The American Journal of Surgery (2016) 211, 727-732

Society of Black Academic Surgeons

Epidemiology of lawnmower-related injuries

in children: A 10-year review
Marielena Bachier, M.D., Alexander Feliz, M.D.*

Division of Pediatric Surgery, University of Tennessee, Health Science Center, Le Bonheur Children’s
Hospital, 51 North Dunlap, Suite P230, Memphis, TN 38105, USA

KEYWORDS: Abstract
Lawnmower; BACKGROUND: Lawnmower-related injuries (LMI) in children are commonly disfiguring and usu-
Injuries; ally preventable. Owing to concerns about the large number and severity of pediatric LMI, we sought to
Children; describe the current epidemiology of these injuries in the United States.
Epidemiology METHODS: Data were obtained from the 2004 to 2013 National Electronic Surveillance system of
the United States Consumer Product Safety Commission for children %20 years old. Demographic,
injury pattern, and treatment data were analyzed.
RESULTS: There were an estimated 93,508 LMI, with an incidence of 9,351 LMI per year. The hand
and/or fingers (30.1%), lower extremity (16.8%), and face and/or eye (14.0%) were the body parts most
commonly injured. Amputations (relative risk [RR]: 11.5; 95% confidence interval [CI]: 11.00 to
12.10; P , .0001) and fractures (RR: 2.82; 95% CI: 2.64 to 3.00; P , .0001) were more likely to require
hospitalization.
CONCLUSIONS: The estimated annual incidence of LMI in children has remained unchanged over
the past decade, and has remained constant when compared with a previous 15-year review using Con-
sumer Product Safety Commission data for the same age group. Reinforcement of prevention strategies
and manufacturer redesign of lawnmowers are long overdue.
Ó 2016 Elsevier Inc. All rights reserved.

Lawnmower-related injuries (LMI) in children are
commonly disfiguring and usually preventable. The
morbidity of these injuries is aggravated in children
because of their smaller sized extremities and the potential
for progressive deformity because of ongoing musculoskel-
etal development, leading to greater requirement for
There were no relevant financial relationships or any sources of support
in the form of grants, equipment, or drugs.
The authors declare no conflicts of interest.
Disclosures: The authors report no proprietary or commercial interest
in any product mentioned or concept discussed in this article.
* Corresponding author. Tel.: 11-901-287-5108; fax: 11-901-
2874434.
E-mail address: afeliz@uthsc.edu
Manuscript received June 2, 2015; revised manuscript November 13,
2015
surgical re-evaluation. Likewise, long-term physical
disability and psychosocial scarring are magnified due to
a child’s expected lifespan.1–4
In 2001, the American Academy of Pediatrics’ (AAP)
Committee on Injury and Poison Prevention released a
policy statement delineating three main strategies for
prevention of LMI: (1) design changes of lawnmowers to
enhance safety, (2) appropriate age and maturity guidelines
for mower operation, and (3) education of parents, child
caregivers, and children regarding the hazards associated
with lawnmowers.5 The AAP’s specific lawnmower injury
prevention tips are summarized in Table 1.6
Despite injury prevention guidelines, data from the
National Electronic Surveillance System (NEISS) of the
United States Consumer Product Safety Commission
(CPSC) estimated 9,400 LMI injuries per year in children

0002-9610/$ - see front matter Ó 2016 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.amjsurg.2015.11.025
728
Table 1 American Academy of Pediatrics’ injury prevention tips6
American Academy of Pediatrics’s lawnmower injury prevention tips
 Children should be at least 12 years old before they operate any lawnmower, and at least 16 years old for a ride-on mower.
 Children should never be passengers on ride-on mowers.
 Always wear sturdy shoes whereas mowing–not sandals.
 Young children should be at a safe distance from the area you are mowing.
 Pick up stones, toys, and debris from the lawn to prevent injuries from flying objects.
 Use a mower with a control that stops it from moving forward if the handle is released.
 Never pull backward or mow in reverse unless absolutely necessary; if so, carefully look for others behind you.
 Always wear eye and hearing protection.
20 years or younger.7 Approximately 7% of LMI required
hospitalization, which represented twice the hospitalization
rate for overall consumer product-related injuries.7,8 It is
unknown whether these decade-old estimates represent
the current incidence of lawnmower injuries to children
in the United States. Because of the continuing large num-
ber and severity of these injuries, we aimed to determine
the epidemiology, injury patterns, and outcomes of LMI
to children in the United States over the past decade.
Methods
Data source
Data were obtained from the NEISS of the United States
CPSC for all LMI occurring between 2004 and 2013 in
patients 20 years and younger. CPSC product codes for
walk-behind and ride-on lawnmowers were included:
1,401, 1,405, 1,422, 1,439, and 1,448.
The NEISS collects data from a probability sample of
approximately 100 emergency departments in the United
States and its territories. Collected data are then weighted
based on the sample design to produce national estimates of
the number of consumer product-related injuries treated in
hospital emergency rooms.9,10
Variable definition
Data regarding patient demographic, injury distribu-
tion, type of injury, and emergency departments disposi-
tion were collected. Injury distribution was categorized
according to body part: face and/or eye, head and/or neck,
trunk, upper extremity, hand and/or fingers, lower ex-
tremity, and foot and/or toes. Injuries to the trunk
represent a composite of LMI to the chest, the abdomen,
and the pubic region. Similarly, injuries to the upper
extremity include LMI to the shoulder, upper arm, elbow,
lower arm, and wrist; injuries to the lower extremity
include LMI to the upper leg, knee, lower leg, and ankle.
The American Journal of Surgery, Vol 211, No 4, April 2016
Types of injuries were classified according to NEISS
categories and included amputation, fracture, foreign
body (projectile injury), and burns. Soft tissue injuries
included contusions, abrasions, crushing injuries, hema-
tomas, strains, and sprains. Lacerations included puncture
and avulsion wounds.
Data analysis
Statistical analyses were conducted using JMP Pro10
software. Pearson’s chi-square was used to compare cate-
gorical variables. Significance was established at P , .05.
Results
There were an estimated 93,508 LMI during the 10-year
time frame in patients 20 years and younger. The estimated
national incidence of 9,351 LMI per year (10.6 LMI per
100,000 children per year; based on the 2010 US Census
data) remains unchanged when compared with a previous
estimate by Vollman et al (Table 2). The majority (79.5%)
of LMI occurred in males. There was a bimodal age distri-
bution with a peak incidence of LMI in 3-year-old and 16-
year-old patients; the median age at time of injury was
13 years (Fig. 1). A total of 36% (n 5 33,833) of LMI
occurred in children less than 12 years old.
The incidence of LMI remained relatively unchanged
during the past decade (Fig. 2). Seasonal variations were
evident, with a peak incidence of LMI during the spring
and summer, which is consistent with the expected use of
lawnmowers (Fig. 3).
Injuries occurred more frequently to the hands and/or
fingers (30.1%), lower extremity (16.8%), and face and/or
eye (14.0%). These frequently injured body parts correlate
with the data reported by Vollman et al (Table 2); however,
in Vollman’s study foot and/or toes were more commonly
injured than in this cohort (17.7% vs 12.6%). Lacerations
(32.9%), soft tissue injuries (22.9%), and burns (13.5%) ac-
counted for most LMI. Together, fractures and amputations
M. Bachier and A. Feliz Lawnmower injuries in children: 10 year review 729

Table 2 Ten-year national estimates: clinical characteristics of lawnmower-related injuries

15-Year national
10-Year national estimates (n 5 140,700)
estimates (n 5 93,508) Vollman et al7
Average annual incidence 9,351 9,400
Population-based annual incidence* 10.6 10.7
Median age (Q1, Q3) 13.0 (6, 17) 10.7 (6.0)†
Male (%) 79.5 78.0
Race: % white/black/other/unknown 64/8/5/23 d
Body part injured (%)
Head/neck 5.5 4.6
Face/eyeball 14.0 10.6
Trunk 8.6 4.6
Upper extremity/hand and finger 9.4/30.1 7.4/34.6
Lower extremity/foot and toe 16.8/12.6 18.9/17.7
Other 3 1.6
Types of injuries (%)
Fracture/amputation 8.7/3.8 10.3/5.1
Burn/soft tissue injury/laceration 13.5/22.9/32.9 15.5/21.4/41.2
Foreign body (projectile injury) 3.5 3.3
Other 14.6 3.2
Type of lawnmower (%)
Walk-behind 8.4 d
Ride-on 21.2 d
Not specified 70.4 d
Emergency department disposition (%)
Discharged 93.9 d
Admitted or transferred 5.5 d
Other .5 d
*X Injuries per 100,000 children per year; based on the 2010 US census report for current cohort and the 2000 US census report for Vollman et al.
†
Mean (6 standard deviation).

led to 12.5% of LMI. The leading types of injuries are
similar to those reported in the 15-year national review
by Vollman et al (Table 2). Information regarding the
type of lawnmower was not available for the majority
(w70%) of LMI.
Bivariate analyses
Among patients who required hospitalization, injuries to
the foot and/or toes (43.0%), hands and/or fingers (19.9%),
and lower extremities (13.5%) were most prevalent (Table 3).

9000

8000

7000
Estimated Cases

6000

5000

4000 Female

3000 Male

2000

1000

0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Age (years)

Figure 1 Ten-year national estimates: age by gender.

730 The American Journal of Surgery, Vol 211, No 4, April 2016

12000

10000

Estimated Cases
8000

6000

4000

2000

0
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Year of Injury

Figure 2 Ten-year national estimates: annual incidence.

LMI to the foot and/or toes (relative risk [RR]: 5.25; 95% con-
fidence interval [CI]: 5.00 to 5.54; P , .001) and LMI to the
trunk (RR: 1.43; 95% CI: 1.32 to 1.56; P , .001) were more
likely associated with a requirement for admission or transfer
to another hospital.
Amputations (31.2%), lacerations (24.8%), and fractures
(21.1%) accounted for most LMI among patients requiring
admissions or transfers (Table 4). Patients with amputations
had the greatest risk of requiring hospitalization (RR: 11.5;
95% CI: 11.00 to 12.10; P , .0001). Similarly, fractures
had a higher risk of requiring hospitalization (RR: 2.82;
95% CI: 2.64 to 3.00; P , .0001).
Comments
A previous 15 year (1990 to 2004) report by Vollman
et al7 using CPSC data for the same population documented
an average of 9,400 injuries annually. Our data identified an
estimated incidence of 9,351 injuries annually. This demon-
strates that the incidence of LMI in children has remained
relatively unchanged over the past 2 decades.
Similar to previous literature,4,7,11 injuries to the extrem-
ities and face were found to be the leading body part
injured. Although lacerations, soft tissue injuries, and burns
were the most common types of injuries, our data show that
amputations and fractures are more commonly associated
with the need for hospitalization.
These findings gain relevance when considering current
prevention strategies. The AAP’s Committee on Injury and
Poison Prevention position article states that prevention of
LMI requires 3 levels of action: (1) changes in the design of
lawnmowers, (2) establishment of guidelines regarding the
appropriate age for operation of lawnmowers, and (3)
implementation of education strategies to parents and
children.
Data generated from the United States. CPSC has
contributed to changes in the design of lawnmowers as
stipulated by the voluntary standard American National
Standards Institute and Outdoor Power Equipment (ANSI/
OPEI B71.1).12,13 In 1982, a mandatory standard required
that rotary blades stop within 3 seconds of operators
releasing a ‘‘deadman’’ control. A report by Adler et al in
1994 showed a decrease in injuries associated to blade con-
tact; however, there was no significant reduction in injuries

18000
16000
14000
Estimated Cases

12000
10000
8000
6000
4000
2000
0
Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec
Month of Injury

Figure 3 Ten-year national estimates: monthly incidence.

M. Bachier and A. Feliz Lawnmower injuries in children: 10 year review 731

Table 3 Ten-year national estimates: injury distribution by emergency department disposition

10-Year national estimates (n 5 93,032)*
Body part (%) Admitted (n 5 5,151) Discharged (n 5 87,881) RR (95% CI) P value
Head/neck 134 (2.6) 4,976 (5.7) .46 (.39–.55) ,.0001
Face/eye 174 (3.4) 12,833 (14.6) .21 (.18–.25) ,.0001
Trunk 608 (11.8) 7,336 (8.3) 1.43 (1.32–1.56) ,.0001
Upper extremity 207 (4.0) 8,549 (9.7) .40 (.35–.46) ,.0001
Hand/fingers 1,024 (19.9) 26,987 (30.7) .58 (.54–.62) ,.0001
Lower extremity 696 (13.5) 14,980 (10.7) .77 (.71–.83) ,.0001
Foot/toes 2,214 (43.0) 9,436 (17.0) 5.26 (5.00–5.54) ,.0001
Other 94 (1.8) 2,784 (3.2) d d
d 5 Other; includes multiple injuries and RR calculations do not have clinical relevance.
*Attrition due to missing data regarding emergency departments disposition.

because of blade contact when mowers were backing
up.8,12 More so, a subsequent report by Adler et al13 in
2004 failed to show any further decrease in the incidence
of LMI between 1993 and 2003. The ANSI/OPEI B71.1-
2003 standards included a safety feature that prevents
backing up with powered blades.14 Most recently, the
ANSI/OPEI B71.1-2012 has taken into account modifica-
tions to prevent injuries associated to tipping over and
mower instability. Whether manufacturers implement these
new recommended changes in mower design, or whether
these modifications result in decreased injuries remains to
be studied.
Injury prevention guidelines and education to caretakers
and children are key components in reducing the incidence
of LMI. The AAP-injury prevention tips (Table 1) address
behavioral changes required to minimize blade contact,
thrown object, and reverse and/or run-over hazards. No rec-
ommendations are made by the AAP regarding behavioral
changes to prevent injuries associated to rolling and/or
tipping over of mowers. The ‘‘CPSC fact sheet: riding
lawnmowers’’ injury prevention strategies echo the ANSI/
OPEI B71.1-2003 recommendations which include (1)
slowing down before turning, (2) not using ride-on mowers
on slopes, and (3) acknowledging manufacturer weight and
counterweight recommendations.14 The authors recom-
mend that the AAP expand their injury prevention strate-
gies to include prevention of injuries associated to rolling
and/or tipping hazards. In addition, our data show that
36% of LMI occurred in children less than 12 years old,
and that the great majority of injuries occurred during the
spring and summer. These findings highlight the need to
reinforce education on age-limit guidelines and to heighten
awareness of prevention strategies during the mowing
season.
Limitations of this study include the retrospective design
and the use of a consumer safety database. These may bias
data that are collected and limit access to detailed clinical
information. Importantly, type of lawnmower could not be
assigned to approximately 70% of LMI. Consequently, the
incidence, injury distribution, type of injury, and level of
care for injuries associated with walk-behind vs ride-on
lawnmowers could not be assessed because of the nature of
the data. A case series has shown that injuries caused by
ride-on lawnmowers are more likely to require hospital
admission and surgical intervention.11 This finding suggests
that injuries associated to ride-on mowers have greater
complexity and demand a higher level of care. Further
insight into these data need to be explored, as it may help
guide prevention efforts. It may potentially guide prehospi-
tal triage in directing patient care to dedicated trauma
centers.
Likewise, data for cost analysis are not presented here, yet
it is relevant to the discussion of pediatric lawnmower
injuries. In 2004, Loder et al reported a case series of 53

Table 4 Ten-year national estimates: type of injury by emergency department disposition

10-Year national estimates (n 5 93,032)*
Diagnosis (%) Admitted (n 5 5,151) Discharged (n 5 87,881) RR (95% CI) P value
Burn 340 (6.6) 12,218 (13.9) .45 (.41–.50) ,.0001
Amputation 1,608 (31.2) 1,918 (2.2) 11.5 (11.00–12.10) ,.0001
Soft tissue injury 197 (3.8) 21,226 (24.2) .13 (.12–.15) ,.0001
Laceration 1,279 (24.8) 29,401 (33.5) .67 (.63–.71) ,.0001
Foreign body 188 (3.6) 3,108 (3.5) 1.03 (.89–1.19) .67
Fracture 1,086 (21.1) 6,974 (7.9) 2.82 (2.64–3.00) ,.0001
Other 453 (8.8) 13,036 (14.8) d d
d 5 Other, includes multiple injuries and RR calculations do not have clinical relevance.
*Attrition due to missing data regarding emergency departments disposition.
732
children with lower-extremity amputations and showed that
80% of their amputees sustained injuries, whereas using ride-
on lawnmowers. Prosthetic costs from the time of injury to
the age of 18 years ranged from $73,140 to $116,040 US
dollars per single lower-extremity amputation. Furthermore,
using NEISS data to estimate the number of pediatric
amputations per year because of lawnmowers, the annual
burden for prosthetic costs was estimated to range between
43.88 and 75.42 million US dollars.15
The NEISS data represent a probability sample used to
generate national injury estimates and not actual national
injury occurrence. Nonetheless, NEISS is a well-
established database since 1973, and its accuracy has
been validated for multiple consumer product-related in-
juries. It has the benefit of having been the data source for
previous national analyses on LMI which facilitates
comparisons across time.
Conclusions
Despite the previously mentioned limitations, our data
support a robust conclusion that the estimated annual
incidence and injury patterns of LMI in children have
remained unchanged over the past 2 decades. Reinforce-
ment of prevention strategies and manufacturer redesign of
lawnmowers are long overdue.
Acknowledgments
Study conception and design, analysis and interpretation
of data, and critical revision were done by M.B. and A.F.
Acquisition of data and drafting of article were carried out
by M.B.
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