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Equestrian sports are very popular in Ireland, with a large number of amateur and novice riders who participate on a recreational basis. There is also a well-developed equestrian sport industry, spanning a broad variety of disciplines including racing, show jumping, and cross country riding. Despite the high level of interest and participation, there are few demographic studies of equestrian sport participation in Ireland. Horse riding is also a high risk activity, particularly for those lacking in training or experience. An Irish study found that equestrian sports were involved in 41.8% of sports related cases seen by the national spinal injuries unit, of which 92% were non-professionals. A review of an American emergency department surveillance system found comparable rates of injury between all-terrain vehicle (ATV) use and equestrian activities. Equestrian sports also had a higher rate of hospitalisation when compared to all sports and recreational injuries. When equestrian accidents occur, they have the potential to be very serious, often resulting in poor functional outcomes, mostly relating to orthopaedic injuries and head trauma, including pain or weakness in injured limbs, chronic pain and headaches, and impaired balance. Fourth nerve palsy and loss of vision have also been documented.
Pattern of Injury
Most frequently, accidents occur while riding, with riders presenting with damage to the upper extremities, head, neck and spine after a fall, though the exact percentages vary between studies, possibly due to regional variation in rider behaviour or small sample size. The pattern of injury varies with age and sex. Males are more likely to present with rib fractures, heart and lung injuries when compared with females. There is also significant variation in injury pattern with rider age, with younger patients more likely to suffer from head injuries (the commonest cause of death in equestrian injury), while older females are more likely to suffer from vertebral, pelvic and rib fractures. There is also a significant minority of injuries which occur while grooming or otherwise handling horses in the form of kicks and bites, which can cause very serious injury requiring plastic and maxillofacial surgery. This essay will endeavour to briefly discuss Head and upper limb injuries, the two most common forms of injury seen in equestrians.
Head injury encompasses damage to a broad variety of anatomical features, including disruption of soft tissue and bone. Soft tissue injuries to the head include damage to the skin, subcutaneous tissue, muscles, vessels and nerves in the thin layer of tissue covering the neurocranium. It also includes injuries to the soft tissues deep to the bony structures, such as the meninges, brain, and attendant blood supply. Head injuries can be associated with severe maxillofacial injuries.
In an equestrian context, head injury results from impact, either by falling or from a kick. In this case, there may be focal impact damage. Cuts and lacerations to the skin at the point of impact are the most superficial focal damage. There may be a skull fracture if the impact was strong enough, though they are less common in children than in adults, as their skulls are more elastic. Fractures can be linear or depressed. Depressed fractures occur when part of the skull deforms inwards, and does not move back into its original position after the force which generated the fracture is removed. Depressed fractures indicate serious head trauma, and are known to be a possible cause of epilepsy. Depressed fractures can be associated with comminution of the bone. In this case, pieces of comminuted bone can be forced into the cranial vault, sometimes tearing the dura mater. Comminuted fractures with an open scalp wound provide an opportunity for direct seeding of the brain with infectious organisms, and should be debrided and repaired by a surgeon as soon as possible. Linear fractures show no depression, and are only of interest as marker of potential bleeding or damage to tissue inside the skull. Base of skull fractures are particularly difficult to diagnose and treat. Some key signs include periorbital ecchymosis (raccoon eyes), which indicates fracture and haemorrhage from the cribriform plate, ecchymosis over the mastoid process (Battle's sign), which indicates likely middle cranial fossa fracture, and more general signs such as cerebrospinal fluid leaking from nostrils or ears.
Potential brain injuries are of particular concern when faced with head trauma. Brain injuries can result directly from trauma, or occur secondary to damage to other structures surrounding the brain itself. Examples of traumatic brain injury (TBI) which are caused by direct trauma such as deceleration include concussion, contusion and diffuse axonal injury. Diffuse brain injury occurs because the brain has some freedom of movement with respect to the skull, and in cases of deceleration or impact, it can bang against the interior of the skull. This causes potentially reversible damage in the form of axonal stretching, and irreversible damage from the shearing of axons. Direct brain injury is quite common in equestrian head injury, in the form of concussion, which stems from reversible axonal stretching damage.
Intracranial haemorrhage, depending on location can be a direct or indirect cause of brain injury, and is well documented in the equestrian population. Bleeding between layers of the meninges (intradural), or into the space between the dura matter and the bony skull (extradural), creates a mass of blood or haematoma (usually through rupture of a meningeal artery). Extradural haematomas primarily pose a risk to the patient through volume displacement inside the skull leading to compression of the brain and increased intracranial pressure. The kinds of injury which produce intradural haematomas are more likely to be associated with primary brain injury, as they require the tearing of cerebral vasculature (venous blood from the superior sagittal sinus in dural border haemorrhage, or a cerebral artery in subarachnoid haemorrhage) or coalescence of contusions in order to form. Intradural haematomas can also cause secondary brain injury through compression of the brain tissues. Haematomas intrude into space normally occupied by the brain and meninges. The skull has room to accommodate haematomas between 50ml and 150ml in size through displacement of CSF and venous blood. After this limit has been exceeded, the haematoma begins to compress the brain tissue and cause increased intracranial pressure (ICP).
Ischaemia and increased intracranial pressure is another significant challenge in head trauma. This can result in impaired perfusion of the brain tissue. Increased ICP limits perfusion by diminishing the pressure gradient between the arteries supplying the head and the capillary beds supplying the brain. As ICP approaches mean arterial pressure, perfusion of the cranial capillary beds is compromised, and ischaemic damage can occur.
Raised ICP can cause herniation of parts of the brain through gaps in its membranous support structures and the skull. This is frequently a consequence of large haematomas displacing CSF and brain tissue. Supratentorial compression can cause herniation of the uncal process of the temporal lobe through the tentorium, compressing the third cranial nerve. Compression of this nerve results in dipolopia. Subfalcine herniation occurs as the most supero-medial parts of the frontal lobe are pushed contralaterally underneath a layer of dura mater which separates the hemispheres of the brain. This herniation can disrupt blood supply and cause further increases in ICP. Further increases in ICP can cause the cerebellar tonsil through the foramen magnum of the skull, leading to compression of the brain stem. This process, known as â€œconingâ€Â is life threatening, as damage to the brain stem compromises the brain's ability to maintain vital processes such as regulating heart rhythm and breathing. In addition to compression of the brain stem, the third cranial nerve becomes trapped and compressed between the brain stem and the brim of the foramen magnum.
Facial injury in the equestrian context can occur as a result of a fall, but also from receiving a kick at head level. Both can be quite serious, often necessitating assessment and treatment by a plastic surgeon. Equestrian helmets are open at the front, and give little protection to the protruding structures of the face. One case in the literature describes a 53 year old female equestrian was kicked by her horse while unmounted, and had a 3cm x 0.5cm foreign body lodged at the orbital apex, communicating with the cranial vault, while only leaving a 5mm laceration hidden at the superior lid margin as evidence a penetrating injury had occurred. In this case, the foreign body was found and successfully removed after the patient exhibited signs of increased intraocular pressure, but it demonstrates the risk associated with handling horses while dismounted, and that injuries which appear to be blunt in nature can have a penetrating component when occurring in the context of a contaminated environment.
Injuries to the upper extremeties
Equestrians frequently present with damage to the upper extremities. This is likely due to the mechanics of falling from horseback, attempting to use the upper limb to break their fall, or cushion their landing. In particular, arm fracture and dislocation seem to be the most common, with risk stratified by age. Younger riders were more likely to suffer from an upper limb injury, but relative risk declines with increasing age. The complications of fracture and dislocation include compartment syndromes, blood loss, infection and deformity.
Ischaemia is of particular concern, as occlusion of blood vessels can result from loss of skeletal alignment in fracture, or from a dislocation at the joint. The most common cause is arterial kinking where part of a bone has been moved out of place, but ragged bone edges can also cut or tear arteries. The signs and symptoms of arterial arrest are coldness of the skin, pallor, parasthesiae distal to the site of arrest, and abolition of distal pulses in the limb. Rapid restoration of blood flow is required to prevent ischaemic death of poorly perfused distal tissue and preserve future limb function. If reduction of the fracture fails to restore arterial supply, the vessel may be torn, or undergoing vasospasm triggered by intimal damage. Both of these problems will require emergency surgery and internal fixation of the fractured bone. Neat divisions of the artery can be repaired with end to end anastomosis. Reversed vein grafts are used for spastic vessels and arterial injuries not amenable to anastomosis. Another form of ischaemic injury is avascular necrosis. Avascular necrosis occurs when the blood supply to the bone itself has been disrupted by trauma. It is quite unusual in the long sections of the limb bones, but has been frequently documented in the head of the femur and in the small bones of the wrist (carpal bones), areas which do not have redundant arterial supply. In particular, a fall on an outstretched hand is likely to result in shearing of the small vessels supplying the scaphoid and lunate bones. This results in a gradual softening of the bone as the osteocytes within die, and new bone formation is halted. Joints articulating with bones undergoing avascular necrosis tend to undergo early and severe osteoarthritic change.
Compartment syndrome is a condition in which muscles within a tough compartment of deep fascia auto-infarct, due to reduction of the pressure gradient between the fascial compartment and systolic blood pressure. Compartment pressure increases due to swelling of the tissues contained within, which can occur secondary to bleeding, contusion or ischaemia. The swollen tissues are contained within their fascial sheath and cannot expand beyond the sheath's limits, thus the compartment pressure rises significantly. The distal pulses may remain unaffected in patients developing compartment syndromes, as blood supply to unaffected compartments will continue via undamaged arteries. Patients are at risk of developing a compartment syndrome when the difference between systolic pressure and compartment pressure is less than 30mmHg, or less than 15-20mm in distal areas with small muscles, such as the hand. The only major sign of a developing compartment syndrome is raised tension in the affected compartment, which can be palpated. Symptoms include worsening pain in the limb despite immobilisation and reduction of injuries and parasthesias in regions supplied by nerves running through the affected area. The symptomatic cues are useful in diagnosis, but this information is unavailable if the patient is unconscious. Head injury is frequently seen in equestrian accidents, which can render the patient unconscious.
Spinal trauma is also a major concern for injured equestrians. While there is a lower incidence of spinal injury than upper limb injury, the potential for mortality and long term disability is greater. Spinal injury is often paired with head and upper body trauma, and so cases should be treated with a high index of suspicion, due to the prevalence of these related injuries in equestrians. Patients will often present with pain at the site of injury, usually exacerbated by movement, with or without sensory loss below the site of injury. There may be tenderness, deformity and bruising in the area and the patient may exhibit abnormal reflexes upon neurological assessment.
Participation in equestrian sport is associated with a broad variety of injuries, but with a particularly high risk of head and upper limb trauma. In contrast to most categories of trauma, females are more commonly injured than males, reflecting the predominantly female population of equestrians. Amateur riders are more likely to be injured than professional riders, but there is a high rate of recidivism in the population, and people are likely to have been injured while engaging in behaviour they knew was risky. The pattern of injuries varies depending on age group. Younger riders are more likely to suffer head trauma and older riders more likely to suffer from fractures to their ribs, pelvis and spine. Equestrians of all ages should be encouraged to use protective equipment, particularly helmets. Body protectors are of unproven benefit, but may reduce the chance of injury to the thorax and abdomen.