Treadmill Injuries in the Pediatric Population

Journal of Surgical Research 170, 139–142 (2011) doi:10.1016/j.jss.2011.02.015 ASSOCIATION FOR ACADEMIC SURGERY Treadmill Injuries in the Pediatric Population David Juang, M.D., Frankie B. Fike, M.D., Carrie A. Laituri, M.D., Vincent E. Mortellaro, M.D., and Shawn D. St. Peter, M.D.1 Department of Surgery, Children’s Mercy Hospital, Kansas City, Missouri Submitted for publication December 14, 2010 Background. Exercise equipment such as treadmills are becoming commonplace in residential homes, placing small children at risk for injury. These injuries can be severe and may require surgical intervention. While it is our clinical perception that these injuries are on the rise, they remain largely unreported in the literature. Therefore, we reviewed our experience to evaluate the incidence and outcomes of treadmillassociated injuries in children. Methods. After receiving exempt IRB approval, we retrospectively reviewed all patients who sustained treadmill-related injuries that required evaluation by a surgeon from July 2005 to February 2010. Data collected included patient demographics, injury details, injury management, and outcomes. Results. We identified 19 children who required treatment for treadmill-related injuries. Mean age at injury was 4.1 y (1.3–10.5 y), and 63% were male. The treadmill was in use by another person in 17 cases (89%). The hand was involved in 79%. All burns were <10% body surface area and 18 (90%) were <5 %. Admission was required in two cases, and four (21%) children required skin grafting. Healing was complicated by hypertrophic scarring in four patients (21%). Mean length of active therapy was 9.2 ± 7.0 d and involved a mean of 6.0 ± 3.5 healthcare visits. Mean hospital charges were $5700. Conclusion. Treadmill-related burn injuries in children are preventable injuries that can pose a substantial burden on patients and families. Supervision is paramount in prevention of these injuries, and strategies should include child safety features in equipment designs along with consumer awareness. Ó 2011 Elsevier Inc. All rights reserved. 1 To whom correspondence and reprint requests should be addressed at Center for Prospective Clinical Trials, Department of Surgery, Children’s Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108. E-mail: [email protected]. Key Words: burns; trauma; treadmill; pediatric; charges. INTRODUCTION Treadmills have grown in popularity over recent years and have become commonplace in American homes. Small children are at risk for injury in the presence of large equipment with moving parts previously relegated to commercial settings. It has been our clinical perception that these injuries are on the rise; therefore, we reviewed our experience to evaluate the incidence and portray the clinical course of treadmill-associated injuries in children. In this study, we describe our experience with treadmill-associated burn injuries. METHODS After receiving exempt IRB approval, a retrospective review was conducted on patients who sustained a treadmill-related injury from July 2005 to February 2010. Patient demographics, mechanism of injury, anatomic location of injury, length of hospital stay, types of surgical procedures, length of therapy, number of healthcare visits, and hospital charges were noted. Healthcare visits included independent visits to burn clinic, physical therapy, and occupational therapy. Data were expressed as mean 6 standard deviation. RESULTS A total of 19 children with treadmill-related injuries were identified. Mean age was 4.1 y (range 1.3–10.5 y). Gender distribution was 63% male. In 17 cases (89%), the injury occurred while the treadmill was in use by an adult. The injured patient was running on the treadmill in two cases, the ages of whom were 10.3 and 10.5 y. There was an increase in the number of injuries seen per year during the study timeframe (Fig. 1). All 19 patients suffered friction burns (Table 1). The burn injury involved the hand in 79% of cases. Outpatient 139 0022-4804/$36.00 Ó 2011 Elsevier Inc. All rights reserved. 140 JOURNAL OF SURGICAL RESEARCH: VOL. 170, NO. 1, SEPTEMBER 2011 12 10 Number of Patients 10 8 6 6 4 2 2 1 0 0 2005 2006 2007 2008 2009 Year FIG. 1. Histogram demonstrating the number of cases seen per year. (Color version of figure is available online.) management was utilized in 89% of patients. Mean length of active treatment was 9.2 6 7.0 d. An operation was required in four patients (21%). Some degree of hypertrophic scar formation was seen in four of the 19 patients but was managed conservatively. The average number of healthcare visits was 6.0 6 3.5. The average hospital charges amounted to $5700 6 $10,700 (range $500–$40,000) (Table 2). DISCUSSION We are currently witnessing a rise in the media attention to fitness and exercise. Americans are now investing in home exercise equipment previously only seen in commercial settings. Though adults will obviously benefit from routine exercise, the equipment places small children at risk. All gyms, clubs, and exercise have a rule posted in plain view stating children may not be there without adult supervision. Pediatric injuries due to treadmills have increased in frequency since early reports in the 1990s [1–6]. In 1999, the US Consumer Product Safety Commission issued a warning regarding the risk of injury to children from exercise equipment, and advised parents to keep children away from the equipment; a seemingly easy solution albeit difficult to implement in regards to curious children [7]. A review of the National Electronic Injury Surveillance System (NEISS) data from 2007 to 2009 demonstrated an increase in pediatric injuries due to exercise equipment from 45,942 in 2007 to 49,065 in 2009 [8]. Our data affirms this trend with an obvious pattern on the histogram displayed in Figure 1 showing the rise. In addition to incidence, the charges incurred deserve comment. We have chosen to use charges because they are objectively measurable and recordable as a data point. The patients and families are directly affected by these charges and not the cost associated with treatment and care. In two previous series, mean hospital charges were reported to be $1970 and 2385 for this type of injury [9,10]. The mean hospital charge in our series was clearly higher at $5707. We can surmise from our data that the increased mean charge is due to some of our patients requiring initial inpatient treatment and care and subsequent grafting. These few patients with TABLE 1 Patient Demographics and Mechanism of Injury Patient Age (y) Wt (kg) Gender 1 2 3 4 5 6 7 8 9 1.83 7.58 6.58 3.38 4.24 10.54 1.68 3.84 1.82 12.00 23.20 18.80 17.70 14.10 40.70 11.80 20.50 10.50 M M M F F F M M M 10 11 12 13 14 15 16 17 18 19 Means 3.41 1.94 1.62 1.33 1.91 10.28 2.83 1.52 3.29 8.58 4.1 14.20 13.45 12.60 9.88 14.20 31.50 17.50 10.40 NR 25.20 17.68 M M F M M F M M F F Mechanism of injury Friction, treadmill, grabbed treadmill Friction, treadmill, grabbed treadmill Friction, treadmill, grabbed treadmill Friction, treadmill, grabbed treadmill Friction, treadmill, grabbed treadmill running on treadmill and fell Friction, treadmill, grabbed treadmill Friction, treadmill Friction, treadmill, hand caught in treadmill Friction, treadmill Friction, treadmill Friction, treadmill Friction, treadmill Friction, treadmill Friction, treadmill, fell on the treadmill Friction, treadmill Friction, treadmill Friction, treadmill Friction, treadmill Injured while treadmill in use by adult Y Y Y Y Y N Y Y Y Y Y Y Y Y N Y Y Y Y 141 JUANG ET AL.: TREADMILL INJURIES IN THE PEDIATRIC POPULATION TABLE 2 Distribution of Injury, Treatment, and Charges Patient Burn location Treatment Complications Outcomes 1 Left hand and fingers SSD then collagenase* 2 R hand SSD, Duoderm, Eucerin* 3 4 L hand (5th digit) L wrist FTSGy FTSGy 5 R hand (4-5th digit) SSD then polysporin* 6 SSD* 7 Knees, lower legs, L shoulder Bilateral arms Duoderm then Eucerin 8 9 R hand and fingers R hand SSD then collagenase* FTSGy 10 Fingers SSD, then Duoderm* 11 R fingers SSD* 12 R foot SSD* hypertrophic scarring 13 B dorsal hands SSD* 14 R hand SSD* 15 SSD, Duoderm* 16 L foot, L knee, L fingers R hand Infxn L hand prior to burn eval Hypertrophic scarring Healed with hypertrophic scar, 4th digit tight Fully healed 17 18 19 R hand L fingers R hand SSD, polysporin, then Eucerin* SSD* SSD then Eucerin* FTSGy Hypertrophic scarring Home with polysporin wound care, Jobst glove Healing upon D/C from clinic STSG took Hypertrophic scarring FTSG with min hypertrophic scarring @ 1 y f/u D/C from clinic with polysporin wound care Unknown Good healing, mild discoloration Burns completely healed f/u at 2 years with good result after FTSG Nearly completely healed at clinic D/C Completely healed, slight pulling of R ring finger Minimal hypertrophic scar Bilateral hands healed Healed, slightly tight R middle digit Minimal hypertrophy Healed Grafted on day 18 Total hospital charges (dollars) $40,753 $1393 $11,238 $2310 $1007 $1466 $1484 $2389 $2803 $756 $1286 $2179 $620 $877 $501 $20,254 Mean charges ¼ $5707.25 Eucerin (Biersdorf Germany). Duoderm (Convatec USA). * SSD ¼ silver sulfadiazine. y FTSG ¼ full thickness skin graft. dramatically higher charges demonstrate the possibility for a more complicated course in some situations despite attempts to manage these lesions without an operation. Three of our patients do not have recorded charges due to limitations of our electronic record and archives. Interestingly, two of these patients who were treated prior to 2008 in which we are unable to obtain charges, also required grafting as part of their treatment. Given the trend to increased charges in patients who require operations, we would suspect that these patients’ extrapolated charges would correlate with the current data presented. These figures are even more striking if one also takes into account the inability to capture the entire cost to the family and society with loss of productivity, travel, and other injury-associated costs, including the costs associated with outpatient care [11, 12]. Earlier reports advocated the use of early surgery and skin grafting in the treatment of hand burns in children, citing better functional results and decreased need for reconstructive procedures [13–16]. More recent reviews advocate outpatient management of burns as both safe and a feasible option in the care of burn patients [17]. Recent data have also shown that early grafting of hand burns did not show any benefit in regards to function, scar formation, daily activity limitations, and overall satisfaction [18]. By delaying grafting, we are then able to manage patients on an outpatient basis and subsequently identify those patients who will ultimately require grafting as well as those who will require contracture releases due to hypertrophic scarring. This approach has resulted in good functional outcome in the cases reported in the literature, with a reduction in unnecessary surgical procedures 142 JOURNAL OF SURGICAL RESEARCH: VOL. 170, NO. 1, SEPTEMBER 2011 [2, 4, 19]. The choice of FTSG versus STSG in our series is due to the preference of the operative surgeon and location of injury being the hand. In our experience, we have had excellent cosmetic and functional outcomes using FTSG for these types of injuries. There are no mandatory guidelines to assist in avoiding these preventable injuries. Prevention remains the key since the majority of the children injured are not the primary users of the treadmills. Improved labeling and warnings in instructions would be an important first step, as a previous study found that 95% of treadmills had no labels or poorly located labels [9]. The specific suggestion for prevention that would be consistent with any large machinery should be outlined in the instructions; small children should not be in the immediate vicinity when the machine is operational. Additional prevention strategies would include locking rooms where exercise equipment is in use or stored, positioning the equipment to maximize visibility of the room and its occupants, and educating children on the dangers of the exercise equipment. Previous studies have suggested implementing design modifications and child safety measures but these remain technically difficult to implement and are costly. Improved parental supervision and education remains paramount. REFERENCES 1. Han T, Han K, Kim J, et al. Pediatric hand injury induced by treadmill. Burns 2005;31:906. 2. Carman C, Chang B. Treadmill injuries to the upper extremity in pediatric patients. Ann Plast Surg 2001;47:15. 3. Attalla MF, al-Baker AA, al-Ekiabi SA. Friction burns of the hand caused by jogging machines: a potential hazard to children. Burns 1991;17:170. 4. Banever GT, Moriarty KP, Sachs BF, et al. Pediatric hand treadmill injuries. J Craniofac Surg 2003;14:487. discussion 491–2. 5. 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