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Epidemiology of Aquatic and Recreational Water Sport Injuries: A Case-

Control Analysis

Article  in  Orthopedics · September 2015

DOI: 10.3928/01477447-20150902-60

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 n Feature Article

Epidemiology of Aquatic and Recreational

Water Sport Injuries: A Case-Control
Analysis
Ian Kane, BS; Alvin Ong, MD; Kris E. Radcliff, MD; Luke S. Austin, MD; Mitchell Maltenfort, PhD;
Fotios Tjoumakaris, MD

abstract

The purposes of the current investigation are to evaluate the epidemiology of water
sport injuries at a coastal tertiary trauma center and to determine the association of these
activities with spinal column injury and to determine whether aquatic trauma injuries
differ significantly from those that occur terrestrially. A retrospective review of a con-
secutive series of 105 patients with aquatic-based mechanisms of injury admitted to a
Level II trauma center over a 3-year period, as well as a matched control cohort with
terrestrial-based mechanisms of injury, was conducted. Patients were treated at a Level
II trauma center from January 1, 2008, to December 31, 2010. All patients received a
full trauma work-up on arrival. Patients were identified retrospectively from a pro-
spectively collected database (N=5298). Eligible patients were identified from billing/
coding data as having mechanisms of injury related to an aquatic setting. Patients
were evaluated using standard trauma protocols. Spinal column and cord injury
occurrence and differences between groups were reviewed. Personal watercrafts ac-
counted for the majority of injuries (n=39). Cervical (33.3%), closed-head (25.7%),
and thoracolumbar (21.9%) injuries accounted for the majority of injury types. The
cervical spinal column and the spinal cord were at an increased risk of injury in the
aquatic injury cohort (P<.0001). The current data show the high incidence of spinal
column and cord injuries in this patient population relative to controls. Practitioners
who care for trauma patients near an aquatic environment should be aware of the
high prevalence of these injuries, with proper spinal cord preservation protocols in
place to optimize outcome. [Orthopedics. 2015; 38(9):e813-e818.]

The authors are from the New York Medical College (IK), Valhalla, New York; and the Rothman
Institute of Orthopedics at Jefferson University Hospital (AO, KER, LSA, MM, FT), Philadelphia,
Pennsylvania.
Mr Kane, Dr Maltenfort, and Dr Tjoumakaris have no relevant financial relationships to disclose.
Dr Ong is a paid consultant for Smith & Nephew and Stryker. Dr Radcliff is a paid consultant for Glo-
bus, Medtronic, and DePuy. Dr Austin receives personal fees from Tornier.
Correspondence should be addressed to: Fotios Tjoumakaris, MD, Rothman Institute, 2500 English
Creek Ave, Bldg 1300, Egg Harbor Township, NJ 08234 (Fotios.Tjoumakaris@rothmaninstitute.com).
Received: October 3, 2014; Accepted: January 6, 2015.
doi: 10.3928/01477447-20150902-60

SEPTEMBER 2015 | Volume 38 • Number 9 e813

n Feature Article
S
everal studies have been conducted
on fracture epidemiology in the
setting of specific risk factors, such
as bicycling,1,2 motor vehicle collision,3
and even airplane injuries.4 A large-scale
evaluation has not been done for the epi-
demiology of water-based recreational
injuries occurring over several years at
a populated coastal city. Summer in a
coastal region is often accompanied by a
surge of unique traumatic incidents asso-
ciated with the aquatic environment and
related recreational activities.5,6 There is
an increase in tourism to these regions
and many of the incoming ocean-goers
are less familiar with the risks and dan-
gers associated with water-based recre-
ational activities compared with individu-
als who encounter them more often. By
examining the epidemiology of injuries
arising from this seasonal-specific set-
ting, it is believed that more favorable
patient outcomes can be obtained through
efficient injury management.
Spinal cord injuries in particular are
devastating injuries that can result in per-
manent impairment of function and loss
of quality of life, and in some instances
can be fatal.7 Optimum outcome is often
achieved when the health care team car-
ing for these injured patients is well sea-
soned in caring for these injuries with cur-
rent spinal protocols and treatments (eg,
American Association of Neurological
Surgeons guidelines8), including spinal
immobilization and nonoperative vs op-
erative stabilization.
Spinal cord injuries are most common
following high-energy mechanisms, which
are involved with numerous recreational
activities.9-15 These include contact sport-
ing activities,16-18 motorized vehicle opera-
tion, and falls.19 On coastal waters, a vari-
ety of recreational activities exist that carry
a predisposition to spinal cord and other
traumatic injuries.20 These include surf-
ing, personal motorized watercraft opera-
tion (ie, riding a wave-runner or boating),
swimming, kayaking, and bodysurfing. In-
juries often occur following these activities
e814
due to the high-force nature of these mech-
anisms combined with the possibility that Table 1
the event may occur in shallow water near
Patient Demographics
the shoreline, which can lead to headfirst
Aquatic Terrestrial
encounters with the ocean floor. Demographic (Case) (Control)
The purpose of the current investigation
Male, No. (%) 75 75
was to evaluate the nature and mechanisms (71.4) (71.4)
of injury of recreational water sports in a Age, mean, y 37.19 38.85
coastal environment. In addition, the au- Female, No. 30 30
thors sought to determine whether the risk (%) (28.6) (28.6)
of spinal cord and column injury or other Age, mean, y 34.50 36.30
types of bodily injury were more signifi- ISS, mean 8.89 9.30
cantly associated with water-based activi-
LOS, mean, d 5.41 6.02
ties relative to those that occur on land in a
Abbreviations: ISS, injury severity score;
defined trauma population. LOS, length of stay.
Materials and Methods
Institutional review board approval act tests, Wilcoxon rank sum tests, and a
was obtained for this study. All patients Bonferroni correction.
were retrospectively identified from a pro-
spectively collected database of patients Results
admitted to the trauma service at the au- During the study period, there were
thors’ local tertiary trauma center situated 5298 trauma admissions, 1672 of which
on the East Coast. This trauma database occurred during the summer months. Trau-
and registry are maintained by the admit- ma patients were then excluded from the
ting trauma service and collect patient de- case group (n=5193) if they did not meet
mographic data relating to mechanism of the criteria of having a mechanism of in-
injury, injury severity score (ISS), length jury originating from a recreational water
of stay (LOS), complications encoun- sport. In the aquatic injury group, there
tered, transfusion requirements, surgical were 75 men (mean age, 37.19 years) and
procedures performed, age, gender, and 30 women (mean age, 34.50 years), with
medical comorbidities. a mean ISS of 8.89. Mean LOS was 5.41
Patients enrolled from January 1, days, with a mean LOS in the intensive
2008, to December 31, 2010, served as care unit (ICU) of 5 days.
the cohort population of patients. This Twenty-eight (26.7%) patients re-
represented 5298 patients admitted as an quired surgical stabilization. Mecha-
alert during this time frame. Patients for nisms of injury included 24 (22.9%)
the case group were eligible for inclu- wave-runner accidents, 15 (14.3%) boat-
sion if they were admitted/injured in the ing accidents, 14 (13.3%) bodyboarding
context of water-based activity or rec- injuries, 13 (12.4%) falls, 11 (10.5%)
reational sport (eg, swimming, surfing, diving accidents, 9 (8.6%) body-surfing
boating, personal watercraft use). This accidents, 9 (8.6%) surfing accidents,
led to 105 patients eligible for inclusion. 8 (7.6%) hits by a wave, 1 (1.0%) tubing
For comparative analysis, a control group accident, and 1 (1.0%) explosion.
of patients (matched by age, gender, and Complications included 9 (8.6%) in-
ISS) were also obtained from admissions fections, 6 (5.7%) cases of pneumonia/
during the same time frame and from the atelectasis, 2 (1.9%) pre-hospital cardiac
same larger cohort (Table 1). Patients arrests (traumatic arrests, not due to oc-
in both cohorts were analyzed in similar clusion of coronary arteries), 2 (1.9%)
fashion and compared using Fisher’s ex- incidences of deep venous thrombosis,
Copyright © SLACK Incorporated
 n Feature Article

and 1 (1.0%) myocardial infarction. There

were 27 (25.7%) concussions, of which Table 2
7 (6.7%) had significant closed-head
Injuries and Complications
hematomas (epidural hematoma, sub-
No. (%)
dural hematoma, subarachnoid hema-
toma, intraparenchymal hematoma, or in- Injury/Complication Aquatic (Case) Terrestrial (Control)

traventricular hematoma). There were 57 Spinal column injury 57 (54.3) 13 (12.4)

(54.3%) spinal column injuries, of which Spinal cord injury 20 (19.0) 1 (1.0)
20 (19.0%) were significant spinal cord Concussion 27 (25.7) 23 (21.9)
injuries that resulted in neurological defi- Closed-head hematoma 7 (6.7) 2 (1.9)
cits. Ten (9.5%) patients required a blood Surgical stabilization 28 (26.7) 19 (18.1)
transfusion. Torso-visceral injury 13 (12.4) 20 (19.0)
The control group consisted of an
Transfusion 10 (9.5) 3 (2.9)
equivalent distribution of gender and
Skull fracture 9 (8.6) 6 (5.7)
similar mean ages and ISS. Mean LOS
Infection 9 (8.6) 12 (11.4)
was 6.02 days and mean ICU LOS was
not recorded. Nineteen (18.1%) patients Pneumonia/atelectasis 6 (5.7) 2 (1.9)
required surgical stabilization. Mecha- Pneumo-/hemothorax 6 (5.7) 7 (6.7)
nisms of injury included 51 (48.6%) mo- Cardiac arrest 2 (1.9) 0
tor vehicle collisions, 31 (29.5%) falls, Deep venous thrombosis 2 (1.9) 0
14 (13.3%) pedestrians struck, 5 (4.8%) Myocardial infarction 1 (1.0) 0
gunshot wounds, 3 (2.9%) falling ob- Pulmonary embolism 0 1 (1.0)
jects, and 1 (1.0%) assault.
Retroperitoneal hematoma 0 9 (8.6)
Complications included 12 (11.4%)
Embolization 0 1 (1.0)
infections, 9 (8.6%) retroperitoneal he-
Mortality 0 0
matomas, 2 (1.9%) cases of pneumonia/
atelectasis, 1 (1.0%) pulmonary em-
bolus, and 1 (1.0%) embolization. There
were 23 (21.9%) concussions, of which 2
Table 3 Table 4
(1.9%) were significant closed-head he-
matomas. There were 11 (10.5%) spinal Spinal Column Injury Spinal Cord Injury
column injuries of which 1 (1.0%) had No. (%) No. (%)
a significant spinal cord injury resulting Aquatic Terrestrial Aquatic Terrestrial
in neurological deficits. Three (2.9%) Injury Region (Case) (Control) Injury Region (Case) (Control)
patients required a blood transfusion Cervical 35 (33.3) 2 (1.9) Cervical 19 (18.1) 0
(Table 2). Lumbar 13 (12.4) 8 (7.6) Thoracic 1 (1.0) 0
In the aquatic injury group, the spinal Thoracic 10 (9.5) 3 (2.9) Lumbar 0 1 (1.0)
column injuries occurred in the cervical Sacral 2 (1.9) 0 Sacral 0 0
region in 35 (33.3%) patients, lumbar
region in 13 (12.4%), thoracic region in
10 (9.5%), and sacral region in 2 (1.9%); Discussion jury in the aquatic injury cohort compared
spinal cord injuries occurred in the cervi- These data indicate that, in a coastal with the terrestrial cohort (19.0% vs 1.0%,
cal region in 19 (18.1%) and the thoracic environment, recreational aquatic injuries respectively).
region in 1 (1.0%). In the terrestrial co- are a common cause of morbidity. Spinal Cervical injuries represented a large
hort, the spinal column injuries occurred column injuries were more common fol- risk among the aquatic injury cohort, with
in the lumbar region in 8 (7.6%) patients, lowing aquatic injuries (54.3%) than fol- 33.3% of patients sustaining a cervical in-
thoracic region in 3 (2.9%), and cervical lowing terrestrial injuries (12.4%) (Fig- jury compared with the terrestrial group,
region in 2 (1.9%); the spinal cord injury ure 1). Spinal column injuries were also which included 1.9% of patients who sus-
occurred in the lumbar region in 1 (1.0%) significantly more likely (P<.0001; odds tained cervical injuries. This difference
patient (Tables 3-4). ratio: 24.21) to involve a spinal cord in- was found to be significant (P<.0001;

SEPTEMBER 2015 | Volume 38 • Number 9 e815

n Feature Article
Figure 1: Bar graphs showing spinal injuries.
odds ratio: 25.24). Thoracic (P=.08229),
lumbar (P=.3579), and sacral (P=.4976)
injuries were all greater in the aquatic in-
jury cohort; however, this difference was
found to be insignificant.
In the terrestrial cohort, lumbar inju-
ries were the most common spinal column
injury (7.6%) but still had a lower inci-
dence rate than the aquatic injury cohort
(12.4%). The cervical spine was at great-
est risk of resulting in a debilitating spinal
cord injury following an aquatic injury.
Spinal cord injuries were almost exclu-
sively due to cervical injuries, with 18.1%
of patients in the aquatic injury cohort
sustaining a spinal cord injury. Concus-
sion rates were similar between groups
(24.8% vs 21.9%) and closed-head hema-
tomas were greater, but not significantly
greater (P=.1702), in the aquatic injury
group than in the terrestrial group (6.7%
vs 1.9%, respectively) (Figure 2).
The observed injury distribution
among the groups was consistent with
what was expected by the research team.
Aquatic spinal cord injuries most often
occurred in shallow waters that allowed
for the patient’s head to strike the ground
under the water in a flexed position. In ad-
dition, the lack of restraining equipment
present on personal watercrafts combined
with the high speeds that these watercrafts
are able to achieve makes an ejection off
the vehicle following a sudden decelera-
tion a highly likely scenario. These eject-
ed individuals are traveling at a high rate
of speed when striking the water, leading
to a head-on collision with the ground. It
is possible that with a larger sample size
the rate of traumatic closed-head hema-
e816
Figure 2: Bar graphs showing head injuries.
tomas could be found to be significantly
greater, but this was not found to be the
case during the time frame of this study.
The use of alcohol and other recre-
ational substances also contributed to the
observed pattern of injury. The number
of intoxicated patients in the aquatic in-
jury cohort was greater than the terrestrial
cohort (13.3% vs 7.6%, respectively) but
was not significantly greater (P=.2596).
This increased rate is consistent with the
vacation atmosphere, which led to the
seasonal increase in aquatic injuries in
this setting. Intoxicated vacationers are
less inhibited and less coordinated, which
could have led to the occurrence of the in-
jury and to additional compromise of the
spinal cord.
When examining the incidence of in-
fections, it was found that among the 9
patients who had a positive culture docu-
mented during admission, there was also
an extended average LOS in the ICU
compared with the rest of the cohort (12
vs 5 days, respectively) in these patients.
Two of those patients had their first posi-
tive cultures more than 1 week after ad-
mission and were likely nosocomial in
origin. Of the 5 patients who required sur-
gical stabilization, only 1 used an intra-
wound antibiotic infused substance (mul-
tiple antibiotic impregnated beads) and
none used intra-wound vancomycin pow-
der. Three infections occurred in patients
also experiencing a spinal cord injury
and 2 occurred in patients with closed-
head hematomas. Most of the infections,
with the exception of the likely nosoco-
mial ones, were the result of aspiration or
wound contamination.
The majority of aquatic injuries were
due to personal watercraft (wave-runner
and boating) accidents (37.2%) followed
by bodyboarding (13.3%), falls into wa-
ter (12.4%), diving (10.5%), bodysurfing
(8.6%), surfing (8.6%), and being struck
by waves (7.6%). This shows that within
this population, personal watercrafts rep-
resented the most common mechanism for
injury. Personal motorized watercrafts can
achieve speeds equivalent to cars and oth-
er land-based motor vehicles traveling on
a highway; therefore, it is not surprising
that collisions and other forms of sudden
deceleration events are often associated
with trauma center criteria injuries.
Bodyboarding resulted in cervical inju-
ries 57.1% of the time and was not associ-
ated with injuries to any other segment of
the spinal column. Bodysurfing accidents
were always associated with an injury to
the spinal column, with 88.9% of injuries
to the cervical spine and 11.1% to the tho-
racic spine. Diving injuries almost always
resulted in injury to the spinal column,
with 63.6% resulting in cervical injuries.
Being struck by a wave commonly result-
ed in spinal column injuries, with 50% of
injuries to the cervical spine and 25% to
the thoracic spine. Surfing was most often
associated with cervical injuries (44.4%),
and personal watercraft (wave-runner)
injuries were most commonly associated
with lumbar spine injuries (29.2%). Falls
and boating were less likely to result in a
spinal trauma and did not favor any spe-
cific region of the spinal column. Personal
watercraft (wave-runner) accidents were
also associated with torso-visceral inju-
ries in 25% of patients, which seems con-
sistent with the observed risk to the lower
spinal column.
It is worth noting that the difference
in LOS was close to being significantly
different (P=.008028) after correcting
the P value for error with a Bonferroni’s
Correction (P=.00385 needed for signifi-
cance). The median LOS was 3 days for
the aquatic injury cohort and 5 days for
the terrestrial cohort. The difference ap-
Copyright © SLACK Incorporated

pears to arise from several outlier patients
who required an extended hospital stay
due to numerous other factors, including
injury care, continuing health manage-
ment, and inability to obtain placement in
an appropriate care facility. Therefore, it
is unclear whether this value reflected the
care necessary for the presenting injuries.
Although there are no known large-
scale epidemiologic studies of coastal
water sport injuries published, there have
been studies that tangentially touched
on the issue. A study of male patients
who sustained spinal injuries related to
water-based incidents related diving and
alcohol use to the likelihood of injury.21
Individual mechanisms have been exam-
ined and their epidemiologies reported.
Recreational boating and the risks and in-
juries associated with that activity was the
subject of a recent epidemiologic study,
which showed that the most likely cause
of death on the water was human error.22
Another study examined canoeing, kayak-
ing, and rafting and the injuries associated
with participation in these activities.23
Waterskiing24 and personal watercraft-
related injuries25,26 were examined and
showed a high increase in injuries related
to personal watercraft use and guidelines
for safer recreational uses were suggested.
Skimboarding injuries27 were also exam-
ined for their prevalence to result in lower
extremity injury; however, there were no
trauma admissions following a skimboard
accident during the time frame that was
examined in the current study, suggest-
ing that these injuries tend to not qualify
for admission to a trauma center. Wave-
related injuries were examined and
showed a high risk for the elderly due to
preexisting cervical spondylosis result-
ing in central cord syndrome following
hyperextension of the neck, as well as the
ocean-goer with weak swimming skills.28
Other studies have looked at water-based
injuries and deaths without the context of
engagement in a water sport. These stud-
ies include an examination of pediatric in-
juries in relation to any source of water29
SEPTEMBER 2015 | Volume 38 • Number 9
and all water-based fatalities based on au-
topsy information.30
A limitation of this study was the ret-
rospective nature of the analysis. Retro-
spective studies may be more susceptible
to selection bias. Although all data were
collected prospectively, it was not record-
ed with the current study in mind and it is
possible that pertinent data may have been
overlooked. Patients who expired at the
scene of the accident would not have been
included, making it reasonable to assume
there is some degree of survivorship bias
present. It was surprising to the investiga-
tors that neither group included any fa-
talities from the time emergency medical
services assumed care of the patients until
discharge. Although this is an encourag-
ing scenario, it is not the typical situation
experienced while dealing with as many
high-velocity mechanisms of injury as
were included in this study.
Conclusion
To the authors’ knowledge, this is the
largest epidemiologic series to date on
aquatic and water sport injuries. The data
show the high incidence of spinal column
and spinal cord injuries in this patient
population relative to controls. Practitio-
ners who care for trauma patients near an
aquatic environment should be aware of
the high prevalence of these injuries, with
proper spinal cord preservation protocols
in place to optimize outcome. Awareness
of the associated risk of closed-head inju-
ries should also be taken into account dur-
ing the workup of patients involved in these
high-risk activities. Future strategies aimed
at preventing these injuries in seasonal visi-
tors and native coastal inhabitants should
be a critical part of any comprehensive re-
gional trauma program.
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