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  • Original Contribution
  • Open Access

Characteristics of sports and recreation-related emergency department visits among school-age children and youth in North Carolina, 2010–2014

  • 1Email author,
  • 2,
  • 3, 4, 8,
  • 5,
  • 6, 7 and
  • 5
Injury Epidemiology20185:23

https://doi.org/10.1186/s40621-018-0152-0

  • Received: 9 January 2018
  • Accepted: 3 April 2018
  • Published:

Abstract

Background

Sports and recreational activities are an important cause of injury among children and youth, with sports-related traumatic brain injuries (TBIs) being of particular concern given the developing brain. This paper reports the characteristics of sport and recreation-related (SR) emergency department (ED) visits among school-age children and youth in a statewide population.

Methods

This study included all injury-related visits made to all North Carolina 24/7 acute-care civilian hospital-affiliated EDs by school-age youth, 5–18 years of age, during 2010–2014 (N = 918,662). Population estimates were based on US decennial census data. Poisson regression methods were used to estimate incidence rates and rate ratios.

Results

During the five-year period, there were 767,075 unintentional injury-related ED visits among school-age youth, of which 213,518 (27.8%) were identified as SR injuries. The average annual absolute number and incidence rate (IR) of SR ED visits among school-age youth was 42,704 and 2374.5 ED visits per 100,000 person-years (95% confidence interval [CI], 2364.4–2384.6), respectively. In comparison to other unintentional injuries among school-age youth, SR ED visits were more likely to be diagnosed with an injury to the upper extremity (Injury Proportion Ratio [IPR] = 1.28; 95% CI, 1.27–1.29), the lower extremity (IPR = 1.14; 95% CI, 1.13–1.15), and a TBI or other head/neck/facial injury (IPR = 1.12; 95% CI, 1.11–1.13).

Among ED visits made by school-age youth, the leading cause of SR injury was sports/athletics played as a group or team. The leading cause of team sports/athletics injury was American tackle football among boys and soccer among girls. The proportion of ED visits diagnosed with a TBI varied by age and sex, with 15–18 year-olds and boys having the highest population-based rates.

Conclusions

Sports and recreational activities are an important component of a healthy lifestyle, but they are also a major source of injury morbidity among school-age youth. Physical activity interventions should take into account sex and age differences in SR injury risk.

Keywords

  • Injury surveillance
  • Youth sports
  • Epidemiology
  • Emergency department
  • Traumatic brain injury

Background

Physical activity, along with a healthy diet, is one of the most commonly suggested solutions to the childhood overweight and obesity epidemic (Ebbeling et al. 2002; Goran et al. 1999). Despite the benefits of physical activity and organized sports participation, there are inherent risks to engaging in physical activity, in particular, risk of injury (Marshall and Guskiewicz 2003). Children and youth bear a disproportionate burden of sports and recreation-related (SR) injuries, with an estimated two-thirds of all medically attended SR injuries occurring among 5–24 year-olds (Centers for Disease Control and Prevention 2002; Conn et al. 2003). As compared to other types of injury, youth are more likely to have a diagnosis of a strain/sprain, fracture, superficial wound/contusion, and traumatic brain injury (TBI), including concussion (Burt and Overpeck 2001). TBIs are of particular concern because of the potential for possible long-term adverse health outcomes (Andruszkow et al. 2014; Babikian and Asarnow 2009; Sariaslan 2016; Taylor et al. 2002).

Most prior studies of SR injuries have used survey or sampling methods to estimate incidence. In addition, many of these publications are greater than 10 years old and have focused on high school and college athletes. This is one of the first studies to use a broad definition to describe the characteristics and incidence of sports and recreation-related injury and TBI among school-age youth in a well-defined population, only.

Methods

This population-based descriptive epidemiologic study examined the incidence, circumstances, and characteristics of SR injuries in children and youth. All NC ED visits for SR injury made by children 5–18 years of age during the period January 1, 2010 – December 31, 2014 were included. A broad and inclusive definition of SR injury was utilized, based on a public health model that underscores the importance of children developing lifetime patterns of healthy public activity within an environment of effective public health interventions designed to minimize injury risk (Marshall and Guskiewicz 2003).

Injury ascertainment

The ED visit data were obtained from the North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT) for the period January 1, 2010 – December 31, 2014. The Department of Emergency Medicine at the University of North Carolina at Chapel Hill and the NC Division of Public Health operate NC DETECT for the purpose of timely syndromic public health surveillance as mandated under state law since 2005 (Carolina Center for Health Informatics 2017; North Carolina State Government 2004). As of December 31, 2014, NC DETECT collected ED visit data from 123 acute-care, hospital-affiliated, civilian EDs in the state, representing an estimated 99% of total NC ED visits (Carolina Center for Health Informatics 2017; Harmon et al. 2012). During the five-year period of study, NC DETECT collected over 23 million ED visits, with an average of 4.7 million ED visits per year (Carolina Center for Health Informatics 2017).

An ED visits was defined as injury-related if it received an ICD-9-CM External Cause of Injury Code (E-code) indicating a valid mechanism of injury, and unintentional-injury-related if it contained an E-code indicating an injury of an unintentional intent (i.e. an injury not inflicted on purpose; “accidental”) in the range of E800-E869 or E880-E929 (National Center for Injury Prevention and Control 2007; National Center for Injury Prevention and Control 2014). The NC Division of Public Health and the University of North Carolina at Chapel Hill approved this study.

Case definition of a sports and recreation-related (SR) injury

The E-code-based case definition of SR injury was designed specifically for this study. Table 2 contains a list and brief description of the E-codes included in the definition of SR injury. For certain categories of sports and recreational activities, E-codes were grouped together due to the relatedness of the E-codes and/or due to small numbers of ED visit totals.

NC DETECT captures up to five E-codes for each patient visit. When multiple E-codes met the case definition (Table 2), the ED visit was classified according to the most specific E-code. For example, if an individual patient visit contained the following two E-codes: E849.4 (place for recreation and sport) and E007.0 (American tackle football), then ED visit was classified as being due to American tackle football. If the patient visit contained two E-codes of similar specificity, the visit was classified according to the first listed E-code. For example, if an ED visit contained the following two E-codes: E001.0 (walking, marching and hiking) and E001.1 (running), the ED visit would be classified as being due to walking, marching, and hiking. Table 1 contains the order in which E-codes were assigned, with “1” (e.g. E006.2 “Activities involving golf”) referring to the highest level of specificity and “7” referring to the lowest level of specificity (e.g. E849.4 “Accidents occurring in place for recreation and sport”). Over two-thirds of ED visits contained only one E-code for a SR (68.0%), with 26.0% and 6.0% of ED visits contained two and three E-codes for a SR injury, respectively.
Table 1

Selected characteristics of unintentional injury-related ED visits among school-age children: NC, 2010–2014

Characteristics

ED visits due to sports and recreation-related injuries

Total number of unintentional injuries

(N = 213,518)

(N = 767,075)

Age, No. (%)

 5–9 years

49,491 (23.2)

232,316 (30.3)

 10–14 years

94,875 (44.4)

275,738 (35.9)

 15–18 years

69,142 (32.4)

259,021 (33.8)

Sex, No. (%)

 Male

145,005 (67.9)

443,797 (57.9)

 Female

68,500 (32.1)

323,228 (42.1)

 Missing

13

50

Disposition, No. (%)

 Discharged

202,313 (96.8)

722,624 (96.7)

 Admitteda

5234 (2.5)

16,871 (2.3)

 Died

33 (0.0)

183 (0.0)

 Otherb

1419 (0.7)

7916 (1.1)

 Missing

4519

19,481

County urban/rural designations, No. (%)

 Urban

136,871 (64.2)

487,227 (63.6)

 Mostly rural

62,117 (29.1)

232,223 (30.3)

 Completely rural

4191 (2.0)

14,929 (1.9)

 Out-of-state

10,094 (4.7)

31,782 (4.1)

 Missing

245

914

Mode of transport, No. (%)

 Walk-in

166,709 (88.2)

681,567 (85.2)

 Ambulancec

12,784 (6.8)

80,712 (10.1)

 Otherd

9517 (5.0)

37,935 (4.7)

 Missing

24,508

118,448

Expected source of payment, No. (%)

 Medicaid

89,376 (42.7)

354,035 (47.2)

 Insurance company

80,573 (38.5)

240,262 (32.1)

 Self-pay

17,212 (8.2)

73,835 (9.9)

 Othere

21,913 (10.5)

81,461 (10.9)

 Missing

4444

31,348

Month, No. (%)

 Dec. - Feb.

37,622 (17.6)

148,609 (19.4)

 March–May

61,015 (28.6)

212,405 (27.7)

 June - Aug.

48,733 (22.8)

197,943 (25.8)

 Sept. - Nov.

66,148 (31.0)

208,118 (27.1)

Hour of day, No. (%)

 12:00–5:59 AM

8480 (4.0)

42,083 (5.5)

 6:00–11:59 AM

28,400 (13.3)

115,875 (15.1)

 12:00–5:59 PM

73,124 (34.2)

266,935 (34.8)

 6:00–11:59 PM

103,514 (48.5)

342,182 (44.6)

Abbreviations: ED emergency department, no. number, Dec. December, Feb. February, Aug. August, Sept. September, Nov. November

aThe category of admitted includes transfers to other facilities

bThe category other disposition contains left against medical advice, left without being seen, observation unit, and other disposition

cThe category ambulance contains ground, helicopter, fixed wing, other type of ambulance, and unspecified type of ambulance

dThe category other mode of transport contains other mode of transport

eThe category other expected source of payment contains Medicare, no charge, other form of government payment, workers’ compensation, and other expected source of payment

Case definition of a traumatic brain injury (TBI)

This study used the Centers for Disease Control and Prevention (CDC) TBI case definition to identify ED visits due to TBIs. The CDC TBI definition comprises ICD-9-CM codes 800.00–801.99 (fracture of the vault or base of the skull); 803.00–804.99 (other or multiple fractures of the skull); 850.0–850.9 (concussion); 851.00–854.99 (intracranial injury); 950.0–950.9 (optic chiasm, optic pathways, or visual cortex); and 959.01 (head injury, unspecified) (Marr and Coronado 2004). The following code was excluded from the definition: 995.55 “shaken infant syndrome”. As NC DETECT collects up to eleven ICD-9-CM diagnosis codes per patient visit, the ED visit was classified as being due to a TBI if the visit contained a TBI diagnosis code in any position. The majority of ED visits contained one diagnosis code for TBI (90.8%) while the maximum number of diagnosis codes for TBI was five (0.01%).

Covariates

Sociodemographic covariates included patient sex, patient age (categorized as 5–9, 10–14, and 15–18 years), and urban-rural classification based on NC county of residence. Patient county of residence was classified according to US Census urban-rural designations (urban, mostly rural, completely rural, and out-of-state) (US Census Bureau 2016).

This study also examined discharge disposition (admitted, died, discharged from the ED, and other disposition), mode of transport (walk-in, ambulance, and other specified mode of transport), expected source of medical payment (Medicaid, insurance company, self-pay, and other specified source of payment), seasonality of visit (December–February, March–May, June–August, and September–November), and time of visit (12:00–5:59 AM, 6:00–11:59 AM, 12:00–5:59 PM, and 6:00–11:59 PM).

Injury diagnoses were categorized using the Barell Injury Diagnosis Matrix according to the nature of injury (e.g. fracture) and location (e.g. upper extremity) using the first listed ICD-9-CM injury diagnosis code (Barell et al. 2002).

Statistical analysis

This study used descriptive epidemiologic methods such as the Pearson’s chi-square test and Fisher’s exact test (for expected cell counts < 5) to characterize SR ED visits. In addition, injury proportion ratios (IPRs) and 95% confidence intervals (CIs) were calculated to compare differences among Barell Injury Diagnosis Matrix classifications between SR injuries and other unintentional injuries. All 95% CIs not containing 1.00 for IPRs were considered statistically significant with an IPR > 1.00 suggesting a risk association (Knowles et al. 2010). As an example, the following calculation compares the proportion of SR upper extremity fractures to the proportion of fractures due to other types of unintentional injury:
$$ IPR=\frac{\left(\frac{Number\ of\ SR\ ED\ visits\ with\ an\ upper\ extremity\ fracture\ }{Total\ number\ of\ SR\ ED\ visits}\right)}{\left(\frac{Number\ of\ other\ unintentional\ injury- related\ ED\ visits\ with\ an\ upper\ extremity\ fracture}{Total\ number\ of\ other\ unintentional\ injury- related\ ED\ visits}\right)} $$

There is no comprehensive and systematic data collection method that enumerates exposure to sports and recreational activity in the US. Therefore, the denominator for all rate calculations consisted of the NC resident population of 5–18 year-olds. All rates are presented per 100,000 person-years to ensure comparability across the thousand-fold range of incidence. Age group and sex specific incidence rates were calculated using the National Center for Health Statistics bridged-race mid-year population estimates for NC as the denominator (National Center for Health Statistics 2016). The numerator included visits from non-NC residents as well as NC residents. Out-of-state residents were included in the numerator (injury cases) because comprehensive data for out-of-state ED visits by NC residents were not readily available and excluding NC ED visits by out-of-state residents would introduce a downwards bias in the rates. Incidence rate estimates and 95% confidence intervals (CIs) were generated using a Poisson model. All analyses were performed using SAS software, version 9.4 (SAS Institute, Inc.; Cary, NC).

Results

Injury incidence

During the period 2010–2014, 767,075 (27.6%) ED visits were identified as being due to unintentional injury mechanisms, out of a total 2.8 million ED visits among children 5–18 years of age. Of these 767,075 unintentional-injury related ED visits, 213,518 visits (27.8%) were related to SR activities. From 2010 through 2014, there was an annual average number of 42,704 SR NC ED visits or 2374.5 (95% CI, 2364.4–2384.6) ED visits per 100,000 person-years among school-age youth, 5–18 years of age. SR injuries accounted for 27.8% of all ED visits unintentional injury among school-age children.

Selected characteristics of emergency department visits

Table 1 displays the characteristics of ED visits due to total unintentional injury-related ED visits in comparison to SR ED visits among youth, 5–18 years of age. About two-thirds of all SR ED visits involved boys, a higher proportion than total unintentional injury-related ED visits. In the majority of SR and unintentional injury-related ED visits, the patient was discharged from the ED without admission to the hospital. The most common mode of transport to the ED for both SR and total unintentional injury-related ED visits was “walk-in” to the ED via private or public transportation; however, the proportion was slightly higher for SR ED visits (88.2%) versus total unintentional injury-related ED visits (85.2%). Among SR ED visits, the most commonly cited expected source of payment was Medicaid (42.7%) followed by insurance company (38.5%). The fall and spring seasons contained the highest proportion of ED visits for both SR and total unintentional injury-related ED visits, but SR ED visits exhibited greater seasonal trends, with more pronounced differences between fall/spring and winter/summer seasons. For both SR and unintentional injury-related ED visits, the time of day with the highest proportion of visits was during evening hours of 6:00–11:59 PM.

Table 2 displays the case definition for SR injuries organized by E-code category. The three most common E-code categories observed among school-age children and youth 5–18 years of age was “Sports/athletics played as a group or team” (e.g. American tackle football, basketball, and soccer), “other outdoor recreational activities” (e.g. outdoor activities such as roller-skating/skateboarding and snow/off-road vehicles), and “falls/struck by/against in sports”.
Table 2

Sports/Recreation-related ED visits among school-age children: NC, 2010–2014

E-codea

Description

Specificityb,c

N (%)

E007 (.0–.7, .9)

Sports/athletics played as a group or team

1

72,821 (34.1)

 E007.0

American tackle football

1

24,420 (11.4)

 E007.6

Basketball

1

23,342 (10.9)

 E007.5

Soccer

1

10,108 (4.7)

 E007.3

Baseball and softball

1

8840 (4.1)

 E007.7

Volleyball

1

1708 (0.8)

 E007.4

Lacrosse and field hockey

1

883 (0.4)

 E007.1

American touch/flag football

1

636 (0.3)

 E007.2

Rugby

1

285 (0.1)

 E007.9

Other activities played as a group or team

5

2599 (1.2)

E006(.2, .3, .6, .9), E008 (.0–.2, .4)

Sports/athletics played individually

1

6162 (2.9)

 E008.1

Wrestling

1

3572 (1.7)

 E008.4

Martial arts

1

525 (0.2)

 E008.2

Racquet and hand sports

1

186 (0.1)

 E006.2

Golf

1

159 (0.1)

 E008.0

Boxing

1

156 (0.1)

 E006.3

Bowling

1

106 (0.0)

 E006.6

Track and field events (excludes running)

1

100 (0.0)

 E006.9

Other activities played individually

5

1358 (0.6)

E886.0, E917 (.0, .5)

Fall, or struck by/striking against, in sports

6

23,934 (11.2)

 E917.0

Struck by/against in sports, no subsequent fall

6

19,060 (8.9)

 E917.5

Struck by/against in sports with subsequent fall

6

2627 (1.2)

 E886.0

Fall on same level from collision, pushing, or shoving, by or with other person in sports

6

2247 (1.1)

E008.9

Other specified sports/athletic activity (NEC)

5

779 (0.4)

E005 (.0, .2, .4, .9)

Dancing and other rhythmic movement

1

5517 (2.6)

 E005.4

Cheerleading

1

2080 (1.0)

 E005.2

Gymnastics

1

1796 (0.8)

 E005.0, E005.9

Dancing and other activity involving rhythmic movement

1

1641 (0.8)

E005.1, E001 (.0–.1), E009 (.0–.9), E010 (.0–.9)

Cardiorespiratory and muscle strengthening activities, not elsewhere specified

5

15,413 (7.2)

 E001.1

Running

5

9130 (4.3)

 E001.0

Walking, hiking, and marching

5

4311 (2.0)

 E009 (.0–.9)

Other cardiorespiratory exercise

2

321 (0.2)

 E010 (.0–.9)

Other muscle strengthening exercises

2

1641 (0.8)

 E005.1

Yoga

1

10 (0.0)

E005.3, E006.5, E007.8, E008.3, E884.0

Activities involving play and other activities usually unstructured

5

18,209 (8.5)

 E884.0

Fall from playground equipment

5

11,811 (5.5)

 E005.3

Trampoline

1

4623 (2.2)

 E008.3

Frisbee

1

152 (0.1)

 E006.5

Jumping rope

1

147 (0.1)

 E007.8

Physical games generally associated with school recess, summer camp and children

5

1476 (0.7)

E006.4, E800-E807 (.3), E810-E819 (.6), E820-E825 (.6), E826 (.1,.9), E827-E829 (.1)

Pedal cycle

3

20,984 (9.8)

 E800-E807 (.3), E820-E825 (.6), E826 (.1,.9), E827-E829 (.1)

Nontraffic-related (i.e. off-road)

3

18,591 (8.7)

 E810-E819 (.6)

Traffic-related (i.e. on-road)

3

1006 (0.5)

 E006.4

Bike riding, unspecified

5

1387 (0.6)

E002 (.0–.9), E830-E838 (.0, .1, .3, .4, .5, .8, .9), E883.0, E902.2, E910 (.0, .1, .2, .8, .9)

Recreational activities involving bodies of water

4

3889 (1.8)

 E002.6, E910.0, E830-E838 (.4)

Waterskiing

2

212 (0.1)

 E002 (.0–.5, .7–.9), E830-E838 (.0, .1, .3, .5, .8, .9), E883.0, E902.2, E910 (.1, .2, .8, .9)

Other activities involving water and watercraft

4

3677 (1.7)

E003 (.0–.9), E004 (.0–.9), E006 (.0, .1), E820-E821 (.0, .1, .5, .8, .9), E822-E825 (.5), E826-E829 (.2), E885 (.0–.2), E922 (.4, .5)

Other outdoor recreational activities

4

30,774 (14.4)

 E006.0, E885 (.1,.2)

Roller skating and skateboarding

4

12,376 (5.8)

 E820-E821 (.0, .1, .8, .9)

Snow and other off-road vehicles

3

6477 (3.0)

 E003 (.0–.9), E885 (.3, .4)

Snow skiing, snowboarding, and other activities involving snow and ice

3

3774 (1.8)

 E006.1, E820-E825 (.5), E826-E829 (.2)

Animal being ridden

3

2515 (1.2)

 E885.0

Fall from non-motorized scooter

3

2485 (1.2)

 E922 (.4, .5)

Air gun

2

1593 (0.7)

 E004 (.0–.9)

Climbing, rappelling and jumping off

3

1554 (0.7)

E849.4

Injury occurred at a place of recreation or sport, no further detail

7

15,036 (7.0)

Total

  

213,518 (100.0)

Abbreviations: ED emergency department, NEC not elsewhere classified

aActivity E-codes (E-codes E001-E030) describing activities resulting in injury were added to ICD-9-CM starting October 1, 2009 (Bronnert 2009)

bDuring the period 2010–2014, NC DETECT collected up to five E-codes describing the type of injury. For emergency department visits with more than one E-code, preference was given to ED visits with more specific E-codes (“1”) over visits with less specific E-codes (“7”). For ED visits with more than one E-code of the same specificity level, assignment was based on the first-listed E-code

cFor each category header, the level of specificity is the mode for that category

Location and nature of injury

Table 3 compares SR ED visits and ED visits due to other unintentional injury mechanisms, as classified by the Barell Injury Diagnosis Matrix. Among SR ED visits, the most common location of injury was upper extremities, lower extremities, and head/face/neck. Fractures of the upper extremity were particularly common in comparison to the proportion of injuries that were due to upper extremity fractures among ED visits due to other mechanisms of unintentional injury (6.1%; IPR: 2.44 [95% CI, 2.40–2.48). In addition, both lower extremity, lower extremity strains/sprains, and upper extremity sprains/strains were nearly twice as common among SR ED visits relative to other unintentional injury mechanisms.
Table 3

Unintentional injury-related ED visits among school-age children, by Barell injury diagnosis category: NC, 2010–2014

Barell injury diagnosis categorya

ED visits due to sports and recreation-related injuries (N = 189,679)

Other unintentional injury-related ED visits (N = 470,751)

Total unintentional injury-related ED visits (N = 660,430)

IPR (95% CI)e

Upper extremity, No. (%)

69,581 (36.7)

135,251 (28.7)

204,832 (31.0)

1.28 (1.27–1.29)

 Fracture

28,024 (14.8)

28,542 (6.1)

56,566 (8.6)

2.44 (2.40–2.48)

 Open wound

2142 (1.1)

29,464 (6.3)

31,606 (4.8)

0.18 (0.17–0.19)

 Sprain/strain

14,367 (7.6)

20,715 (4.4)

35,082 (5.3)

1.72 (1.69–1.76)

 Superficial wounds and contusions

12,050 (6.4)

33,487 (7.1)

45,537 (6.9)

0.89 (0.88–0.91)

 Other and unspecified injuriesb

12,998 (6.9)

23,043 (4.9)

36,041 (5.5)

1.40 (1.37–1.43)

Lower extremity, No. (%)

53,450 (28.2)

116,833 (24.8)

170,283 (25.8)

1.14 (1.13–1.15)

 Fracture

7188 (3.8)

10,032 (2.1)

17,220 (2.6)

1.78 (1.73–1.83)

 Open wound

3958 (2.1)

23,450 (5.0)

27,408 (4.2)

0.42 (0.41–0.43)

 Sprain/strain

23,868 (12.6)

37,266 (7.9)

61,134 (9.3)

1.59 (1.57–1.61)

 Superficial wounds and contusions

9268 (4.9)

29,120 (6.2)

38,388 (5.8)

0.79 (0.77–0.81)

 Other and unspecified injuriesb

9168 (4.8)

16,965 (3.6)

26,133 (4.0)

1.34 (1.31–1.37)

TBIs and other head/face/neck, No. (%)

46,858 (24.7)

103,632 (22.0)

150,490 (22.8)

1.12 (1.11–1.13)

 TBI

9424 (5.0)

8543 (1.8)

17,967 (2.7)

2.74 (2.66–2.82)

 Fracture

1778 (0.9)

1519 (0.3)

3297 (0.5)

2.90 (2.71–3.11)

 Open wound

12,732 (6.7)

38,912 (8.3)

51,644 (7.8)

0.81 (0.80–0.83)

 Sprain/strain

37 (0.0)

78 (0.0)

115 (0.0)

1.18 (0.80–1.74)

 Superficial wounds and contusions

9472 (5.0)

29,119 (6.2)

38,591 (5.8)

0.81 (0.79–0.83)

 Other and unspecified injuriesb

13,415 (7.1)

25,461 (5.4)

38,876 (5.9)

1.31 (1.28–1.33)

Torso, No. (%)

9431 (5.0)

27,366 (5.8)

36,797 (5.6)

0.86 (0.84–0.88)

 Fracture

367 (0.2)

552 (0.1)

919 (0.1)

1.65 (1.45–1.88)

 Open wound

488 (0.3)

2200 (0.5)

2688 (0.4)

0.55 (0.50–0.61)

 Sprain/strain

842 (0.4)

5209 (1.1)

6051 (0.9)

0.40 (0.37–0.43)

 Superficial wounds and contusions

5735 (3.0)

14,461 (3.1)

20,196 (3.1)

0.98 (0.96–1.01)

 Other and unspecified injuriesb

1999 (1.1)

4944 (1.1)

6943 (1.1)

1.00 (0.95–1.06)

Vertebral column, No. (%)

4609 (2.4)

26,302 (5.6)

30,911 (4.7)

0.43 (0.42–0.45)

 Fracture

269 (0.1)

669 (0.1)

938 (0.1)

1.00 (0.87–1.15)

 Open wound

0 (0.0)

0 (0.0)

0 (0.0)

 Sprain/strain

4331 (2.3)

25,615 (5.4)

29,946 (4.5)

0.42 (0.41–0.43)

 Superficial wounds and contusions

0 (0.0)

0 (0.0)

0 (0.0)

 Other and unspecified injuriesb,c

< 10

18 (0.0)

27 (0.0)

System-wide and late effects of injury, No. (%)

1324 (0.7)

38,897 (8.3)

40,221 (6.1)

0.08 (0.08–0.09)

Other and unspecified location of injuryd, No. (%)

4426 (2.3)

22,470 (4.8)

26,896 (4.1)

0.49 (0.47–0.50)

Abbreviations: ED emergency department, no. number, IPR injury proportion ratio, CI confidence interval, TBI traumatic brain injury

Missing: 23839 visits due to sports and recreation-related injuries and 106,645 ED visits due to other unintentional injury mechanisms were missing a valid injury diagnosis code

aCategorization based on first-listed injury diagnosis code

bOther and unspecified injuries include injuries to the internal organs, nerves, and blood vessels, as well as burns, amputations, dislocations, crushing injuries, and unspecified injuries

cIn order to protect patient anonymity, cells with counts of 1–9 ED visits are suppressed

dOther and unspecified location consists of spinal cord injuries, system wide injuries, late effects of injuries, and other and unspecified injuries

eInjury Proportion Ratio and 95% CI compares percent in sports/recreational to percent in non-sport /rec recreational (Knowles et al. 2010)

NC DETECT contains data fields for up to eleven diagnoses. Among SR ED visits, 5.0% of visits had a diagnosis of TBI in the first data field and 12.0% of SR ED visits had a diagnosis of TBI in any one of the eleven available data fields. The proportion of SR ED visits with a diagnosis of TBI was higher than that for other unintentional injury mechanisms (1.8%; IPR = 2.74 [95% CI, 2.66–2.82]). Although not as common, fractures to the head/face/neck were also higher among SR ED visits (0.9%; IPR = 2.90 [95% CI, 2.71–3.11]).

Activity at time of injury

Tables 4 and 5 display the absolute numbers and incidence rates of injury-related ED visits as well as the proportion of these visits with a diagnosis of TBI, stratified by the type of sport or recreational activity for age group and sex. Among 5–9 year-olds, the most common category of sport and recreational injury was activities involving “play and other activities, usually unstructured” such as “falls from playground equipment”. On the other-hand, “sports/athletics played as a group or team” were by far the most common activity for 10–14 and 15–18 year-olds. Among 10–14-year-olds, American tackle football was the most common cause of injury related to team sports; however, among 15–18 year-olds, basketball was the most common cause of injury related to team sports. For recreational activities, the most common cause of injury was pedal cycling for both 5–9 and 10–14-year-olds. Among 15–18-year-olds, the most common cause of injury was “falls and other injuries resulting from roller skating and skateboarding”. Regarding sports/athletic categories with a diagnosis of TBI, the category of sport with the highest proportion of TBI was American touch/flag football among 5–9-year-olds and rugby among 10–14 and 15–18 year-olds (33.3 and 29.1% respectively). Among recreational activities, the activity with the highest proportion of TBI across all age groups was water-skiing (Table 4).
Table 4

Age-group specific rates of sports/recreation-related injuries and proportions of TBI among school-age children: NC, 2010–2014

Sport/ recreational activitya,b

Age group

5–9 years of age

10–14 years of age

15–18 years of age

No.

Ratec

% with TBI

P-valued

No.

Ratec

% with TBI

P-valued

No.

Ratec

% with TBI

P-valued

Team sports

6551

204.6

13.2

<.001

35,750

1108.3

11.5

0.002

30,520

1190.2

13.7

0.87

 American tackle football

2274

71

12.8

0.05

12,953

401.6

13.4

<.001

9193

358.5

16.9

<.001

 Basketball

1427

44.6

12.5

0.21

10,204

316.3

8.6

<.001

11,711

456.7

8.5

<.001

 Soccer

1196

37.3

9.8

0.06

4897

151.8

12.2

0.011

4015

156.6

19.0

<.001

 Baseball/softball

1266

39.5

17.9

<.001

4821

149.5

11.8

0.14

2753

107.4

14.1

0.44

 Volleyball

36

1.1

11.1

>.99

879

27.3

7.5

<.001

793

30.9

10.8

0.02

 Lacrosse/field hockey

28

0.9

10.7

>.99

302

9.4

21.5

<.001

553

21.6

25.1

<.001

 Touch/flag football

85

2.7

21.2

0.005

309

9.6

14.2

0.08

242

9.4

17.4

0.09

 Rugby

0

0.0

48

1.5

33.3

<.001

237

9.2

29.1

<.001

 Other team sports

239

7.5

12.6

0.61

1337

41.4

10.8

0.76

1023

39.9

13.3

0.75

Individual sports

755

23.6

8.7

0.02

2542

78.8

10.2

0.15

2865

111.7

13

0.32

 Wrestling

277

8.7

9.4

0.27

1419

44

11.5

0.64

1876

73.2

13.7

0.94

 Martial arts

106

3.3

8.5

0.33

259

8.0

10

0.58

160

6.2

13.1

0.85

 Racquet

16

0.5

6.3

>.99

79

2.4

8.9

0.53

91

3.5

7.7

0.10

 Golf

58

1.8

17.2

0.17

58

1.8

15.5

0.28

43

1.7

16.3

0.61

 Boxinge

<10

40

1.2

2.5

0.12

115

4.5

7.8

0.07

 Bowling

44

1.4

2.3

0.06

34

1.1

0

0.03

28

1.1

0.0

0.03

 Track and fielde

<10

39

1.2

5.1

0.31

58

2.3

10.3

0.46

 Other individual sports

250

7.8

7.6

0.05

614

19

8.5

0.04

494

19.3

13.4

0.86

Fall/struck by/against in sports

2724

85.1

15.2

<.001

11,714

363.2

15.8

<.001

9496

370.3

19.7

<.001

Other team/individual sports, NEC

128

4.0

9.4

0.45

375

11.6

10.1

0.55

276

10.8

12

0.41

Dancing and rhythmic movement

1009

31.5

5.9

<.001

2604

80.7

10.1

0.09

1904

74.2

14.5

0.24

 Cheerleading

103

3.2

10.7

0.80

1006

31.2

16.6

<.001

971

37.9

20.2

<.001

 Gymnastics

563

17.6

5.0

<.001

938

29.1

7.0

<.001

295

11.5

10.2

0.08

 Other dancing/rhythmic movement

343

10.7

6.1

0.002

660

20.5

4.4

<.001

638

24.9

8.0

<.001

Cardio and strength training

4453

139.1

13.0

0.001

6084

188.6

6.3

<.001

4876

190.1

4.8

<.001

 Running

3253

101.6

14.5

<.001

3948

122.4

6.7

<.001

1929

75.2

5.4

<.001

 Walking

1071

33.4

8.9

0.007

1631

50.6

6.4

<.001

1609

62.7

5.3

<.001

 Other cardio

64

2.0

9.4

0.60

134

4.2

2.2

0.001

123

4.8

4.1

0.002

 Strength training

63

2.0

12.7

0.76

367

11.4

4.1

<.001

1211

47.2

3.3

<.001

 Yogae

<10

<10

<10

Play/unstructured activities

12,188

380.6

8.1

<.001

5039

156.2

7.5

<.001

982

38.3

9.0

<.001

 Fall from playground equipment

9290

290.1

8.9

<.001

2246

69.6

9.7

0.03

275

10.7

13.8

0.93

 Trampoline

2396

74.8

4.6

<.001

1816

56.3

3.6

<.001

411

16.0

4.1

<.001

 Frisbee

12

0.4

8.3

>.99

61

1.9

11.5

0.93

79

3.1

12.7

0.80

 Jumping rope

58

1.8

8.6

0.49

74

2.3

4.1

0.05

15

0.6

6.7

0.71

 Activities involving physical games

432

13.5

9.5

0.19

842

26.1

10.0

0.30

202

7.9

10.9

0.25

Pedal cycle

9145

285.6

12.8

<.001

8713

270.1

10.6

0.14

3126

121.9

14.3

0.25

 Nontraffic

8297

259.1

12.7

<.001

7775

241

10.4

0.045

2519

98.2

14.1

0.46

 Traffic

210

6.6

25.7

<.001

382

11.8

24.1

<.001

414

16.1

17.6

0.02

 Unspecified

638

19.9

8.9

0.04

556

17.2

4.3

<.001

193

7.5

9.8

0.12

Activities involving water

1001

31.3

13.1

0.11

1528

47.4

14.8

<.001

1360

53

15.0

0.14

 Waterskiing

17

0.5

47.1

<.001

77

2.4

27.3

<.001

118

4.6

23.7

0.001

 Other activities involving water

984

30.7

12.5

0.32

1451

45.0

14.1

<.001

1242

48.4

14.2

0.58

Other recreational activities

7244

226.2

11.7

0.56

14,149

438.6

10.5

0.02

9381

365.8

13.9

0.45

 Roller skating/skateboarding

2428

75.8

7.5

<.001

6514

201.9

8.0

<.001

3434

133.9

11.5

<.001

 Snow/off-road vehicles

1257

39.3

16.8

<.001

2791

86.5

14.5

<.001

2429

94.7

15.9

0.001

 Snow skiing, snowboarding, etc.

541

16.9

22.4

<.001

1706

52.9

14.0

<.001

1527

59.5

17.3

<.001

 Animal being ridden

414

12.9

21.5

<.001

978

30.4

20.9

<.001

1123

43.8

20.7

<.001

 Scooter

1433

45.1

11.4

0.96

929

28.8

9.3

0.07

123

4.8

2.4

<.001

 Air gun

377

11.8

2.7

<.001

768

23.8

2.3

<.001

448

17.5

1.1

<.001

 Climbing/rappelling

794

24.8

8.7

0.01

463

14.4

4.8

<.001

297

11.6

5.7

<.001

Place of recreation/sport

4293

134.1

13.0

0.001

6387

198

9.4

<.001

4356

169.9

9.9

<.001

Total

49,491

1545.5

11.5

94,885

2941.6

11.1

69,142

2696.3

13.6

aAmong ED visits with more than one sports and recreation-related E-code, categorization was based on the most specific E-code. In instances when two or more E-codes were the same level of specificity, categorization was based on the first-listed E-code

bSport/recreational activity designations have been abbreviated for display; for complete descriptions, please see Table 1

CPopulation-based incidence rates are per 100,000 person-years

dPearson chi-square tests (expected cell counts > 5) and Fisher’s Exact tests used (expected cell counts < 5) were used for calculation of p-values

eIn order to protect patient anonymity, cells with counts of 1–9 ED visits are suppressed

Table 5

Sex-specific rates of sports/recreation-related injuries and proportions of TBI among school-age children: NC, 2010–2014

Injury sport/recreational activitya,b

Sex

Boys

Girls

No.

Rate (95% CI)c

% with TBI

P-valued

No.

Rate (95% CI)c

% with TBI

P-valued

Team sports

56,562

1231.9 (1221.8–1242.1)

12.5

0.32

16,256

369.4 (363.8–375.1)

12.9

<.001

 American tackle football

23,603

514.1 (507.5–520.7)

14.9

<.001

817

18.6 (17.3–19.9)

6.9

<.001

 Basketball

18,204

396.5 (390.8–402.3)

7.7

<.001

5137

116.7 (113.6–120.0)

12.7

<.001

 Soccer

5930

129.2 (125.9–132.5)

13.6

0.02

4177

94.9 (92.1–97.8)

16.1

<.001

 Baseball/softball

5315

115.8 (112.7–118.9)

14.9

<.001

3524

80.1 (77.5–82.8)

11.1

0.52

 Volleyball

288

6.3 (5.6–7.0)

6.9

0.004

1420

32.3 (30.6–34.0)

9.6

0.14

 Lacrosse/field hockey

695

15.1 (14.1–16.3)

22.6

<.001

188

4.3 (3.7–4.9)

26.6

<.001

 Touch/flag football

519

11.3 (10.4–12.3)

17.0

0.003

117

2.7 (2.2–3.2)

13.7

0.31

 Rugby

232

5.1 (4.4–5.7)

29.3

<.001

53

1.2 (0.9–1.6)

32.1

<.001

 Other team sports

1776

38.7 (36.9–40.5)

11.9

0.36

823

18.7 (17.5–20.0)

12.2

0.21

Individual sports

5023

109.4 (106.4–112.5)

12.0

0.17

1139

25.9 (24.4–27.4)

8.6

0.02

 Wrestling

3256

70.9 (68.5–73.4)

12.9

0.55

316

7.2 (6.4–8.0)

7.9

0.10

 Martial arts

361

7.9 (7.1–8.7)

12.5

0.94

164

3.7 (3.2–4.3)

6.7

0.09

 Racquet

90

2.0 (1.6–2.4)

10.0

0.46

96

2.2 (1.8–2.7)

6.3

0.15

 Golf

111

2.4 (2.0–2.9)

15.3

0.39

48

1.1 (0.8–1.4)

18.8

0.08

 Boxing

144

3.1 (2.7–3.7)

6.3

0.02

12

0.3 (0.2–0.5)

8.3

>.99

 Bowling

52

1.1 (0.9–1.5)

1.9

0.02

54

1.2 (0.9–1.6)

0.0

0.004

 Track and field

59

1.3 (1.0–1.7)

6.8

0.24

41

0.9 (0.7–1.3)

9.8

>.99

 Other individual sports

950

20.7 (19.4–22.0)

10.0

0.02

408

9.3 (8.4–10.2)

10.3

0.74

Fall/struck by/against in sports

18,414

401.0 (395.3–406.9)

17.2

<.001

5518

125.4 (122.1–128.7)

17.7

<.001

Other team/individual sports, NEC

496

10.8 (9.9–11.8)

10.7

0.20

283

6.4 (5.7–7.2)

10.6

0.92

Dancing and rhythmic movement

587

12.8 (11.8–13.9)

8.9

0.006

4930

112.0 (108.9–115.2)

11.1

0.48

 Cheerleading

38

0.8 (0.6–1.1)

10.5

>.99

2042

46.4 (44.4–48.5)

18.1

<.001

 Gymnastics

250

5.4 (4.8–6.2)

10.4

0.30

1546

35.1 (33.4–36.9)

6.3

<.001

 Other dancing/rhythmic movement

299

6.5 (5.8–7.3)

7.4

0.006

1342

30.5 (28.9–32.2)

5.9

<.001

Cardio and strength training

8601

187.3 (183.4–191.3)

9.5

<.001

6810

154.7 (151.1–158.5)

5.7

<.001

 Running

5257

114.5 (111.4–117.6)

11.4

0.009

3872

88.0 (85.3–90.8)

6.2

<.001

 Walking

1930

42.0 (40.2–44.0)

8.4

<.001

2381

54.1 (52.0–56.3)

5.2

<.001

 Other cardio

152

3.3 (2.8–3.9)

6.6

0.03

168

3.8 (3.3–4.4)

2.4

<.001

 Strength training

1258

27.4 (25.9–29.0)

3.4

<.001

383

8.7 (7.9–9.6)

5.2

<.001

 Yogae

<10

<10

Play/unstructured activities

9633

209.8 (205.7–214.0)

8.8

<.001

8575

194.9 (190.8–199.0)

7.0

<.001

 Fall from playground equipment

6150

133.9 (130.6–137.3)

9.9

<.001

5660

128.6 (125.3–132.0)

8.4

 

 Trampoline

2420

52.7 (50.6–54.8)

5.4

<.001

2203

50.1 (48.0–52.2)

2.9

<.001

 Frisbee

119

2.6 (2.2–3.1)

10.1

0.41

33

0.7 (0.5–1.1)

18.2

0.16

 Jumping rope

43

0.9 (0.7–1.3)

11.6

0.85

104

2.4 (2.0–2.9)

3.8

0.02

 Activities involving physical games

901

19.6 (18.4–20.9)

10.3

0.04

575

13.1 (12.0–14.2)

9.4

0.28

Pedal cycle

14,561

317.1 (312.0–322.3)

13.4

0.004

6420

145.9 (142.4–149.5)

9.3

<.001

 Nontraffic

12,757

277.8 (273.1–282.7)

13.3

0.02

5832

132.5 (129.2–136.0)

9.1

<.001

 Traffic

845

18.4 (17.2–19.7)

21.1

<.001

160

3.6 (3.1–4.2)

25.6

<.001

 Unspecified

959

20.9 (19.6–22.3)

7.8

<.001

428

9.7 (8.8–10.7)

5.8

<.001

Activities involving water

2397

52.2 (50.2–54.3)

14.4

0.006

1492

33.9 (32.2–35.7)

14.4

<.001

 Waterskiing

133

2.9 (2.4–3.4)

26.3

<.001

79

1.8 (1.4–2.2)

27.8

<.001

 Other activities involving water

2264

49.3 (47.3–51.4)

13.7

0.10

1413

32.1 (30.5–33.8)

13.7

<.001

Other recreational activities

19,297

420.3 (414.4–426.3)

12.3

0.15

11,475

260.8 (256.0–265.6)

11.1

0.27

 Roller skating/ skateboarding

8012

174.5 (170.7–178.4)

11.0

<.001

4364

99.2 (96.3–102.2)

4.9

<.001

 Snow/off-road vehicles

4541

98.9 (96.1–101.8)

15.1

<.001

1935

44.0 (42.1–46.0)

16.4

<.001

 Snow skiing, snowboarding, etc.

2470

53.8 (51.7–56.0)

17.7

<.001

1304

29.6 (28.1–31.3)

14.4

<.001

 Animal being ridden

627

13.7 (12.6–14.8)

16.9

0.001

1887

42.9 (41.0–44.9)

22.2

<.001

 Scooter

1321

28.8 (27.3–30.4)

12.5

0.91

1164

26.5 (25.0–28.0)

7.6

<.001

 Air gun

1380

30.1 (28.5–31.7)

2.2

<.001

213

4.8 (4.2–5.5)

1.4

<.001

 Climbing/rappelling

946

20.6 (19.3–22.0)

7.0

<.001

608

13.8 (12.8–15.0)

6.9

0.002

Place of recreation/sport

9434

205.5 (201.4–209.7)

10.7

<.001

5602

127.3 (124.0–130.7)

10.3

0.23

Total

145,005

3158.2 (3141.9–3174.5)

12.6

68,500

1556.6 (1545.0–1568.3)

10.8

Missing: 13 missing sex

Abbreviations: No. number, CI confidence interval, TBI traumatic brain injury, NEC not elsewhere classifiable

aAmong ED visits with more than one sports and recreation-related E-code, categorization was based on the most specific E-code. In instances when two or more E-codes were the same level of specificity, categorization was based on the first-listed E-code

bSport/recreational activity designations have been abbreviated for display; for complete descriptions, please see Table 1

cPopulation-based incidence rates are per 100,000 person-years

dPearson chi-square tests (expected cell counts > 5) and Fisher’s Exact tests used (expected cell counts < 5) were used for calculation of p-values

eIn order to protect patient anonymity, cells with counts of 1–9 ED visits are suppressed

There was also a difference in injury patterns by sex. Except for volleyball, rates of “sports/athletics played as a group or team” were higher among boys for all listed sports categories. Among boys, rates of ED visits due to American tackle football were highest, while for girls, rates of basketball-related ED visits were highest for team sports/athletics. Not all categories of sports/recreational activities were higher for boys, however. Girls were nearly nine times more likely to visit an ED due to “activities involving dancing and rhythmic movement” than boys (Table 5). In terms of TBI diagnosis, the three sports/athletics activities with the greatest proportion of TBI-related ED visits among boys were rugby (29.3%), lacrosse/field hockey (22.6%), and American touch/flag football (17.0%). Among girls, the three sports/athletics activities with the greatest proportion of TBI-related ED visits were rugby (32.1%), lacrosse/field hockey (26.6%), and soccer (16.1%) (Table 5).

Discussion

This study used a broad case definition to identify SR ED visits among school age children and youth in a large, well-defined US population. Results indicate that injuries due to sport and recreational activities have substantial high incidence and represent a potentially serious public health problem in the population. There are approximately 43,000 ED visits per year in NC for youth sports injury, 12% of which received a diagnosis of TBI. In addition, much of the literature has focused on more severe SR injuries resulting in hospitalization and death. These injuries represent the “tip of the iceberg” of the total number of SR injuries (Muller et al. 2005). ED visit data provide a more comprehensive picture of the total number, type, and severity of injuries associated with SR activities (Andrew et al. 2012; Dempsey et al. 2005; Gabbe et al. 2005; Gao et al. 2010; Yang et al. 2007).

Consistent with previous population-based studies of SR injuries, fractures and strains/sprains of the upper and lower extremities were the most common types of injuries identified in this study (Bijur et al. 1995; Burt and Overpeck 2001; Conn et al. 2003). There were also more diagnoses of TBI among SR ED visits than other mechanisms of unintentional injury. NC DETECT ED visit data do not capture information on medical cost or length of hospital stay. However, due to the higher proportion of TBI diagnosis reported among SR ED visits, it is possible that these visits may have greater long-term cost than other types of unintentional injuries among children. Previous studies have found that diagnoses of even mild to moderate TBI are associated with high medical costs and may result in sequelae requiring long-term medical care (Leibson et al. 2012; Schneier et al. 2006; Taylor et al. 2002).

Consistent with the literature, population-based rates of SR injuries were higher among boys in comparison to girls (Burt and Overpeck 2001; Conn et al. 2003; Howard et al. 2014). This likely reflects different patterns of participation; that is, the elevated incidence rate among boys is likely a reflection of their greater participation in organized sports activities. These findings may also reflect differences in the perception of risk, variation in the likelihood of injury, and gender differentials in care-seeking by parents (Morrongiello and Rennie 1998; National Federation of High Schools 2016).

Incidence rates of SR injury peaked among children 10–14 years of age. The rate of SR injury declined by 26% among 10–14 and 15–18 year-old girls. Meanwhile, the corresponding decrease among boys was less than 1 %. While physical activity levels tend to decrease in adolescence for both sexes, the baseline level of physical activity and the age at which activity levels start to decline is lower for girls than boys (Caspersen et al. 2000; Sallis 1993).

The team sports with the greatest proportion of ED visits with a diagnosis of TBI were rugby and lacrosse/field hockey. The sport with the highest population-based incidence of TBI was American tackle football. Overall, boys had higher incidence rates of SR TBIs. However, for select sports such as basketball, baseball/softball, rugby, and soccer, the proportion of ED visits with a diagnosis of TBI was higher for girls than boys. This finding is consistent with prior literature indicating that girls may be at a greater risk for several types of sports injuries, including knee injuries and TBIs, than boys (Caine et al. 2008; Darrow et al. 2009; Gessel et al. 2007; Powell and Barber-Foss 2000). In particular, soccer has a relatively high risk of acute injury, especially among girls (Koutures and Gregory 2010). Soccer-related TBIs are most commonly caused by collision with other players, contact with the ground, inadvertent contact with the ball, and intentional contact with the ball (“heading”) (Gessel et al. 2007). While prevention efforts have often focused on instructing children in proper heading technique, or banning heading altogether, it is unclear whether these efforts have made much of an impact on preventing TBIs among children (Comstock et al. 2015; Delaney and Frankovich 2005).

Similar to other states, NC has developed legislation and prevention programs for preventing and managing sports injuries, particularly TBIs (Bloom 2015; Gopfert et al. 2017). In general, these programs have increased the availability of certified athletics trainers at schools; have improved education of coaching staff, student-athletes, and parents; and have led to the development of return-to-play guidelines after TBI. In addition to school-based programs, the medical community has an important role in tackling SR injuries. For example, NC student-athletes with a diagnosis of TBI must be cleared by a physician before returning to play. Therefore, EDs have developed programs linking patients with community services, such as designated concussion clinics, designed to promote TBI recovery and prevent future injuries (WakeMed Health and Hospitals 2009). While these school- and healthcare-based programs are commendable, they often fail to address injury among younger student-athletes and do little to prevent injury due to unorganized sports and recreational activities.

This study has several limitations. NC DETECT ED visit data are collected by hospitals for clinical, billing, and other administrative purposes. The use of these data for public health surveillance is a secondary function. However, data missingness was low (< 15%) for individual data elements used in analyses. Another limitation of this study is related to the use of statewide NC ED visit data. While population-based studies have many strengths, results may not be generalizable to other jurisdictions. Although NC is a large state, (ranked 9th in the US in terms of population) the distribution of physical activity, as well as injury and healthcare usage, may differ from other regions of the US. Ice hockey and lacrosse, for example, have strong regional bases in the mid-east, mid-west, and north-east regions, but currently are less popular in the south, whereas there is less regional variation in participation in sports such as baseball, softball, soccer, football, and basketball.

Finally, the broad definition of sports and recreational activities used in this study included organized school sports, organized community sports, unorganized sports, and recreational outdoor activities. While this comprehensive definition is a strength, it precluded the use of specific activity-time denominators for the calculation of exposure-based rates due to the lack of exposure data sources at the population level in NC (or any other US jurisdiction). While this study identified American tackle football, basketball, and soccer as the three organized sports activities with the highest population-based rates of injury, it is possible that the use of an exposure-based denominator would produce a different results.

Conclusion

Sports and recreational activities are an important source of morbidity among school-aged children and youth in North Carolina. This is one of the first descriptive epidemiologic studies to use a comprehensive definition to characterize sports and recreation-related injury in a well-defined United States population. In addition, this study indicates that physical activity promotion programs should take into account differences in risk of sports and recreation-related injury by sex and age group.

Abbreviations

CDC: 

Centers for Disease Control and Prevention

CI: 

Confidence interval

E-code: 

External cause of injury code

ED: 

Emergency department

ICD-9-CM: 

International Classification of Diseases, Ninth Revision, Clinical Modification

IPR: 

Injury proportion ratio

IR: 

Incidence rate

NC DETECT: 

North Carolina Disease Event Tracking and Epidemiologic Collection Tool

NC: 

North Carolina

NEC: 

Not elsewhere classified

NFHS: 

National Federation of High Schools

SR: 

Sports and recreation-related

TBI: 

Traumatic brain injury

US: 

United States

Declarations

Acknowledgments

The authors would like to acknowledge Dr. Lana Deyneka and Zachary Faigen with the Epidemiology Section, Communicable Disease Branch of the North Carolina Division of Public Health. In addition, they would like to acknowledge Amy Ising, Dennis Falls, and Clifton Barnett at the Carolina Center for Health Informatics for their assistance in data acquisition and management.

Availability of data and materials

The dataset supporting the conclusions of this article is not available. These data are owned by the North Carolina Division of Public Health and contain protected health information.

Data attribution and disclaimer

NC DETECT is a statewide public health syndromic surveillance system, funded by the NC Division of Public Health (NC DPH) Federal Public Health Emergency Preparedness Grant and managed through collaboration between NC DPH and UNC-CH Department of Emergency Medicine’s Carolina Center for Health Informatics. The NC DETECT Data Oversight Committee does not take responsibility for the scientific validity or accuracy of methodology, results, statistical analyses, or conclusions presented.

Authors’ contributions

KJH designed the study, developed the case definition, obtained the data, and performed statistical analysis. SKP assisted with obtaining the data, institutional approval, and interpretation of results. JRM, DBR, and AEW contributed to the study design and interpretation of results. SWM supervised the study, contributed to the study design and development of the case definition, and interpretation of results. All authors contributed to the development of the manuscript. All authors read and approved the final manuscript.

Ethics approval and consent to participate

The University of North Carolina at Chapel Hill Office of Human Research Ethics/Institutional Review Board approved this study (Study #: 16–1789).

Competing interests

The authors declare that they have no competing interests.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Authors’ Affiliations

(1)
Department of Epidemiology, University of North Carolina at Chapel Hill, 2101 McGavran-Greenberg Hall, CB #7435, Chapel Hill, NC 27599-7435, USA
(2)
Injury and Violence Prevention Branch, Chronic Disease and Injury Section, NC Division of Public Health, NC Department of Health and Human Services, 5505 Six Forks Road, Raleigh, NC 27609, USA
(3)
Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, 125 Fetzer Hall, CB# 8700, Chapel Hill, NC 27599-8700, USA
(4)
Matthew Gfeller Center, University of North Carolina at Chapel Hill, 2207 Stallings-Evans Sports Medicine Complex, CB# 8700, Chapel Hill, NC 27599-8700, USA
(5)
Department of Epidemiology, University of North Carolina at Chapel Hill, 2102B McGavran-Greenberg Hall, CB# 7435, Chapel Hill, NC 27599-7435, USA
(6)
Department of Emergency Medicine, University of North Carolina at Chapel Hill, Physicians Office Building, 170 Manning Dr., CB# 7594, Chapel Hill, NC 27599-7594, USA
(7)
Carolina Center for Health Informatics, University of North Carolina at Chapel Hill, Floor 1, 100 Market Street, CB #7597, Chapel Hill, NC 27516, USA
(8)
Injury Prevention Research Center, University of North Carolina at Chapel Hill, CVS Plaza, Suite 500, 137 East Franklin Street, CB# 7505, Chapel Hill, NC 27599-7505, USA

References

  1. Andrew NE, Gabbe BJ, Wolfe R, Cameron PA. Trends in sport and active recreation injuries resulting in major trauma or death in adults in Victoria, Australia, 2001–2007. Injury. 2012;43(9):1527–33.View ArticleGoogle Scholar
  2. Andruszkow H, Deniz E, Urner J, Probst C, Grün O, Lohse R, et al. Physical and psychological long-term outcome after traumatic brain injury in children and adult patients. Health Qual Life Outcomes. 2014;12:26.View ArticleGoogle Scholar
  3. Babikian T, Asarnow R. Neurocognitive outcomes and recovery after pediatric TBI: meta-analytic review of the literature. Neuropsychology. 2009;23(3):283–96.View ArticleGoogle Scholar
  4. Barell V, Aharonson-Daniel L, Fingerhut LA, Mackenzie EJ, Ziv A, Boyko V, et al. An introduction to the Barell body region by nature of injury diagnosis matrix. Inj Prev. 2002;8(2):91–6.View ArticleGoogle Scholar
  5. Bijur PE, Trumble A, Harel Y, Overpeck MD, Jones D, Scheidt PC. Sports and recreation injuries in US children and adolescents. Arch Pediatr Adolesc Med. 1995;149(9):1009–16.View ArticleGoogle Scholar
  6. Bloom OJ. Gfeller-Waller concussion awareness act. NC Med J. 2015;76(2):90–1.Google Scholar
  7. Bronnert J. Assigning E-Codes: two new sections go into effect October 1. J AHIMA. 2009;80(9):70–1.Google Scholar
  8. Burt CW, Overpeck MD. Emergency visits for sports-related injuries. Ann Emerg Med. 2001;37(3):301–8.View ArticleGoogle Scholar
  9. Caine D, Maffulli N, Caine C. Epidemiology of injury in child and adolescent sports: injury rates, risk factors, and prevention. Clin Sports Med. 2008;27(1):19–50.View ArticleGoogle Scholar
  10. Carolina Center for Health Informatics. NC DETECT. 2017. https://ncdetect.org/. Accessed 16 Apr 2017.
  11. Caspersen CJ, Pereira MA, Curran KM. Changes in physical activity patterns in the United States, by sex and cross-sectional age. Med Sci Sports Exerc. 2000;32(9):1601–9.View ArticleGoogle Scholar
  12. Centers for Disease Control and Prevention. Nonfatal sports-and recreation-related injuries treated in emergency departments--United States, July 2000-June 2001. MMWR Morb Mortal Wkly Rep. 2002;51(33):736–40.Google Scholar
  13. Comstock RD, Currie DW, Pierpoint LA, Grubenhoff JA, Fields SK. An evidence-based discussion of heading the ball and concussions in high school soccer. JAMA Pediatr. 2015;169(9):830–7.View ArticleGoogle Scholar
  14. Conn J, Annest JL, Gilchrist J. Sports and recreation related injury episodes in the US population, 1997–99. Inj Prev. 2003;9(2):117–23.View ArticleGoogle Scholar
  15. Darrow CJ, Collins CL, Yard EE, Comstock RD. Epidemiology of severe injuries among United States high school athletes. Am J Sports Med. 2009;37(9):1798–805.View ArticleGoogle Scholar
  16. Delaney JS, Frankovich R. Head injuries and concussions in soccer. Clin J Sport Med. 2005;15(4):216–9.View ArticleGoogle Scholar
  17. Dempsey R, Layde PM, Laud PW, Guse CE, Hargarten SW. Incidence of sports and recreation related injuries resulting in hospitalization in Wisconsin in 2000. Inj Prev. 2005;11(2):91–6.View ArticleGoogle Scholar
  18. Ebbeling CB, Pawlak DB, Ludwig DS. Childhood obesity: public-health crisis, common sense cure. Lancet. 2002;360(9331):473–82.View ArticleGoogle Scholar
  19. Gabbe BJ, Finch CF, Cameron PA, Williamson OD. Incidence of serious injury and death during sport and recreation activities in Victoria, Australia. Br J Sports Med. 2005;39(8):573–7.View ArticleGoogle Scholar
  20. Gao Y, Johnston RC, Karam M. Pediatric sports-related lower extremity fractures: hospital length of stay and charges: what is the role of the primary payer? Iowa Orthop J. 2010;30:115.Google Scholar
  21. Gessel LM, Fields SK, Collins CL, Dick RW, Comstock RD. Concussions among United States high school and collegiate athletes. J Athl Train. 2007;42(4):495–503.Google Scholar
  22. Gopfert A, Hove M, van Mytton J, Emond A. How do we keep children safe in school sport? A systematic review of policies, consensus statements and guidelines to prevent school sports injury. Arch Dis Child. 2017;102(Suppl 1):A56.Google Scholar
  23. Goran MI, Reynolds KD, Lindquist CH. Role of physical activity in the prevention of obesity in children. Int J Obes Relat Metab Disord. 1999;23(S3):S18-S33.Google Scholar
  24. Harmon KJ, Waller AE, Barnett C, Proescholdbell SK, Marshall S, AJ Dellapenna, Jr. The UNC Department of Emergency Medicine Carolina Center for Health Informatics Report - Overview and Analysis of NC DETECT Emergency Department Visit Data for Injuries: 2010. Carolina center for health informatics, Department of Emergency Medicine, University of North Carolina at Chapel Hill. 2012. https://ncdetect.org/reports/. Accessed 16 Apr 2016.
  25. Howard AF, Costich JF, Mattacola CG, Slavova S, Bush HM, Scutchfield FD. A statewide assessment of youth sports- and recreation-related injuries using emergency department administrative records. J Adolesc Health. 2014;55(5):627–32.View ArticleGoogle Scholar
  26. Knowles SB, Kucera KL, Marshall SW. Commentary: the injury proportion ratio: what’s it all about? J Athl Train. 2010;45(5):475–7.View ArticleGoogle Scholar
  27. Koutures CG, Gregory AJM. Injuries in youth soccer. Pediatrics. 2010;125(2):410.View ArticleGoogle Scholar
  28. Leibson CL, Brown AW, Hall Long K, Ransom JE, Mandrekar J, Osler TM, et al. Medical care costs associated with traumatic brain injury over the full spectrum of disease: a controlled population-based study. J Neurotrauma. 2012;29(11):2038–49.View ArticleGoogle Scholar
  29. Marr AL, Coronado VG, editors. Central Nervous System Injury Surveillance Data Submission Standards-2002. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2004.Google Scholar
  30. Marshall SW, Guskiewicz KM. Sports and recreational injury: the hidden cost of a healthy lifestyle. Inj Prev. 2003;9(2):100–2.View ArticleGoogle Scholar
  31. Morrongiello BA, Rennie H. Why do boys engage in more risk taking than girls? The role of attributions, beliefs, and risk appraisals. J Pediatr Psychol. 1998;23(1):33–43.View ArticleGoogle Scholar
  32. Muller R, Lloyd J, Hanson D, Durrheim D, Vardon P, McFarlane K, et al. The injury iceberg: an ecological approach to planning sustainable community safety interventions. Health Promot J Aust. 2005;16(1):5.View ArticleGoogle Scholar
  33. National Center for Health Statistics. Bridged-Race Population Estimates 1990–2015. CDC WONDER. 2016. https://wonder.cdc.gov/. Accessed 15 Nov 2016.Google Scholar
  34. National Center for Injury Prevention and Control. Definitions for WISQARS™ Nonfatal. 2007. https://www.cdc.gov/ncipc/wisqars/nonfatal/definitions.htm. Accessed 20 Apr 2017.Google Scholar
  35. National Center for Injury Prevention and Control. Proposed Matrix of E-code Groupings. 2014. https://www.cdc.gov/injury/wisqars/ecode_matrix.html. Accessed 20 Apr 2017.Google Scholar
  36. National Federation of High Schools. 2014–15 High School Athletics Participation Survey [Internet]. National Federation of State High School Associations; 2016. http://www.nfhs.org/ParticipationStatics/PDF/2014-15_Participation_Survey_Results.pdf. Accessed 20 Apr 2017.
  37. North Carolina State Government. Sect. 1034b Artic. 22 Chapter 130A-480 NC General Statutes. H1414 SL 2004–124. 2004. http://www.ncga.state.nc.us/EnactedLegislation/Statutes/rtf/ByArticle/Chapter_130A/Article_22.rtf. Accessed 16 Apr 2017.
  38. Powell JW, Barber-Foss KD. Sex-related injury patterns among selected high school sports. Am J Sports Med. 2000;28(3):385–91.View ArticleGoogle Scholar
  39. Sallis JF. Epidemiology of physical activity and fitness in children and adolescents. Crit Rev Food Sci Nutr. 1993;33(4–5):403–8.View ArticleGoogle Scholar
  40. Sariaslan A. Long-term outcomes associated with traumatic brain injury in childhood and adolescence: a nationwide Swedish cohort study of a wide range of medical and social outcomes. PLoS Med. 2016;13(8):e1002103.View ArticleGoogle Scholar
  41. Schneier AJ, Shields BJ, Hostetler SG, Xiang H, Smith GA. Incidence of pediatric traumatic brain injury and associated hospital resource utilization in the United States. Pediatrics. 2006;118(2):483.View ArticleGoogle Scholar
  42. Taylor HG, Yeates KO, Wade SL, Drotar D, Stancin T, Minich N. A prospective study of short-and long-term outcomes after traumatic brain injury in children: behavior and achievement. Neuropsychology. 2002;16(1):15.View ArticleGoogle Scholar
  43. US Census Bureau. County Classification Look-up Table. Geogr. Urban Rural. 2016. https://www.census.gov/geo/reference/urban-rural.html. Accessed 21 Apr 2017.
  44. WakeMed Health and Hospitals. WakeMed concussion clinic tackles young athletes’ injuries head-on. 2009. https://www.wakemed.org/body.cfm?id=247&action=detail&ref=189. Accessed 24 Mar 2018.
  45. Yang J, Peek-Asa C, Allareddy V, Phillips G, Zhang Y, Cheng G. Patient and Hospital characteristics associated with length of stay and hospital charges for pediatric sports-related injury hospitalizations in the United States, 2000–2003. Pediatrics. 2007;119(4):e813–20.View ArticleGoogle Scholar

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