuries are on the rise, and the public needs to be aware and be educated to reduce these preventable injuries. More accidents will occur unless treadmill designs are improved, incorporating child safety features and unless mandatory safety standards addressing these risks are enforced. References [1] Abbas MI, Bamberger HB, Gebhart RW. Home treadmill injuries in infants and children aged to 5 years: a review of consumer product safety commission data and an illustrative report of case. J Am Osteopath Assoc 2004;104(9):372-6. [2] Collier ML, Ward RS, Saffle JR, et al. Home treadmill friction injuries: a five-year review. J Burn Care Rehabil 2004;25(5):441-4. [3] Australian Bureau of Statistics 2006 Edition 2. Sport and recreation: a statistical overview, Australia, Document #4156.0. http://www.abs. gov.au (Accessed February 2007). 2089 [4] Attalla MF, Al-Baker AA, Al-Ekiabi SA. Friction burns to the hand caused by jogging machines: a potential hazard to children. Burns 1991;17(2):170-1. [5] Han T, Han K, Kim J, et al. Pediatric hand injury induced by treadmill. Burns 2005;31(7):906-9. [6] Banever GT, Moriarty KP, Sachs BF, et al. Pediatric hand treadmill injuries. J Craniofac Surg 2003;14(4):487-90. [7] Carman C, Chang B. Treadmill injuries to the upper extremity in pediatric patients. Ann Plast Surg 2001;47(1):15-9. [8] Maguina P, Palmieri TL, Greenhalgh DG. Treadmills: a preventable source of pediatric friction burn injuries. J Burn Care Rehabil 2004;25 (2):201-4. [9] Borschel GH, Wolter KG, Cederna PS, et al. Acute management of exercise treadmill-associated injuries in children. J Trauma-Injury Infect Crit Care 2003;55(1):130-4. [10] Marshall J, Lourie GM. Pediatric hand friction burn injuries secondary to treadmills. J Pediatr Orthoped 2003;23(3):407-9. [11] International Organization for Standardisation 2005. ISO Document 20957-6:2005. Stationary training equipment Part 6: treadmills, additional specific safety requirements and test methods. www.iso. org (Purchased February 2007). [12] Australian Government Productivity Commission January 2006. Review of the Australia consumer product safety system. Productivity Commission Research Report. www.pc.gov.au/study/productsafety/ finalreport/index.html (Accessed February 2007). [13] Australasian Legal Information Institute. Trade Practices Act 1974. Section 65C: Product safety standards and unsafe goods. www. austlii.edu.au (Accessed February 2007). [14] US Consumer Product Safety Commission. Consumer product safety alert: prevent injuries to children from exercise equipment. http:// www.cpsc.gov/CPSCPUB/PUBS/5028.html (Accessed February 2007).