Horse riding is a popular sport, which bears the risk of serious injuries. This study aims to assess whether individual factors influence the risk to sustain major injuries.
Retrospective data were collected from all equine-related accidents at a German Level I Trauma Centre between 2004 and 2014. Logistic regression was used to identify the risk factors for major injures.
770 patients were included (87.9% females). Falling off the horse (67.7%) and being kicked by the horse (16.5%) were the two main injury mechanisms. Men and individuals of higher age showed higher odds for all tested parameters of serious injury. Patients falling off a horse had higher odds for being treated as inpatients, whereas patients who were kicked had higher odds for a surgical therapy (OR 1.7) and intensive care unit/intermediate care unit (ICU/IMC) treatment (OR 1.2). The head was the body region most often injured (32.6%) and operated (32.9%). Patients with head injuries had the highest odds for being hospitalised (OR 6.13). Head or trunk injuries lead to the highest odds for an ICU/IMC treatment (head: OR 4.37; trunk: OR 2.47). Upper and lower limb injuries showed the highest odds for a surgical therapy (upper limb: OR 2.61; lower limb: OR 1.7).
Risk prevention programmes should include older individuals and males as target groups. Thus a rethinking of the overall risk assessment is necessary. Not only horseback riding itself, but also handling a horse bears a relevant risk for major injuries. Serious head injures remain frequent, serious and an important issue to be handled in equestrians sports.
In equestrian sport, men are at risk for major injuries, with rising age the risk for major injuries rises.
Despite all prevention measures, head injuries remain the most frequent and serious.
A rethinking is necessary: risk prevention programmes should include older individuals and males as target groups.
Helmet use is urgently recommended; a mandatory helmet use should be considered.
Horseback riding is one of the most popular recreational activities in Europe,
The demographics of equine-related accidents were studied a multiple times.
Studies evaluating risk factors for serious injuries are scarce, and there is no current consensus regarding individual risk profiles. Individual factors like gender, age and accident mechanism might influence the injury pattern and therapy course.
In order to contribute to the understanding of this popular high-risk sport, this study aims to (1) analyse demographics, accident mechanisms, injury patterns, therapy and severity of equine-related accidents, and (2) assess whether individual factors such as age, gender and injury mechanisms influence the risk to suffer a severe injury. If possible groups of risk for major injuries should be defined.
This is a retrospective cohort study. Digital case histories of all patients registered in the emergency department of the department of Trauma Surgery, Orthopaedics and Plastic Surgery at the University Medical Centre Goettingen between 1 January 2004 and 1 April 2014 were computer-based scanned for keywords (‘horse’, ‘pony’, ‘riding’).
Individuals of all age groups involved in an accident while riding or handling a horse, with all kinds of injury, ranging from ‘no injury’ to ‘fatal’ were included. Logically not matching patients (eg, ‘bike riding’), as well as double entries were excluded.
For 770 individuals, data were collected on accident date and patient demographics (gender and age). Accident mechanisms were categorised in the groups ‘fall from horse’, ‘kicked by horse’ and ‘other’. We focused on 648 individuals that fell off the horse or that were kicked by the horse since own and previous results identified these two as the main injury mechanisms.
As applied before
After presenting descriptive statistics, several regression models were performed to study the effect of gender, age, accident mechanism and injury pattern on the injury severity.
All therapy course variables, except of LOS, were binary. For these binary variables, logistic regression was applied while for LOS a model employing the Poisson distribution was fit. As age affects the therapy variables in a non-linear way p(enalized) splines
All models were estimated using the R statistical programming language.
Between 2004 and 2014, 770 individuals were presented to the University Medical Centre with injuries resulting from equestrian sports. In total, 648 (84.2%) of those patients fell off the horse or were kicked by the horse.
Patient characteristics of all 770 individuals and the subgroup of 648 individuals that fell off the horse or were kicked by the horse
All patients | Only fall from horse and kicked by horse | Reference, see | |
n (%) | n (%) | ||
Type of accident | |||
Fall from horse | 521 (67.7%) | 54–81 | |
Kick by horse | 127 (16.5%) | 2–24 | |
Other | 127 (16.5%) | ||
Patient characteristics | |||
Female | 677 (87.9%) | 569 (87.8%) | 49–93 |
Male | 93 (12.1%) | 79 (12.2%) | 7–51 |
Mean age in years (SD) | 25.7 (14.2) | 25.4 (12.2) | 26–38 |
Mean age of females (SD) | 24.3 (12.7) | 23.9 (12.5) | |
Mean age of males (SD) | 36.0 (19.9) | 35.7 (20.4) | |
Injury pattern | |||
Head, face and throat | 251 (32.6%) | 230 (35.5%) | 17–26 |
Trunk | 188 (24.4%) | 173 (26.7%) | 16–32 |
Spine | 141 (18.3%) | 127 (19.6%) | 10–22 |
Upper limb | 170 (22.1%) | 151 (23.3%) | 8–35 |
Lower limb | 175 (22.7%) | 114 (17.6%) | 10–31 |
Observations | 770 | 648 |
Reference to literature as shown in
Literature for reference, recent retrospective studies with same inclusion criteria and n>100
Author, year | n | Sex(♂) | Age | Accidentmechanism | Injuries | Therapy | ||||||||
Fall | Kick | Head/neck | Trunk | Spine | Upper limb | Lower limb | Inpatient | LOS | OP | ICU | ||||
% | % | % | % | % | % | % | % | Days | % | % | ||||
Abu-Zidan | 231 | 41 | 34.1 (14.7) | 67 | 16 | 32 | 30 | 11.2 (32.4) | ||||||
Bilaniuk, | 284 | 16 | 30 (14 to 50) | 26 | 27 | 18 | 19 | 10 | 28 | |||||
Carmichael | 284 | 51 | 37.2 (17.2 to 2–79) | 54 | 22 | 25 | 24 | 10 | 8 | 24 | 42 | |||
Hessler | 198 | 15 | 27,2 (5 to 74) | 17 | 16 | 14 | 35 | 18 | 32 | 6,2 (1 to 63) | 26 | 13 | ||
Johns | 144 | 24 | 81 | 11 | 19 | 27 | 13 | 25 | 24 | 4 (1 to- 62) | ||||
Lang | 1408 | 46 | 33.4 (18.5) | 72 | 20 | 19 | 10 | 20 | 31 | 4 (2 to 7) | 54 | 12 | ||
Loder | 5033 | 34 | 30.0 (17, 0,1 to 11) | 80 | 2 | 24 | 29 | 30 | 16 | 14 | ||||
Schröter | 503 | 10 | 26,2 (14,9) | 24 | 19 | 19 | 22 | 16 | 46 | 5,3 (5,4) | 8 | |||
Thomas | 4122 | 41 | 55 | 24 | 23 | 32 | 22 | 22 | 11 |
ICU, intensive care unit; LOS, length of stay; OP, outpatient.
The larger part of all patients was female (87.9%), they were on average about 10 years younger than males. Injuries to the head, face or throat were the leading accident consequence, but also injuries to all other body regions were commonly observed and made up a share of almost one-fifth (18.3%) to one-fourth (24.4%) of injured patients.
The spinal injuries were prevalently distorsions, commonly at the cervical spine and fractures, mainly at the thoracolumbar junction. There was only one patient with a spinal chord injury and two patients with lesions of the brachial or lumbosacral plexus.
Therapy course of 648 patients that fell off the horse or were kicked by the horse
Therapy course |
| Reference, see table 4 (%) | |
Inpatients | 334 (51.5%) | 11– 46 | |
Female | 285 (85.3%) | ||
Male | 49 (14.7%) | ||
Mean age inpatients (SD) | 26.3 (15.6) | ||
Fall from horse | 274 (82.0%) | ||
Kicked by horse | 60 (18.0%) | ||
Mean LOS in days (SD) | 6.5 (8.9) | 4– 11 | |
Male (SD) vs female (SD) | 9.4 (9.8) | 6.1 (8.7) | |
Fall (SD) vs kicked (SD) | 5.9 (7.0) | 9.6 (14.3) | |
Surgical therapy | 143 (22.1%) | 25–54 | |
Female | 116 (81.1%) | ||
Male | 27 (18.9%) | ||
Mean age (SD) | 29.5 (16.6) | ||
Fall from horse | 106 (74.1%) | ||
Kicked by horse | 37 (25.9%) | ||
ICU/ IMC | 56 (8.6%) | 4–13 | |
Female | 42 (75%) | ||
Male | 14 (25%) | ||
Mean age (SD) | 36 (16.9) | ||
Fall from horse | 44 (78.6%) | ||
Kicked by horse | 12 (21.4%) | ||
Observations | 648 |
Reference to literature as shown in
ICU, intensive care unit; IMC, intermediate care unit; LOS, length of stay.
Details of the 196 surgical procedures that were performed for 143 patients, subdivided in primary and follow-up surgery
Primary surgery | n= |
ORIF or CRIF, all except head | 69 |
(Limbs) | (57) |
(Spine) | (9) |
(Pelvis) | (3) |
Operative reposition without osteosynthesis | 9 |
Head-specific procedures | 28 |
ORIF or CRIF | 20 |
(Midface with orbital reconstruction) | (8) |
(Jaw) | (7) |
(Sole orbital reconstruction) | (3) |
(Sole midface) | (2) |
Craniotomy with CSF drainage | 3 |
Cranial trepanation with CSF drainage | 3 |
Bulbar reconstruction | 1 |
Tympanoplasty | 1 |
Soft tissue procedures | 29 |
Sutures for reconstruction or bleeding control | 18 |
Debridement, haematoma drainage, bursectomy | 9 |
Fasciotomy due to compartment syndrome | 2 |
Other | 8 |
Abdominal procedures (reconstruction aorta, bleeding control liver, exploratory laparotomy with splenectomy) | 3 |
Thoracic drainage | 2 |
Not defined | 3 |
Follow-up surgery | 53 |
Removal of implants | 38 |
Other | 15 |
Procedures | 196 |
CRIF, closed reduction internal fixation; CSF, cerebrospinal fluid; ORIF, open reduction internal fixation.
More than half of the patients (51.5%) were treated as inpatients after being presented to the emergency room. The mean LOS was 6.5 days with 22.1% of all patients undergoing surgery and 8.6% being treated on an ICU or IMC unit.
Males were over-represented in each therapy category. While there were 12.2% males overall, they made up a share of 14.7%, 18.9% and 25% of inpatients, patients that underwent surgery and received ICU or IMC treatment, respectively. Men also spent on average more days in the hospital than females (9.4 vs 6.1).
The mean age, which was 25.4 years for all patients, was higher in each therapy category.
Patients that were kicked by the horse made up a bigger share in all therapy categories (16.5% in all patients vs 18%, 25.9% and 21.4% in the therapy groups) and had a longer mean LOS than patients that fell off the horse (9.6 days vs 5.9 days).
For 143 patients with surgical therapy, 196 procedures were performed (see
The body regions on which the primary procedures were performed are listed in
Primary surgical procedures divided into body regions
n (%) | |
Body region | |
Head | 47 (32.9) |
Trunk | 13 (9.1) |
Upper limb | 46 (32.2) |
Lower limb | 28 (19.6) |
Spine | 9 (6.3) |
Procedures | 143 (100) |
For a detailed illustration of the body regions with surgery, see
Detailed illustration of the body regions on which the primary surgical procedures were performed.
Judging from the descriptive, it might be that males, older people and individuals getting kicked by the horse got more severely injured than females, younger people and individuals that fall off the horse. To disentangle these effects, regression analyses were performed (see
Regression analyses, influence of gender, age, accident mechanism and injured body region on the therapy course
Inpatient treatment | LOS in hospital | Surgical therapy | ICU or IMC treatment | |
Logistic | Count | Logistic | Logistic | |
OR (CI) | Coef (CI) | OR (CI) | OR (CI) | |
Male | 1.38 (0.75 to 2.52) | 0.20***(0.07 to 0.32) | 1.29 (0.69 to 2.42) | 1.46 (0.66 to 3.26) |
Age | Smooth effects of age included, see plots | |||
Kicked by horse | 0.81 (0.50 to 1.32) | 0.52*** (0.42 to 0.63) | 1.72** (1.02 to 2.91) | 1.18 (0.54 to 2.54) |
Head, face and throat | 6.13***(3.96 to 9.50) | −0.34***(−0.43 to –0.25) | 1.43 (0.91 to 2.24) | 4.37***(2.27 to 0.42) |
Trunk | 1.34 (0.86 to 2.08) | −0.09* (−0.18 to 0.01) | 0.37***(0.21 to 0.63) | 2.47*** (1.29 to 4.74) |
Spine | 1.47 (0.90 to 2.41) | 0.06 (−0.05 to 0.18) | 0.70 (0.38 to 1.26) | 1.21 (0.58 to 2.53) |
Upper limb | 1.09 (0.67 to 1.76) | 0.02 (−0.09 to 0.13) | 2.61***(1.58 to 4.34) | 1.06 (0.50 to 2.23) |
Lower limb | 1.12 (0.68 to 1.85) | 0.53***(0.43 to 0.64) | 1.70* (1.00 to 2.88) | 0.91 (0.39 to 2.12) |
Other | 0.18***(0.08 to 0.43) | 0.75***(0.54 to 0.97) | 0.08***(0.02 to 0.35) | 0.31 (0.04 to 2.54) |
Constant | 0.57**(0.36 to 0.91) | 1.70***(1.59 to 1.81) | 0.21***(0.13 to 0.36) | 0.03***(0.01 to 0.06) |
Observations | 648 | 334 | 648 | 648 |
*p<0.1; **p<0.05; ***p<0.01.
ICU, intensive care unit; IMC, intermediate care unit.
Males had 1.4 times higher odds of being hospitalised than females and stayed on average exp(0.2)=1.2 times longer in the hospital after being admitted. The odds for undergoing surgery and for being admitted to the ICU or IMC were also higher for males than for females. However, only the effect for LOS was statistically significant and the group of males admitted to ICU or IMC was with 14 observations (see
The age-depending effect for all therapy variables is illustrated in
Effect of age on (A) inpatient treatment, (B) length of stay in days (LOS), (c) surgery, (d) intensive care unit (ICU) or intermediate care unit (IMC) treatment. Dashed lines indicate confidence intervals.
The U-shaped graphs in (A) and (C) with a turning point close to 20 years show that up to this age the odds of an inpatient treatment and surgery decreased while it increased after that. Wide CIs for very young and old individuals indicate less observations in these areas. For LOS (B), age increases steadily between the age of 5 and 55 years. Out of this bounds, the estimates vary and become more uncertain. The risk of being treated at the ICU or IMC ward (D) increased with age in a linear way. All age effects were statistically significant on a 1% level.
Regarding the accident mechanism the results of risk analyses were ambiguous. Patients that were kicked by the horse had lower odds for being hospitalised than patients that fell off the horse. At the same time they had a 1.7 times higher odds for undergoing surgery, stayed exp(0.52)=1.7 times longer in the hospital when hospitalised. They also had higher odds for being treated in intensive or intermediate care though this coefficient was not statistical significant.
Focusing on the body region, head injuries increase the odds of being hospitalised the most compared with other body regions. Injuries to the head and to the trunk lead to significant higher odds for a treatment on the ICU or IMC compared with individuals with other injuries. The highest odds for an operation are statistically significantly linked to injuries to the upper and lower limb.
Prevention measures are efficient, when they are addressed to defined target groups.
Since the University Medical Centre is the only Level I Trauma Centre within a 70 km range, we assume that the majority of severe accidents in our area was included in the patients collective.
With 770 patients in a 10-year period, equine-related injuries are an important issue to be managed in the emergency department. As illustrated, the characteristics of the described patient collective correspond in all points with the current literature.
Females made up a large share of the patients. However, males were identified as a group of risk prone to serious injuries. They had higher odds for serious outcomes in all tested parameters. We thus confirm recent observations of authors
Patients were not attributed into age groups, thus we were able to analyse the age-depending risk course in detail. The very young patients showed higher odds for being hospitalised and undergoing surgery, but these findings need to be interpreted with caution. The CIs were wide due to few observations. The literature concerning age-related risk for serious injury is scarce. Only one study
With increasing age patients had higher odds for all parameters of serious outcomes. We thus defined them as a group of higher risk and support the findings of previous studies.
While comparing the accident mechanisms, no clear rating of risk was possible. This is in line with the literature: Carmichael
As proposed before
It was illustrated before that the injury pattern resulting from equestrian sports is various. Injuries of all parts of the body play an important role.
In this study, patients with injuries to the head comprised the biggest share. At the same time they were associated with the highest risk for hospitalisation and an intensive or intermediate care treatment. It is remarkable that the head was the body region with the most frequent surgical procedures performed. Osteosynthesis to the orbit and midface played an important role, but also craniotomy and cranial trepanation had to be performed to six patients. A recent study found equine-related accidents to be the most important contributor to sports-related traumatic brain injuries in the USA (45.2%).
Reviewing the literature on major equestrian injuries studies also hints at the serious potential of trunk injuries.
Almost one-fifth of the patients suffered spinal injuries, which is confirmed by the literature.
Most of the open reduction internal fixations (ORIFs) or closed reduction internal fixations (CRIFs) were performed at the limbs. Thus patients with injuries to the upper or lower limbs had the highest odds for undergoing surgery. Since fractures of the long bones are commonly addressed by osteosynthesis, this is sensible from a clinical point of view.
Due to retrospective design only yet existing information could be evaluated and incomplete documentation remains a reason for loss of data. The amount of observations for males was low in some categories leading to little reliable statements.
Relying on observational data, the analysis might suffer from selection bias. For example, it is possible that severe injuries are over-represented in one group, for example, adult male, as they are less likely to go to the hospital with mild injuries compared with other groups. In addition, some groups could have preferences for hospitals in the surroundings. If these preferences are non-randomly distributed, results are biased. However, even advanced sample selection methods are of little use here since we do not have data on persons that get injured but decide to not see a doctor.
Equestrian sports bear the risk for serious injuries. More females and young individuals participate in equestrian sports and therefore are injured more frequently. However, we defined men and individuals of higher age as groups of a higher risk for serious injuries. We thus conclude a necessity of reassessment in prevention questions and see a chance for the improvement of injury prevention.
Caution is required when treating patients of younger age after an equine-related accident since final risk evaluation remains unclear. We confirm that horseback riding as well as handling the horse bears a comparable risk for serious injuries.
Head injuries remain a frequent and serious consequence of equestrian sport. The protective use of helmets was confirmed before, and we again emphasise their use in all situations with the horse.
All authors have approved the revised manuscript and have contributed to this work and are therefore listed in the authors list.
The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
None declared.
Not required.
The design and conduct of this study was approved by the Ethics Committeeof the University Medical Centre Goettingen.
Not commissioned; externally peer reviewed.