PEDIATRICS Vol. 105 No. 3 March 2000, pp. 615-619

Snowmobile Injuries and Deaths in Children: A Review of National Injury Data and State Legislation

Manda R. Rice, BA, Lynn Alvanos, RN, BSN, and Brian Kenney, MD, MPH

From Pediatric Trauma Services, Toledo Children's Hospital, Toledo, Ohio.

	ABSTRACT

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Background.  Snowmobiling is a popular family sport, with annual expenditures over $9 billion. The size and speed of snowmobiles make them potentially dangerous to children. Pediatric snowmobile-related trauma has not been studied in the United States.

Methods.  We analyzed 291 pediatric snowmobile- related injuries and 75 deaths reported to the Consumer Product Safety Commission from 1990 to 1998. We reviewed snowmobile legislation in the states that reported at least 1 death to the Consumer Product Safety Commission during this time period.

Results.  The most common sites of injury were the extremities (48.8%) and the head, neck, and face (28.2%). Head and neck injuries were the predominant cause of death (66.7%). The most common diagnosis was contusion/abrasion (30.9%), followed by laceration (22%), fracture (20.3%), and strain/sprain (14.4%). Nonfatal injuries most often involved ejection from the snowmobile (26.1%), but striking a stationary object was the most common mechanism in fatal crashes. The review of state legislation revealed that few age restrictions or helmet laws exist. Children as young as 8 years old may legally operate a snowmobile in some states. Often, restrictions do not apply to snowmobile use on private property, where 43% of pediatric snowmobile-related injuries occurred.

Conclusions.  Head, neck, and face injuries are common nonfatal injuries and are the most common cause of death. State legislation often lacks age restrictions on private property, and laws requiring helmet use are rare. Legislators have not addressed the dangers of pediatric snowmobile-related injuries. Helmet laws and age restrictions similar to those enacted for motorcycle riders are necessary and appropriate.  Key words:  pediatrics, trauma, off-road motor vehicle, consumer product safety, accident prevention.

Snowmobiling is a popular winter sport in the United States and around the world. In 1998, there were >2.3 million registered snowmobiles in the United States alone.¹ The economic impact of snowmobile use is tremendous, with total annual expenditures on equipment, clothing, accessories, and vacations in the United States and Canada over $9 billion. Because 94.5% of snowmobilers surveyed considered it a family sport, and because the majority of snowmobile owners are married and have children, the education and safety of child snowmobilers is a concern for the injury prevention community.¹ Studies of snowmobile-related injuries have been published,^2-5 but few studies have been devoted to injuries occurring in the pediatric population. The American Academy of Pediatrics (AAP) recognized the problem of snowmobile-related injuries in children in 1988 by publishing a statement on the subject: 18% of snowmobile-related injuries were in children younger than 14 years old and 48% occurred in people between 15 and 24 years old.⁶ These findings led to a recommendation, "Snowmobiles are inappropriate for use by children and young adolescents and should not be used by children younger than 16 years old." The AAP also recommended that riders over 16 years old be required by law to be licensed and that helmets be worn at all times.

Because a significant number of snowmobile- related injuries occur in children, we performed an in-depth analysis of pediatric injury data collected by the Consumer Product Safety Commission's National Electronic Injury Surveillance System (NEISS) and fatality data contained in the National Injury Information Clearinghouse Death Certificate Data Files for 1990-1998. We also studied snowmobile-related legislation to assess whether state law supports the recommendations of the AAP on age restriction, licensing, and helmet use.

	METHODS

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The US Consumer Product Safety Commission (CPSC) monitors injuries and deaths related to over 800 specific products. Data were requested from the National Injury Information Clearinghouse of the CPSC from both the NEISS and the Death Certificate Data Files. NEISS, established in 1972, collects data from a probability sample of hospitals with emergency rooms in the United States and its territories. The data collected from these hospitals are then used to estimate the number of product-related injuries treated in emergency rooms in the entire nation. The sample of 91 emergency departments from which data are collected was updated in 1990 and again in 1997. Changes in caseloads and the opening and closing of hospital emergency departments require that the sample of hospitals be updated regularly to best reflect the national picture.

Data were requested from NEISS for January 1990 to April 1998 for product code 1290 (snowmobiling: activity, apparel, or equipment). The data collected included treatment date, age, gender, diagnosis, body part injured, disposition, location of accident, other consumer products involved with accident, and comments reported by the hospital. We established several broad categories of mechanism of injury by reviewing those used in other studies^2,3 and by reviewing the NEISS data itself. Some comments were not sufficiently detailed to allow categorization. A mechanism could be deduced in 83% of the incidents.

Data were requested for January 1990 to April 1998 for the Death Certificate Data Files. The Death Certificate Data Files are compiled from voluntary reports by state health departments and are not statistically representative of the national population. The data collected included the date of death, age, gender, race, city and state, and remarks. Using the remarks, we deduced a mechanism of injury for 80% of the deaths. Additionally, we deduced the body part injured using the general categories of head, neck, or internal organ injury for 90% of the deaths. Statistical software from the Centers for Disease Control and Prevention EpiInfo 6.0 was used to analyze both the NEISS and Death Certificate Data File data.

Snowmobile-related legislation was compiled from sources available either on the World Wide Web via the Internet or from law libraries. Legislation from all 18 states reporting at least 1 death to the CPSC was analyzed. Over 60% of reported deaths occurred in just 5 states (MN, WI, MI, AK, and NY); the relevant legislation from these states only is reported here.

The number of snowmobiles registered was provided by the American Council of Snowmobile Associations (contact information appears in "Acknowledgments").

	RESULTS

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Injuries

Between 1990 and 1998, 291 incidents involving snowmobiles and children 17 years old and under were reported to NEISS. The NEISS data included only 2 deaths, neither of which was repeated in the Death Certificate Data Files. Boys were involved in 212 (73%) incidents. The median age of victims was 13 years old. Of the injuries, 27% occurred in children 10 years old and under. Snowmobile-related injuries occurred most frequently in the months of January (33%), February (22%), and December (19.9%). Some minor injuries occurred in non-winter months, often associated with the transport or maintenance of snowmobiles (Fig 1). One death occurred in June in the state of New York in which a 6-year-old boy struck a house while operating a snowmobile.

View larger version (19K): [in this window] [in a new window]   Fig. 1.   Occurrence of pediatric snowmobile injuries.

Although most patients were treated and released from the emergency department (90%), 7.6% of patients were admitted to the receiving hospital, 1.4% were transferred to another hospital, and 1% were dead on arrival or died in the emergency room.

The most common diagnoses in the NEISS data were contusion/abrasion (30.9%), followed by laceration (22%), fracture (20.3%), and strain/sprain (14.4%, Table 1). The extremities were the most common sites of injury: upper extremity (28.5%) and lower extremity (20.3%, Table 2). Collectively, injuries to the head, neck, and face accounted for a large proportion of injuries (28.2%). Concussion and internal organ injury accounted for <5% of diagnoses.

The most common mechanisms of nonfatal injury were being thrown or flipped from the snowmobile (26.1%; Table 3), striking a stationary object (24.4%), and injuries caused by striking the machine (dashboard, console, windshield, or handlebars) or catching a body part in the engine or track of the snowmobile (11%). Another frequent mechanism of injury involves pulling passengers behind a snowmobile in a sled or inner tube (8.2%). In 17.2% of the cases, a mechanism of injury could not be determined from the description given.

Fatalities

Of the 75 reported deaths, 76% were males and 24% were females. The median age of the deceased was 14 years old. Striking a stationary object was the mechanism of injury in 42.7% of the cases (Table 3), with 10% of victims being thrown or rolled over by the machine, and 10% hitting another snowmobile. A mechanism of injury could not be deduced in 20% of the cases. Of the deaths caused by hitting a stationary object, 14 children (54%) struck a tree, whereas the other 46% struck objects, such as fences, wires, and buildings. Head and neck injuries were the most frequent cause of death (66.7%; Fig 2). Internal organ injuries (20%) and drowning (subsequent to falling through ice; 4%) account for the rest of fatal injuries for which the cause could be determined. In 9.3% of the cases, a cause of death could not be determined from the information available.

View larger version (31K): [in this window] [in a new window]   Fig. 2.   Pediatric snowmobile-related deaths.

Table 4 shows the states where snowmobile-associated pediatric deaths occurred between 1990 and 1998. The number of registered snowmobiles, also shown in Table 4, roughly correlates with the number of reported deaths. Minnesota (21.3%), Wisconsin (14.7%), Michigan (12.0%), Alaska (8%), and New York (6.7%) reported the largest number of deaths.

Legislation

A review of state legislation about snowmobiles was performed to determine the types of restrictions placed on young snowmobile riders. Snowmobile-related legislation is less restrictive than laws governing the use of other motor vehicles (Table 5). Of the 18 states that we studied, 11 (61%) had no helmet requirements. Seven states have some type of helmet law, although the law often applies only to those under 18 years old and does not apply to operation on private property. Age restrictions are also lacking in most states, and the age restrictions that are in place are not applicable to private property.

	DISCUSSION

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We analyzed pediatric snowmobile injuries and deaths reported to the NEISS of the CPSC and Death Certificate Data Files from 1990 to 1998. Although different in their scope, these 2 data sources show important consistencies in pediatric snowmobile- related injuries. Both the median age and gender distribution were similar in the 2 datasets. Studies consistently show that males are the predominant victims in snowmobile accidents. Among pediatric victims in a Manitoba hospital, 71% were male.² In a study of trauma victims treated at the Mayo Clinic, 90% were male.⁷

Consistent with several other studies, our data show a predominance of lower extremity injuries both in adults^7-10 and in children.² Safety engineers should recognize the injury patterns of various sizes of snowmobile riders to improve the safety of snowmobiles as recommended by the AAP.⁶

Head and neck injuries are commonly reported to be a leading cause of death^4,5,10 in adult studies. Our study highlights the problem of head injuries in children not only as a cause of death but also for nonfatal injuries.

Because the predominant mechanism in fatal crashes was striking a stationary object, the use of marked and groomed snowmobile trails should be encouraged. In a study of snowmobile deaths in Ontario, Canada, only 8% of deaths occurred on trails, versus 66% on lakes and rivers and 26% on roadways.¹⁷ There are currently over 230 000 miles of snowmobile trails in North America.¹ States should support the maintenance of these trails. In many states, snowmobile license and registration fees are already designated for trail maintenance.

Being pulled in a sled or inner tube behind a snowmobile was a significant mechanism of injury. A 1972 study in Montana reported that 40% of passengers injured in snowmobile-related accidents were being towed behind on a sled.³ More recently, a similar type of recreation in which inner tubes are pulled behind boats has been identified as an emerging source of injury in young people.¹¹ Legislators should address this problem by prohibiting this dangerous practice.

The Death Certificate Data Files include the state where the death occurred. Eighteen states had at least 1 reported snowmobile-related pediatric death between 1990 and 1998 (Table 4). Minnesota reported the highest number of deaths (16), along with Wisconsin (11), Michigan (9), and Alaska (6). The number of registered snowmobiles generally correlates with the number of deaths, although data are not available for Alaska (Table 4). It should be noted that the apparent geographic distribution could be affected by the voluntary participation of various health departments; not all health departments reported to the CPSC for the entire period.

Many laws are directed at youths actually operating the snowmobile, rather than riding as a passenger. All 5 states require registration of snowmobiles, and all of them require operators to report snowmobile accidents. The age at which a child may legally operate a snowmobile varies from state to state. In some states, children as young as 8 years old may legally operate a snowmobile on public property if they have completed a state-sponsored safety course. The size, weight, and potential for speed of snowmobiles make them difficult for a small person to control. The common mechanisms of injury and death (loss of control and striking a stationary object, respectively) may be explained by the inability of a child to control a heavy snowmobile.

An overlying theme of state legislation is that the operation of snowmobiles on private property is essentially unrestricted. The NEISS data include the location of an incident; however, in the 1990-1998 data, only 47% of the records included this information. According to available data, 42.5% of incidents occurred on private property (home, farm, or ranch), and 56.3% occurred in public places of recreation, sports, or other public property, indicating a need for safety legislation that applies to private property.

The review of legislation shows that few states have mandatory helmet laws for snowmobile riders, although head and neck injuries are the predominant cause of death in pediatric and adult snowmobile trauma. Although no studies about the efficacy of snowmobile helmets in reducing head injury incidence or severity were found, research in motorcycle and all terrain vehicle safety has shown that mandatory helmet laws can reduce the severity of crashes.^12-14 Consequently, mandatory helmet laws for motorcycle riders have been enacted in several states. Because snowmobiles are capable of attaining speeds similar to that of motorcycles and all-terrain vehicles, legislators should consider enacting helmet laws, age restrictions, and speed limits for snowmobiles that mimic those for other motor vehicles.

Another common feature of motorcycle and snowmobile use is the apparent association with alcohol abuse. Although many authors have documented the association between alcohol use and snowmobile trauma in the adult population,^4,8,1015-17 the relationship between alcohol and pediatric snowmobile crashes has not been explored. The high proportion of alcohol-related snowmobile crashes prompted 1 author to propose that mandatory helmet laws may be ineffective because of the inability of an intoxicated snowmobiler to make the responsible decision to wear a helmet.¹⁸ Of 75 pediatric deaths studied here, only 3 (4%) mention possible alcohol involvement; these were cases involving 16- and 17-year-old victims. The low percentage of alcohol-related pediatric snowmobile crashes may be attributable to incomplete reporting; the CPSC does not have a specific data field for contributing factors, such as alcohol or drug intoxication.

Aside from new safety legislation, better enforcement of existing laws may reduce the number of pediatric snowmobile-related injuries. An adult- directed community-based public education and police surveillance program was introduced in Northern Ontario with the goal of preventing snowmobile-related trauma.¹⁹ The major intervention focused on enforcement of snowmobile regulations by a group of extensively trained volunteers who patrolled local trails promoting safety and assisting police officers. The program effectively reduced the incidence of both injuries and deaths from snowmobile crashes. The authors do not address whether snowmobilers were cited for violating age restrictions, and no mention is made of the range of age of those charged with violations. Education and enforcement campaigns that are age-appropriate and targeted to specific at-risk groups would be most effective in reducing injuries and deaths.

There are several limitations to the data that were analyzed for this study. Rates of injury are impossible to infer because neither the number of people that ride snowmobiles nor the number of miles that are traveled is known. Also, geographic information is not available for the NEISS data and attributable to the voluntary submission of death data, geographic variation in incidence cannot be determined. The voluntary nature of the death certificate data could lead to over- or under-representation of deaths according to reporting habits.

Other significant limitations to the NEISS and Death Certificate Data Files are the lack of collection of data on operator status and helmet use. Information about whether the victim was a passenger or the operator of the snowmobile is not collected specifically. Very few of the narrative descriptions of incidents and deaths allowed a determination. This information would be advantageous in tracking the number of children operating snowmobiles illegally and could guide legislation about age restrictions for operators. Also, the CPSC does not consistently record whether a helmet was worn, so the frequency of helmet use among the victims in this study could not be determined accurately. In this study, a total of 12 records indicated that the victim was wearing a helmet and 5 records indicated that the victim was not wearing a helmet. Collection of this data would be useful for tracking injury severity and outcome and shaping helmet legislation.

	CONCLUSION

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Snowmobile injuries in children continue to be a significant cause of morbidity and mortality. The CPSC estimates that over 12 600 snowmobile-related injuries occurred in 1997 alone.²⁰ Children under 14 years old represented >10% of these cases. Although most children are treated for relatively minor injuries to the extremities, many children suffer severe fractures and internal organ injuries, some fatal. The data presented and our review of state legislation indicates that these recommendations by AAP, published a decade ago, have not been adopted. The 1988 Snowmobile Statement is currently being updated by the Committee on Injury and Poison Prevention of the AAP. Pediatricians should promulgate the recommendations to their patients and support legislation to tighten restrictions on young riders, adopt mandatory helmet laws, and prohibit pulling people behind snowmobiles. The effectiveness of these safety laws should be evaluated by thorough research in both pediatric and adult populations.

	ACKNOWLEDGMENTS

We acknowledge the assistance of Ida Harper-Brown, Technical Information Specialist at the National Injury Information Clearinghouse; and Dr Jagger, ProMedica Health System, for critically reviewing the manuscript.

Snowmobile safety literature may be requested from the International Snowmobile Manufacturers Association, 1640 Haslett Rd, Suite 170, Haslett, MI 48840; 517-339-7788.

Another excellent resource for snowmobile safety information is the National Children's Center for Rural and Agricultural Health and Safety, 1000 N Oak Ave, Marshfield, WI 54449; 888-924-7233. Available at: http://research.marshfieldclinic.org/ children/.

For snowmobile organizations in your state, contact the American Council of Snowmobile Associations, 271 Woodland Pass, Suite 216, E Lansing, MI 48823; 517-351-4362.

	FOOTNOTES

Received for publication Jun 28, 1999; accepted Nov 18, 1999.

Reprint requests to (M.R.R.) Trauma Services, Toledo Children's Hospital, 2142 N Cove Blvd, Toledo, OH 43606. E-mail: manda.rice{at}promedica.org

	ABBREVIATIONS

AAP, American Academy of Pediatrics; NEISS, National Electronic Injury Surveillance System; CPSC, Consumer Product Safety Commission.

	REFERENCES

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