University of Vermont AAHS


June 2000, Vol. XI, Number 2

 Table of Contents

Women Appear to Suffer Worse Outcomes than Men
Editorial Comment: Instructors and Coaches
Horse-related Fatalities in Ohio 1990-1998
Jockey Injuries in the United States
Equestrian Acrobatics in the Adolescent
Horse-related Deaths in North Carolina, 1990-1999
Pediatric Horse-related Injuries in New Mexico
Eventing: The International Safety Committee Report, April 2000
News Items

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Women Appear to Suffer Worse Outcomes than Men After Traumatic Brain Injury (TBI)

Injury is the leading cause of death from birth to age 5 years, resulting in more than 56,000 deaths annually, and TBI is responsible for the majority of these deaths.(1) In the entire U.S. population there are at least 373,000 new cases of TBI each year that require hospitalization.(2) This figure is likely to be an underestimation of total new TBI cases per year, because it under-samples the patients who sustain milder injury and who are never hospitalized. Approximately 99,000 new survivors of TBI each year are classified as disabled.(2) Survivors of TBI tend to be young, which means that there is a high life-long cost of disability. Traumatic brain injury is estimated to create a yearly expenditure of $48.3 billion dollars.(3)

Gender differences in the incidence of TBI are well known. Epidemiological studies have established that many more men than women sustain a TBI.(4) Kraus and Nourfah(5) studied patients hospitalized in 1981 for mild head injury (Glasgow Coma Scale scores of 13-15) and found that the incidence was approximately twice as high in male as in female patients (174.7 and 85.2, respectively, per 100,000). In a different study the investigators found that in men under age 65 years the rate of head injury was almost three times as high (1141 [73%] of 1571) as in women (450127%] of 1571) in a Scottish sample of head-injured patients.(6) The gender difference found in the incidence of TBI is only seen from puberty until middle age, leaving a large part of the life span with roughly equal rates of TBI between the sexes. It is important to note that although men sustain a greater number of TBIs than women, women still comprise a substantial portion of TBI patients (one quarter to one third of the population according to these estimates).

The sex of patients with TBI has not been well studied as a possible explanation for, or confounding factor in, outcomes after TBI. However, what little research exists on gender differences in TBI outcome suggests that outcome may be worse in women than in men. For example, Klauber and colleagues (7) reported that case fatality rates were elevated in women as compared with men in two age groups. Kraus and colleagues (8) have recently reported findings from the UCLA Brain Injury Research Center, in which case fatality rates at the Emergency Department (while in the intensive care unit and after leaving it) were shown to be significantly higher for women than men. In addition, the rate of poor outcomes (that is, death, persistent vegetative state, and severe disability) was significantly elevated for women compared with men at 6, 12, 18 months post discharge. Bazarian and coworkers (9) recently reported that female gender was a significant predictor of the development of post-concussive symptoms at I month after suffering mild TBI.

A recent metaanalysis (10) of published studies of TBI outcome reanalyzed eight studies (20 outcome variables) of TBI in which outcome was reported separately for men and women. This study found that outcome was worse in women than in men for 85% of the measured variables. Although clinical opinion is often that women tend to experience better outcomes than do men after TBI, the opposite pattern was suggested in the results of this metaanalysis. However, this conclusion is limited by the fact that in only a small percentage of the total published reports on TBI outcome was outcome described separately for each sex.


(1) Kraus JF, McArthur DL, Silberman TA: Epidemiology of mild brain injury. Semin Neurol 14:1-7, 1994

(2) Kraus JF, Sorenson SB: Epidemiology, in Silver JM, Yudofsky SC, Hales RE (eds): Neuropsychiatry of Traumatic Brain Injury. Washington, DC: American Psychiatric Press, 1994

(3) Anonymous: Guidelines for the Management of Severe Head Injury. A Joint Initiative of the Brain Trauma Foundation, The American Association of Neurological Surgeons, The Joint Section on Neurotrauma and Critical Care. Washington, DC: Brain Injury Association, 1995

(4) Rimel RW, Giordani B. Barth JT, et al: Disability caused by minor head injury. Neurosurgery 9:221-228, 1981

(5) Kraus JF, Nourjah P: The epidemiology of mild, uncomplicated brain injury. J Trauma 28:1637-1643, 1988

(6) Pentland B, Jones PA, Roy CW. et al: Head Injury in the elderly, Age Ageing 15:193-202, 1986

(7) Klauber MR, Marshall LF, Barrett-Connor E, et al: Prospective study of patients hospitalized with head injury in San Diego County, 1978. Neurosurgery 9:236-241, 1981

(8) Kraus JP, Peek-Asa C, McArthur D: The Independent effect of gender on outcomes following traumatic brain injury. Neurosurg Focus 8 (l):Article 4, 2000

(9) Bazarlan JJ, Wong T, Harris M, et al: Epidemiology and predictors of post-concussive syndrome after minor head injury in an emergency population. Brain Inj. 13:173-189, 1999

Excerpted from

(10) A Metaanalysis of Gender Differences In Outcome After Traumatic Brain Injury. Elana Farace, Ph.D., Wayne M. Alves, Ph.D., Department of Neurosurgery, University of Virginia; and INC Research, Charlottesville, Virginia. Neurosurg Focus 8(1), 2000.

Maureane Hoffman, MD PhD
Associate Professor of Pathology
Assistant Professor of Immunology
Duke University Medical Center
Durham NC 27705 USA

Editorial Comment: Instructors and Coaches: Their Roles and Education

If you're like most horse-people, you probably use the words riding Instructor and coach rather interchangeably. But if I prompt you with the ugly thought of a seven-foot, 300-pound linebacker showing up for a lesson with his football instructor, it might be enough to make you realize that instructors and coaches actually perform two entirely different roles. And if I tug on those two roles hard enough, pulling riding instructors far enough apart from coaches, then perhaps you can understand why the British Horse Society (BHS) is teaming up with the University College of Worcester to offer a equestrian coaching degree.

The role of an instructor is that of a teacher. Instructors teach students how to master the finer, technical aspects of a sport and help them become proficient enough to enjoy the sport with some degree of success.

Instructors usually work with beginners and intermediates in sports that oftentimes require more emphasis on technique than physical fitness, strategy, or teamwork (such as tennis, swimming, snow skiing, golf, and horseback riding). Consequently, instructors must be effective teachers, know the proper techniques of the sport, and be able to follow basic safety principles all of which is probably addressed-through the traditional BHS Instructor certificate.

The role of a coach, on the other hand, is more complicated. Coaches help prepare athletes for competitive sports that demand a certain degree of physical prowess, strategy, and, at times, teamwork (such sports include football, gymnastics, ski racing, show jumping, and polo).

Coaches frequently must function as instructors, teaching athletes the techniques, strategies, and tactics needed to compete. But coaches are expected to be more knowledgeable than instructors are regarding both the sport and human athletic performance. Coaches must thoroughly understand the rules of the sport and the strategies involved, and they must know how to pull teams together and how to prepare athletes physically and psychologically to perform their best. Perhaps it's this last aspect of the role of the coach — to prepare human athletes physically and psychologically — that prompted the BHS to join forces with a university to bring the coaching and sport sciences to their equestrian coaches.

The coaching and sport sciences are areas of study that focus almost exclusively on human athletic performance and the competitive sport environment. The coaching and sport sciences typically include fields like biomechanics, exercise physiology, sport psychology, motor learning, nutrition, sports medicine, sport administration, and pedagogy (the science of teaching).

Please don't let all of this coaching and sport science stuff scare you and make you feel as though the Brits are getting ahead of us, because that type of information is readily available in our own country. Researchers for the National Association for Sport and Physical Education (NASPE) developed a book of National Standards for Athletic Coaches, which guides programs that educate athletic coaches.

Riding instructor education and certification programs in the U.S. can easily meet these standards with help from the American-Sport Education Program (ASEP). ASEP has become the most widely respected athletic coach education program In this country. ASEP educates coaches for over 40 National Governing Bodies and sport associations, 200 universities and colleges, and 1200 youth sport associations (such as the US Tennis Association, University of California at Davis, and YMCA of the USA).

For more Information, you can call NASPE at 1- 800-321-0789 or write to them at 1900 Association Drive, Reston, VA 22091-1599. ASEP can be reached by calling 1-800-747-5698 or writing to PO Box 5076, Champaign, IL 61825.

Johanna L. Harris, MA
Equestrian Athletics, Inc.
118 Lower Sand Branch Rd.
Black Mountain, NC 28711

Horse-related Fatalities in Ohio, 1990-1998


There were 39 horse related deaths in Ohio from 1990 through 1998. The Information presented in this report was taken from a review of death certificates issued during those nine years.

Of the 39, 26 (67%) of the deaths occurred in unmounted accidents. Of the unmounted fatalities, 13 (50%) were in horse drawn vehicles that were struck by automobiles and six were kicked while walking behind horses. Additional unmounted deaths occurred among two racing spectators, another five were found in stalls, all with head injuries. However, there was no description of their accidents. Only 13 or approximately 33% of the deaths occurred while mounted or riding. Of these, nine fell from their horses and in four of the accidents, the horse fell before the rider.

Of all fatalities, 14 (36%) were females and 25 (64%) were males. Ages ranged from 20 months to 82 years. Eleven were under 18 years of age.

The major causes of death were:

• 24 (63%) had severe injuries to the brain and/or cervical spinal cord.

• 14 (35%) were the result of crushing injuries to the chest or abdomen.

One was due to fracture of the tibia with postoperative pulmonary emboli.


Although many of the death certificates were supplemented by a comer's report, there is no record of alcohol or substance abuse. The deaths on horse drawn vehicles were Amish, except one. There are 35,200 Amish people in Ohio. Horses are an important part of their every day living i.e. farming and transportation. Buggies and wagons are the usual means of transportation. It is known that all deaths in horse drawn vehicles were Amish.

There are numerous estimates of unmounted fatalities that average about 34% but those in Ohio have been higher that those in other states. These distressing statistics should be given to the Ohio Department of Transportation so that the department, through more public education can make the roads safer for not only horse drawn vehicles but for everyone.

Three (8%) fatalities were professional horse persons: of the two mounted riders, one was a jockey that fell during a race, the other was a riding instructor, a female 23 years of age that was thrown from a horse in an outdoor track, The third was unmounted and a trainer of race horses, who was found dead in a horse stall. All three victims had massive head injuries. From this study, it is apparent that professional horse-persons should serve not only as role models but for their own safety should wear protective and secured head-gear that are fitted and ASTM/ SEI certified.

George H. Koephi, M.D., AMEA
2222 S Main Street
Findlay, Ohio 45841
Phone (419) 424-3834
E-mail geol32578@aol.coin

Editorial Comment

A unique horse-related fatality pattern Is reported from Ohio with unmounted accidents accounting for 67% of the deaths in 1990-1998. A large Amish population accounts for horses and buggies having to share the roads with motor vehicles which is a dangerous combination. I would be interested in the Ohio Department of Transportation activity in response to this issue.

Lohn F. Stremple, M.S., M.D., M.S., F.A.C.S.
Professor Emeritus of Surgery
University of Pittsburgh 

Jockey Injuries in the United States

Context: In the sport of horse racing, the position of the jockey and speed of the horse predispose the jockey to risk of injury.


To estimate rates of medically treated injuries among professional jockeys and identify patterns of injury events.


Cross-sectional survey from data complied by an Insurance broker. Information on the cause of injury, location on the track, and body part Injured was evaluated.


Official races at US professional racing facilities (n = 114) from January 1, 1993 through December 31, 1996.


A licensed jockey population of approximately 2700 persons.


A total of 6545 injury events occurred during official races between 1993 and 1996 (606 per 1000 jockey years). Nearly 1 in 5 injuries (18.8%) was to the jockey's head or neck. Other frequent sites included the leg (15.5%). foot/ ankle (10.7%), back (10.7%), arm/hand (11.0%), and shoulder (9.6%). Most head injuries resulted from being thrown from the horse (41.8%) or struck by the horse's head (25.2%). Being thrown from the horse was the cause of 55.1% of back and 49.6% of chest injuries.


Our data suggest that jockeys have a high injury rate. Efforts are needed to reduce the number of potential injury events on the track and to improve protective equipment so events do not lead to injury.

Waller AE, Daniels JL
Weaver NL, Robinson P
IAMA 2000; 283.1326-1328

Doris Bixby Hammett, MD 

 Equestrian Acrobatics in the Adolescent

The objective of this study was to compile knowledge of athletic injuries and complaint patterns related specifically to equestrian acrobatics (e.a). A 20-page standardized questionnaire was sent to 114 e.a. participants. The mean age of the participants in e.a. groups was 15 (+ or -) 3 years, that of independent participants 21 (+ or -) 3 years.

A total of 489 Injuries was reported, mainly to muscles and tendons (35%), skin (33%) and joints and ligaments (25%). Bone injuries (6%) and head Injuries (2%) were Infrequent.

Analysis of the localization showed that the head-face-neck region was involved in the injury In 3.9%, the torso in 5.5%, the upper extremities in 28%, pelvis and hip region in 3.9%, and the lower extremities in 52%. More that half the injuries were categorized in severity grade 1 (55%) (not requiring medical attention), 25% were grade II (single medical treatment), 15% grade III (several outpatient medical treatments) and 5% were grade IV (requiring hospitalization).

Nearly half of the injuries to the lower extremities resulted from jumping exercises, while the cause in upper-extremity injuries was from mostly falling (37%). The importance of fall training and limitation of difficulty as well as the number and height of the jumps is discussed.

Regular medical examination and improved education of the trainers are demanded.

Horstmann T, Heitkamp HC,
Mayer F, Hermann M, Kusswetter HW, Dickhuth H
Sportverletx Sportschaden 1998
Jun; 12(2):66-70

Danish Study Commentary

"Equestrian acrobatics" in this Danish study would appear to be the sport that we refer to in the U.S. as vaulting. All available safety statistics on vaulting in the U.S. come from the annual safety reports complied by the safety committee of the American Vaulting Association. These are derived from questionnaires sent annually to all member coaches.

Unfortunately the Danish study does not specify a time frame. It does not clearly define who provided the data or whether injuries occurred in practice, competition or other circumstances. With these limitations, the U.S. experience does appear to be quite similar to the Danish report.

In a 1998 study report of 41 AVA affiliated clubs reporting on 20,000 hours of vaulting practice 66 injuries occurred. These were primarily soft tissue injuries (68%), principally of the ankles and knees. Fractures were involved in 11% of the injuries and all of these were extremity injuries, primarily lower extremity. Only a third of these injuries were even seen by a physician and only 4 injuries (6%) required surgery.

In reviewing AVA safety reports for the past decade and interviewing a large number of the veteran coaches several impressions emerge. As the popularity of the sport increases and the number of participants increases, this continues to be a relatively safe equestrian sport. Injuries severe enough to end a participant's competitive career are almost always knee injuries. Head injuries have been quite rare. I am unable to find a record of a U.S. head Injury that required more treatment than outpatient observation or that resulted in any known neurologic sequale.

Formal safety standards for therapeutic vaulting are currently being developed by a NARHA subcommittee in cooperation with AVA representatives. Similar safety standards will probably eventually be developed for competitive vaulting.

Robert Faulkner, MD
4186 Mill Street
Covington, CA 30209 

Horse-related deaths in North Carolina, 1990-1999

North Carolina has a horse population of 140,000 horses, ponies, mules, burros, and donkeys in 1999 which was an increase of one percent from the 138,000 head reported a year earlier. North Carolina State University estimates that there are as many as 65,000 horse owners in North Carolina. (1) Many of its citizens are involved with horses.


Fifty-one horse related deaths were recorded by the Office of the North Carolina Medical Examiner during the years 1990 to 1999. These deaths can be divided into the following:


1. Deaths that involve a motor vehicle: N=10 (19.6%)

Each of two victims were passengers in a car when the car hit a horse loose on the road. In both cases, the actions of the victims contributed to each death: a 7 month old baby was in the lap of the mother riding in the right front seat of the car without a car seat/safely belt. The second also was in the right front seat with a blood ethanol of 230mg/dl.

Two of the deaths were on two wheeled vehicles. One victim was riding a motorcycle which hit a horse. The second was a moped rider who was racing a horse, ran into the horse, fell and was killed. His blood ethanol was 220 mg/dl. One person was leading a horse beside a road when he was hit by a car. His blood ethanol was 200 mg/dl.

Two persons were in a horse drawn vehicle, one driving the horse, the other riding in the carriage, when they were struck by a car. One horseback rider was thrown to the ground and immediately run over by a van. Two were each riding a horse when hit by a car, another was hit by truck. Blood ethanol were elevated in five (5/11 45.5%) of the eleven including one victim in the car.

2. Deaths involving a horse drawn vehicle N=6 (11.8%)

In one accident, a car hit the pony cart killing the cart driver and passenger, both victims aged 45 years. In one accident, the reins broke with three passengers jumping to safety but the driver of the cart, age 34 years, suffered a basal skull fracture. In the third accident a tree limb was caught in the wheel resulting in the driver being thrown from the vehicle (age 65 years). In another accident the carriage brakes failed and a wheel ran into a ditch throwing the driver into a fence pole. In the final death, the victim, with a C2/C3 fracture dislocation, was found in the field with an unhitched carriage nearby. The harnessed team of horses were caught by a tree not far from the victim.

3. Person not mounted on the horse/not In horse drawn vehicle N=4 (9.8%)

Two victims were kicked in the chest, one was crushed in the stall by the horse. One 4 year old child was kicked in the head by a horse in the pasture.

4. Person attempting to mount a horse. N= 1 (2%)

A witness to the accident stated that the victim fell when his horse bucked while he was attempting to mount. His blood alcohol was 287 ml/dl. He suffered a rib fracture with hemopneumothorax, dying 5 days later with the diagnosis of acute adult respiratory syndrome/pneumonia and renal insufficiency.

5. Victims who fell into a stationary object N=4 (7.8%)

Where known, two persons in separate accidents hit a telephone pole when they fell (one from a horse drawn vehicle). One driver of a carriage was thrown into a fence. A fourth victim hit a tree when he fell.

6. Victims who fell hitting the ground or road N=22 (43.1%)

Some were found on the ground and are assumed to have hit the ground. Four reports identified that the rider hit asphalt or pavement. One victim was riding double with a child.

7. Other N=8 (15.7%)

One mounted victim was hit In the chest by the horse's head. Another mounted victim's horse fell on her. A pregnant mother, in the 32nd week normal gestation in a paragravida two, was kicked in the leg by a horse and suffered an abruptio placenta with the death of her child. One victim was killed In a drive by shooting. One died from a fat embolism from hip trauma, one of cardiogenic shock five days after surgery for reduction and internal fixation of a fractured hip. One victim died from lobar pneumonia two years after his fall during a rodeo. He had residual neurological damage requiring his total care including a gastrostomy for feeding.


  1990-99   1980-89  
CAUSE DEATH Number PerCent Number PerCent
Head 31 60.8 13 48.1
Trunk 8 15.7 6 22.2
Multiple system massive 5 9.8 4 14.8
C spine Neck 2 3.9 1 3.7
Abruptio placentae 1 2.0 0 0.0
Cerebral fat embolis 1 2.0 0 0.0
Gun short 1 2.0 0 0.0
Adult ARDS 1 2.0 0 0.0
Cardeogenic shock 1 2.0 0 0.0
Drowning 0 0.0 2 7.4
Other 0 0.0 1 3.7
TOTAL 41   27  

Head injury was the cause of death in 31 (60.8%) of the cases. Trunk injuries resulted in 8 deaths, followed by 5 with multiple system injuries.


  1990-99   1980-89  
AGE Number Percent Number Percent
0-4 4 7.8 1 3.7
5-14 3 5.9 2 7.4
15-24 6 11.8 4 14.8
25-44 20 39.2 15 55.6
45-64 16 31.4 4 14.8
65+ 2 3.9 1 3.7
TOTAL 51   27  

Most deaths in horse related accidents during 1990-1999 occurred between ages 25 years through 64 years. Two deaths, one each at 2 days and one at 7 months, were incidentally related to horse accidents. In horse related deaths, males were 34 (66.7%) of the victims, females 17 (35.5%). Of the deceased 41 (80.4%) were white, 7 (15.7%) Afro-Americans, 2 (5.9%) Native Americans, and 1 (2%) East Indian.


In 15 of the deceased, blood alcohol levels were from 320 mg/dl to a low of 62 mg/dl including one record with a comment that the blood alcohol was "elevated" without a figure. In the documented adult blood alcohol levels (N=30 - blood levels were obtained from three deceased age 4, 7 and 9 years of age), 42.3% had elevated blood alcohol. In 20 the blood alcohol was not elevated, but this in a few cases was taken at death, several days/hours after admission. In 15 the blood alcohol was not taken: 8 of these victims were under 16 years of age.


During the 10 years of 1980-1989(1), 27 horse related deaths were identified in North Carolina compared with 51 during the last decade. There are more horses in North Carolina and we presume that more persons are riding horses. Other factors could be better records in the medical examiner system in the state or an increase in the severity of injuries in the horse activities.

Ingemarson, Sweden, reported for the decade preceding 1969-1982 the number of horse riders had multiplied more than five times. He further reported that in West Germany, the number of registered riders in the years 1959-1974 increased 350% and riding injuries increased by 350%(2). He reported 57 horse related deaths of which 53 were from traumatic horse related injuries. Buckley reported 54 fatal falls from horses in New Zealand during the years 1977-1986.(3) Ponder estimated 15 horse related deaths per year in Australia from his study of 18 equestrian deaths in South Australia 1975-1985.(4) The Province of Alberta during the years 1975-1990 reported 58 horse-related deaths. (5) United States studies have estimated the national number of deaths to be 217 a year. (6) This figure is low due to non-reporting and the methods of record keeping.

Motor vehicles were involved in only one death in our study for the years 1980-89 (5.7%) compared with 21.6% in the recent decade. Whitlock reported from England on 177 equestrian accidents on roads in West Midlands for 1986 in which 28 (41.2%) involved a motor vehicle. (7) Horses frequently share roads with motor vehicles. The Vital Statistics of the United States gives an average of 7.4 deaths a year for the years 1983-1994 involving a motor vehicle and an animal being ridden or animal drawn vehicle. (8)

In both decades, one death was involved with riding double on the horse.

Head Injuries as the cause of death have increased from 48.1% in the 1980s to 62% in the 1990s. Where the narrative mentioned helmets, none was worn by any of the deceased. In every medical study, head injury is the most frequent cause of death. In Australia 9 of 13 the horse related head injury deaths were not wearing protective headgear during the years under study. In Sweden head injuries were the cause of 38 deaths (72%). This study reported that 23 persons of the 38 deaths used the classical helmet which is not considered to give sufficient protection, in addition two riders lost their helmet when falling from the horse. Adequate helmets were worn only by two mounted riders. (It is unlikely that these helmets met the protective standard of ASTM equestrian standard F1163). In Australia 14 deaths were the result of head injury (72.2%). In the one instance in which a helmet was known to have been worn, it fell off during the fall. In New Zealand head injury was the cause of 33 deaths (62%). Of the 38 deaths in Alberta, 22 (58.9%) were from head injuries. Only one victim was known to have worn an approved helmet.

There were 8 trunk injuries which is above that of the 1980's which were 6, but the percent is decreased in the figures of 1990- 99. Trunk injuries are second to head injury in frequency as the cause of death. The Swedish study reported that thoracic injuries were found in 15% and abdominal injuries in 11%. In Alberta 32% of the deaths were truncal injuries. New Zealand 5.6% internal injuries and 7.4% fractures of spine/trunk, giving 13% trunk injuries.

Multiple system injuries essentially remain the same as did neck/cervical spine injuries. The other causes of death are not sufficient to compare but serve to call attention to events which are involved in horse related deaths.

The North Carolina age figures agree with those of the National Electronic Injury Surveillance System which show that the older riders are having a greater percent of the injuries and deaths. (9) New Zealand in contrast reported 25.9% of deaths in 5-14 years of age, 42.6% in 15-29, with a decrease to 16.7% in ages 30-44. Sweden had similar age span with the 21-25 years (N=8), 6-10 years (N=6) and 36-40 (N=6) dominating Alberta reported 18.4% of the deaths were 5 years of younger. In Australia the ages of 15-24 had the greatest number of deaths (N = 7 38.9%)

In the United States we have educational programs for youth and young riders. These riders are more likely to follow safety protocol than the older traditional riders. The older riders may feel since they have never had an accident or the accident they had was incidental, they do not need protective headgear or to follow the rules of safety.

The male victims during the decade of the 1990s had 68% of the deaths compared with 55.6% in the 1980s. In the NEISS study of horse related accidents, females have more accidents than males, in Sweden female deaths dominate before 25 years of age; from 26 to 59 years of age males and females have equal number of deaths, but above 60 male deaths denominate. In Alberta 55.3% were male and 44.7% were female. in New Zealand 30 (55.6%) horse related deaths were female and 24 (44.4%) were males. In Australia, an equal number of male/female deaths occurred. In the United States Vital Statistics males have a higher percent of deaths In every horse related death category.

North Carolina represents the figures from the United States in which males have more horse related deaths than female. The reasons are not clear.

The North Carolina 1980's study first showed the relation of elevated blood alcohol with horse related deaths. (10) During that period 5 of the 27 (18.5%) deaths had documented elevated blood alcohol. In the 1990's 15 (24%) of the deceased and 42.5% of those adults on which blood alcohol levels were available had documented elevated blood alcohol. We do not know if more of the deceased riders had elevated blood alcohol or if our records are better. However, these figures witness that horseback riding and alcohol intake increase the chance for severe injury.


Head injuries are the cause of the greatest number of horse related deaths with the total number and percent both having increased in the past decade. Protective headgear, ASTM standard (11), SEI certified (12), fitted and secured by a harness, has been shown to increase head protection. No horseback rider should mount a horse without this protection.

When riding a horse, do not drink alcohol (or take other drugs or medication without a doctors advice).

Do not ride double on a horse. In each decade we have had a death related to this activity.

The Department of Motor Vehicles should include instructions for motorists in relation to passing horses and horse drawn vehicles. Two horse related deaths involved neglect of the passenger in the motor vehicle to fasten the seat belt and use a child safety seat.

Riders should wear the warning reflective orange color strips on their clothing and vehicles when on public roads.

The horse community benefits from the information gained from studies of horse related deaths.

Doris Bixby Hammett, MD
Board of Directors
American Medical Equestrian Association
Safety Committee United States Pony Clubs, Inc.
103 Surrey Road
Waynesville, NC 28786

(1) Hammett dB.: AMEA NEWS; November 1991.

(2) Ingemarson H„ Gravestone S et al; Lethal Horse-riding injuries. J. Trauma, 29:25-30. 1989.

(3) Buckley S., Chalmers D., Langley J. Falls from Horses Resulting in Death and Hospitalization: Descriptive Epidemiology. Dunedin Multidisciplinary Health & Development Research Unit, Medical School, University of Otago, PO Box 913, Dunedin. 1991.

(4) Ponder DJ, The grave yawns for the horseman. Med. J. Australia: l4l;612-634, 1984.

(5) Aronson H., Tough SC. Horse-Related fatalities in the province of Alberta, 1975- 1990. Am J For Med and Path 14(1)28-30,1993.

(6) Hammett. DB. Horse Related Deaths. AMEA NEWS Nov 1997.

(7) Whitlock M. Equestrian injuries in England. Barnet General Hospital, Hertfordshire, England.

(8) National Center for Health Statistics. Division of DataServices, 6525 Belcrest Road, Hyattsville, MD 28782-2003. (E813.5).

(9) Hammett, DB. NEISS report. AMEA NEWS Dec 1999.

(10) MMWR- Morbidity and Mortality Weekly Report. Alcohol use and Horseback-riding-associated fatalities - NC. 1992 May 15; 41(19):335, 341-2.

(11) American Society for Testing and Materials. Philadelphia, PA Standard F 1163.

(12) Safety Equipment Institute. 1307 Dolley Madison Blvd. Suite 3A, McLean, VA 22101

Editorial: Horse-Related Deaths in North Carolina

Another revealing and important data base from Doris Bixby Hammett, MD. Data from the Pennsylvania State Department of Health Statistics of recorded deaths coded as result from an accident involving an animal (horse?) being ridden for the years 1989-1998 showed 12 deaths. Of the 12, only one was under 20 years of age.

John F. Stremple, M.S., M.D., F.A.C.S.
Professor Emeritus of Surgery
University of Pittsburgh
160 Monks Road
Saxonburg, PA 16056

 Pediatric Horse-related Injuries in New Mexico


We conducted a retrospective review of children with horse-related injuries admitted to the state's only Level I trauma center. Horse-related injuries were found to be the second leading cause of pediatric trauma admissions to our institution. Half of these children were Native American. Over fifty percent were injured by a horse kick as opposed to a fall. All of the children with head injuries from a horse kick sustained depressed skull fractures and three underwent surgical intervention. All children were discharged home without sequelae.


Horse-related injuries have been recently recognized as potentially very serious resulting in significant morbidity and mortality in the young adult population. ( In fact, the American Academy of Pediatrics (AAP) has set forth guidelines for the prevention of head injuries during horseback riding. New Mexico is a rural state with a high fatality rate of many types of pediatric injuries. We were interested in determining the importance of horse related injuries in the overall picture of traumatic injuries to children admitted to the state's only Level I trauma center.

Materials and Methods

A retrospective chart review was done of all trauma patients less than 15 years of age admitted to our institution for 1990 as compiled by the State Trauma Registry. We reviewed the charts of all children who were injured by horses for circumstances of the incident demographics and detailed injuries. We also reviewed records from the Office of the Medical Investigator for any horse-related deaths in children for 1985-1990.


Mechanism of Injury for Children Admitted to Level I Trauma Center

Mechanism Number Deaths % of Total
Motor vehicle crash 84 12 74.3
Horse 8   7.1
Gunshot wound 7 4 6.1
Falls 6   5.3
Knife 3   2.6
Garden 2   1.8
Other (assault, bite, abuse) 3   2.7


One hundred fifty (150) pediatric trauma patients were admitted to our hospital 1990. The leading causes of admissions are shown in Table I. Horse-related injuries were the second leading cause of admission (n=8). Review of Medical Examiner records for 1985-1990 did not reveal any additional horse-related injuries resulting in death in the pediatric population.

Table 2
Horse Related Injury Summary

Circumstance of Injury Age Sex Ethnicity Length of Stay Mechanism Injury
Riding full gallop 4 F Unk 2d Fall, lethargic, vomiting Basil skull fx
Riding with Friend 10 F Asian 7d Fall, horse rolled onto child Skull fx; liver laceration; eye contusion
Riding in Corral 10 F Native American 5d Fall, Stopped abruptly, child fell onto fence Spleen rupture, cardiac contusion
Not documented 13 M Native American 4d Kicked, Loss of consciousness, seizures Open, depressed skull fx
Not documented 2.5 F Native American 7d Kicked, loss of consciousness Open depressed skull fx w/ brain contusion
Not documented 11 F Native American 4d Kicked, chest pain Kidney fx, post-traumatic pancreatitis
Not documented 7 M Hispanic 5d Kicked, loss of consciousness Open depressed skull fx
Not documented 5 M Hispanic 2d Kicked, loss of consciousness, Ataxia Open depressed skull fx


Four (4) of the eight (8) children were Native American. Three (3) patients were Injured by falling from a horse and five children were kicked by horses (Table 2) The mean age for both groups was similar: 7.0 years for the fall victims and 7.7 years for the kicked children. All the fall victims were female whereas there was nearly an equal number of males and females in the kicked patients (not statistically significant by Fishers exact test). The mean hospital stay for the fall group was 4.6 days, and 4.4 days for the children kicked. Four (4) of the five (5) children injured by being kicked sustained injuries to the head and all of these children had depressed skull fractures; three of these children underwent surgical intervention. Two (2) of the three (3) children who fell sustained non-depressed skull fractures. Three (3) children had abdominal injuries; two (2) from falls and one (1) kicked. One (1) child sustained a chest injury from a fall in addition to her abdominal injury. Seven (7) of the eight (8) admissions were transferred from other non-level I hospitals for further stabilization and work-up. All of the children were discharged home without sequelae and none attended rehabilitation centers.


New Mexico is the fifth largest state in land mass, with a population of 1.6 million people. There is only one Level I trauma center in the entire state, which also serves parts of southern Colorado, west Texas and eastern Arizona. This catchment area has one of the highest percentages of Native American and Hispanic inhabitants in the country. Since non-thoroughbred horses are not required to be registered in New Mexico, it is impossible to estimate the number of horses in the area. We suspect, however, there is a high horse population as 30 out of 33 New Mexico counties are considered rural with numerous ranches, farms, and reservations. While there are an estimated 1.2 million under-20 years old who own horses nationally.(2) It is likely that because of the reasons stated above, many of the young people owning and riding horses in New Mexico are not represented by this figure so the true number would be considerably greater.

Native American children accounted for half of all pediatric admissions related to horse injuries, but comprise less than 10% of the state's population. The high representation of the Native American population in our study correlates with other studies which have shown that Native American children are at higher risk for injuries.(6,7,8,9) A part of Native American life in much of rural New Mexico includes work with livestock and rodeos, so there may be considerable exposure to horses from an early age. The number of children in our study, however, is small and we cannot demonstrate statistical significance.

The Massachusetts SCIPP study found that horseback riding was the second leading recreational cause of concussions.(10). Most studies of hospitalized and non-hospitalized children have found that the upper extremity is the most commonly injured body part in horse-related injuries.(2,3,4,5) In hospitalized children, however, head injuries are the most common injury.(10) This is also confirmed in the studies involving adults as well as children.(12,13,14) In fatal horse-related injuries, head trauma is also the most common injury.(3,15) Fortunately, there were no pediatric deaths in our state from horse-related injuries for 1985-1990.

All of the children In our study who were kicked in the head sustained depressed skull fractures. This has important clinical implications suggesting that a plain skull radiograph may be an acceptable screening test where a computerized tomography (CT) scan is not initially available. Neurosurgery consultation, however, should also be considered early In the course because of the possibility of a depressed or basilar skull fracture, even in patients with a normal neurologic examination.

Our study indicates that the use of helmets would reduce some of the injuries associated with horseback riding. Since four of the children with skull fractures were kicked by a horse, helmets should be worn when a child is around a horse even if not riding. Future studies that include less seriously injured children and more information on the circumstances of the injury would better define the prevalence of this problem and might help to further identify preventive strategies. E-coding and improved documentation on the medical record regarding injury circumstances would also be useful in identifying other injury prevention aspects of pediatric horse related injuries.


This study has identified horse related injuries as a significant cause of pediatric trauma in our state. Implementation of a prevention strategy would include mandating that children wear helmets around horses even when they are not riding. The AAP has set forth guidelines to prevent head injuries in children around horses, including education programs, matching children with horses appropriate to their abilities, and Safety Equipment Institute- approved helmets.(1) Adult supervision should also be added to the list. The high representation of Native American children in our study suggests that adopting an educational program that could be tailored to the needs of children living on the reservations would be useful.

*The authors wish to acknowledge Ingrid Wentzel and Linda Bailie for their technical assistance in the preparation of this manuscript, and Lettie Rutledge for her help with data collection.

Robert Sapien, MD FAA
UNM School of Medicine
Department of Emergency Medicine
2211 Lomas Blvd. NE, AAC 4W
Albuquerque, NM 87131


1. Committee on Sports Medicine and Fitness, American Academy of Pediatrics. Horseback Riding and Head injuries. Ped. 1992; 89:5l2.

2. Bixby-Hammett DM. Youth accidents with horses. Physician Sportsmed 1985; 13(9): 105-109.

3. Bixby-Hammett DM. Pediatric Equestrian Injuries, Ped. 1992189(6): 1173-76.

4. Bixby-Hammett D, Brooks WH. Common Injuries in horsebackriding; A review. Sports Med.


5. Morbidity and Mortality Weekly Report. Injuries associated with horseback riding--United States, 1987 and 1988. Centers for Disease Control. 1990;39(20):3302.

6. Olson LM, Becker TM, Wiggins CL, et al Injury Mortality in American Indian, Hispanic, and NonHispanic White Children in New Mexico, 1958-1982. Soc Sci Med. 1990; 30:479-486.

7. Olson LM, Sklar DP, Cobb L, et al. Analysis of Childhood Pedestrian Deaths in New Mexico, 1986-1990. Ann Emerg Med. 1993;22(3):5l2-516.

8. Parker DJ, Sklar DP, Tandberg DI et al. Fire fatalities among NewMexico children. Ann Emerg Med.1993;22(3);517-522.

9. Davis S, Ledman J, Kilgore J.Drownings of children and youth in a desert state West J Med. 19851143:196201.

10. Ustemick D, Finison K, Gallagher S, et al. The problem of sports and recreational injuries. SCIPP Reports. 198314(2): 1-8.

11. Barone GW, Rodgers BM. Pediatric equestrian injuries: a 14-year review. J Trauma, 1989;29(2): 245-47.

12. Muwanga LC., Dove AF. Head protection for horse riders a cause for concern, Arch Emerg Med. 1985;2;85-87.

13. Whitlock MR,Whitlock J, Johnston B. Equestrian Injuries: a comparison of professional and amateur injuries in Berkshire. Brit J Sports Med. 1987;21(1);25-6.

14. Lloyd RG, Riding and other equestrian injuries: considerable severity. Brit J Sports Med 1987;21(1):22-4.

15. Ingemarsson H, Grevsten S, Thoren L. Lethal horse-riding Injuries. J Trauma, 1989;29(1):25-31.


Editorial Comment

The above study, done in 1990, has not been published as the sample size is small. As horse-related injuries are infrequent and are of interest mainly to those in the equestrian community; and the physicians and medical personnel who treat them, general medical publications editorial boards require numbers not available to those doing research seeking to prevent the accidents, injuries and reduce the severity of the injuries when they occur in our activities.

North Carolina Medical Examiner System provides information that is not available in other states, but North Carolina trauma centers horse related records have not been available for study. Every medical study is of interest as to what it shows. North Carolina has a low Native American population, but 3.9% (N=2) of the deaths in the study reported elsewhere in the AMEA NEWS were Native American. North Carolina had 2 horse related deaths from drowning, a type of horse related death which was reported from Oklahoma, and one of a 9 year old killed while riding her new Christmas horse with her mother and aunt in a drive by shooting. A shooting accident occurred to a horseback rider in West Virginia, so this does appear as a concern.

The FEI safety committee, reported elsewhere in the AMEA NEWS, recommends that the FEI set up and run a world wide statistical database in which the statistical report should cover information regarding the injuries to riders and horses. We should take that farther. Our small medical studies use different perimeters of age, descriptions of body part injured, complications/residual disability, to say nothing of the definitions of fall or the cause of the accident, so that comparisons are difficult. The medical and the horse community should determine what is the greatest concern, and propose a standard form for information that all studies could use which could be complied giving sufficient figures for statistical analysis. One of the first areas that I would recommend is if the rider was wearing a helmet, if so, what type, protective standard, SEI or equivalent, certified, fitted, fastened? The helmet manufactures have been receptive to input for safety and acceptability. I feel that the horse community through its leaders has a foremost position in the sport world in studying the factors for safety in our sports and recommending steps to achieve the goal of the highest level of safety possible. Our challenge is to get the horse community to participate in studies and to take advantage of the information learned and the knowledge available to them.

Doris Bixby Hammett, MD
103 Surrey Road
Waynesville, NC 28786



The International Safety Committee Report, April 2000

Virtually all the Committee's recommendations are addressed to the FEI as the world governing body. However, It is understood that there are large sections of the sport outside the control of the FEI which urgently need an overall monitoring system.

The Committee would like to see the establishment of an Federation Equestre Internationale Annual report to cover at least the following subjects:

a) Medical

b) Veterinary

c) Training of Riders and Horses

d) Cross Country Course Design

e) Training and Appraisal of Officials

f) Rules and Tests

g) Statistics


The Committee recommends that the FEI set up and run a world wide statistical database. The statistical report should cover information regarding the injuries to riders and horses. With the statistics to be reviewed, and published annually by the FEI, and necessary action taken from trends shown.


The Committee recommends that a mandatory passport system for all Riders should be established and designed by the FEI and issued to all the National Federations. This passport will include medical and disciplinary issue records together with rider qualifications. This should become a world-wide system.

The Committee recommends that competitors carry medical details visibly on their person at any time whilst jumping any fences on the competition site.

The Committee recommends that two contact names and telephone numbers must be handed to the event organizers, by each competitor prior to the start of the competition, (for cases of emergency).


The Committee recommends to the FEI that rules to define reckless riding be produced. The Committee recommends the establishment on an international basis of a bi-annual, formal, appraisal system for Officials, Ground Juries, Technical Delegates and Course Designers to be established on an international basis.


The Committee recommends that medical coverage at any Event to be appropriate for on-site management of severe trauma. Medical Officers qualifications to Pre-Hospital Trauma Life Support or equivalent to be mandatory in the Rule Book by the start of 2002 season.

The FEI should establish through its Medical Advisor maximum acceptable response times for paramedics to reach any accident on the cross-country course.

The Committee recommends the need for the designated and protected safety route for emergency vehicles to be further highlighted at all FEI events and monitored by the Technical Delegate at all times.

The Committee recommends that random dope (DRUG) testing, and spot check medical examination of riders should be undertaken by the Chief Medical Officer at any event. The Committee recommends that the FEI establish threshold levels of prohibited substances for humans.

The Committee recommends counseling services to be offered to parents/partners concerned.

The Committee recommends that an On-site Doctor should confirm riders are fit to compete again before the sign them off in the passport.

The Committee recommends that following a fall, if the Fence Judge has any doubts about injury to horse or rider the combination should be held; the subsequent decision to continue should be made with greatest care by the official veterinarian and/or doctor.

The Committee recommends that the FEI ask National Federations to develop an educational program to include fitness, diet, recovery from injury, use of appropriate medication, drugs and alcohol and care of safety equipment for their riders.

The Committee recommends to the FEI that they have a medical advisory body (like the veterinarians) for all disciplines.


The Committee recommends that a comprehensive study of helmets to be urgently undertaken to establish the highest possible international specification for Eventing. This mandatory specification is to be coupled with an education/awareness program to ensure that all users and officials understand that to have good equipment in good condition and properly fitted becomes a requirement of taking part in Eventing.

The Committee asks the FEI to require standards and structural integrity of all helmets to be inspected at all FEI Three- Day Events.

The Committee recommends research be undertaken to establish the practicality of improving neck protection for riders.

The Committee asks the FEI to produce and recognize an international Standard for Body Protectors.

The International Eventing Safety Committee
The Secretariat
58 Marmion Road
London, SW11 5PA

News Items

AMEA Annual Meeting Slated for October 20-21 in Ohio


The AMEA Annual Meeting is scheduled for October 20-21, 2000. Join us for the annual members meeting and conference held at Lake Erie College, 391 W Washington Street, Painesville Ohio. Registration will begin at 8:00 am, October 20.


Please make your reservations Immediately, as space is limited. For reservations contact Quail Hollow Hotel and Conference Center 11080 Concord Hambden Road Painesville Ohio 44077-9557 Phone 440-350-3511 Fax 440-352-0125


$200.00 Physicians; $175.00, Non-Physicians; $100.00, Students. Please complete the registration form and return to the AMEA Office. For questions please call La Juan at 903-509-2473




Name _______________________________________

Phone ______________ Fax _____________________

Affiliation ____________________________________

Address _____________________________________

PHYSICIAN ............. .$200


STUDENT..... ........... $100

School/Study __________

Please complete and return with registration fee to:

AMEA Annual Meeting, 5318 Old Bullard Road, Tyler, Texas 75703.

Check or money order only.


Call for Papers

October 20-21, Cleveland, Ohio, will be the date and place for the eleventh annual meeting of the American Medical Equestrian Association. Mark your calendars and plan to attend. John F. Stremple, MD, F.A.C.S., Professor Emeritus of Surgery, University of Pittsburgh, will be the coordinator of the program.

The AMEA welcomes medical papers relating to the equestrian sports. If you have a presentation or wish additional information contact:

Dr. Stremple
160 Monks Road
Saxonburg, PA, 16056
Telephone 724-352-4691
FAX 724/352-7693


Sidney, Australia Olympics meeting of medical personnel

H.O.R.S.E. Australia, is hosting a meeting of medical personnel at the Hawkesbury Agricultural College on 23-24 September between the 3DE's and the start of Show Jumping and Dressage. All medical and paramedical and others welcome.

Any members of the AMEA who have something of interest to present please contact Dr. Craig Macaulay, Chairman of H.O.R.S.E., email, phone mobile 0418560942 [code for Aust 01161].

Secretary Elizabeth Wilson
P.O. Box 162
Lancefield Victoria Australia 3435
Phone 3 54291284 [code for Aust 01161]
Henry Hicks FRACS is the convener of the meeting.
address 10 Docker St Wagga Wagga N.S.W. Australia 2650 

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