In New Zealand, horse riding is a popular recreational activity with participation rates of 2.6% in the overall population.1 However, it is considered a dangerous sport which rivals rugby, motor racing and cycling, and when normalised for hours of activity results in higher hospital admission rates than other high-risk activities, such as motorcycle riding.2 Injuries resulting from interaction with horses are common, can be severe and have been well-documented internationally,3–7 and in New Zealand.8 While New Zealand participation rates in equestrian activity have decreased over the years, there is no up-to-date data on the number or severity of equine-related injuries, or whether they are also decreasing. Thus, the current extent and cost of the problem is unclear.

Horses pose a significant risk and people are most commonly injured during falls. These falls largely result in damage to the limbs/extremities, head,5–7,9 traumatic brain injury (TBI)10,11 or spinal cord injuries (SCI).12 Equestrian activity is considered one of the greatest contributors to sport-related TBI,13,14 posing a significant public health burden.11 While mortality rates for equine-related injuries are low, they commonly result from TBI for adults4 and children.15

Studies in New Zealand have shown similar injury patterns to those found overseas; with injuries being female dominated, largely resulting from falls and most to the head/face.8,16–18 Bentley, Macky and Edwards (2006) analysed Accident Compensation Claims (ACC) over a one-year period in New Zealand and found horse riding to be the most dangerous of the adventure tourism sports they examined, followed by mountain biking, tramping/hiking and surfing.16 Another New Zealand study found most injuries were to those under 19 years old and New Zealand Europeans (88.6%) while Māori had lower injury rates (11%).17 Smartt and Chalmers, linking New Zealand ACC data with nationwide public hospital discharge data, showed injuries occurring on farms and to those 35–49 years old to be common, with injuries to bystanders also significant (21%). The average age-standardised hospitalisation injury rate was 233 per 100,000 (95% CI: 210–259).18 They did not report on ethnicity data but found the average cost for initial hospitalisation was NZ$3,000.18 According to Accident Compensation New Zealand (2018) statistics, the cost and number of compensation claims for horse riding injuries has increased since 2012, with claims totalling more than NZ$20 million for the year ending June 2017.19

To assist targeted injury prevention strategies, this paper will provide up-to-date data on equine-related injuries for those patients hospitalised in the Midland region of New Zealand. It will also determine 1) if the number and pattern of injuries is changing; 2) what the present cost of injuries is; and 3) identify any at-risk groups or ethnic group differences in injury patterns and outcomes. The Midland region makes for a good site for an examination of horse-related injuries due to the large geographical area and demographic profile that is similar to New Zealand as a whole.20

Methods

Patients

All patients admitted to any hospital within the Midland region in a five-year period (1 January 2012–31 Dec 2016), as a direct result of an equine-related trauma, were identified from the Midland Trauma registry. This was done through searches of horse-related presentations using relevant keywords: ‘horse’, ‘pony’, ‘jockey’, ‘trot’, ‘polo’, ‘rodeo’ and ‘equestrian’ from the free-text memos. Patients were excluded if the injury occurred from a non-equine horse (eg, rocking horse) or the injury occurred from equipment associated with horses, such as a cart, without the horse present.

The Midland region is located in the middle of the North Island of New Zealand and comprises five district health boards (DHBs): Bay of Plenty, Lakes, Tairawhiti, Taranaki and Waikato. Data from Tairawhiti district were excluded from the study as they were a later addition to the registry. The included DHB boundaries hold a total population of 849,774 (Census 2013, NZ Stats), with approximately 20–24% identifying as Māori, and take in the major population centres of Hamilton, New Plymouth, Rotorua and Tauranga.21 Injuries were categorised based on injury memo as the following ‘mechanisms’; fall (falls from horse or bucked/thrown off), kicked, or knocked, by a horse (includes being hit, struck, pushed, crushed or landed/rolled on by the horse), injured by riding equipment (caught in reins, stirrups, etc.), trampled by the horse (including stomped or stood on), injured by non-riding equipment (rope, horse float, gate etc.) and other (eg, injured while dismounting, fell over while leading/working with horse, bitten, or horse vs vehicle).

Measures and analysis

Demographic, mechanism, injury and outcome data were retrieved for analysis. Outcome data included injury location (by DHB region), injury severity score (ISS) (major >12 or minor <13), position of injured person (mounted on the horse or unmounted), activity (work vs non-work), length of hospital stay (LOS) (days) and whether the patient required surgery or not. Other outcomes included the number of fatalities and TBIs, and the Abbreviated Injury Scale (AIS) scores.22 Direct in-hospital costs were analysed only for patients admitted to Waikato Hospital. Costs were drawn directly from the hospital costing system and linked to trauma admissions based on patient details and hospital admission/discharge dates to provide total cost at the individual trauma admission level. Fisher’s exact test or Pearson’s chi-square test were used for categorical variables, and Student’s t-test (as appropriate) were used for continuous variables and a P<0.05 was considered significant.

Results

There were 701 patients identified as having an equine-related injury. These patients made up 3.5% of the total trauma events recorded in the registry (19,781) across the five-year period. Table 1 presents the sample characteristics by injury mechanism.

The most common mechanism of injury was a fall followed by being kicked or knocked by the horse while 30.9% (185) of injuries were to bystanders or animal handlers; this includes six riders who were attempting to mount while injured. Both genders generally followed the same pattern for mechanism of injury, except for being injured by riding equipment being higher for males. The mean age for the whole group was 36.5 years (SD 19) with a median age of 38 years (IQR 9–51) and the female mean age (35.0, SD 18.3, median 37, IQR 17–49, n=485) was younger than that of males (39.7, SD 20.7, median 40, IQR 22–57, n=216). Children were more frequently injured by a fall or trampled, when compared to adults. The greatest mean age was for those injured by non-riding equipment (49 years) and the youngest for those injured by being trampled (32 years).

The group were predominantly New Zealand European/other European (81.6%, n=572) compared with 15.1% Māori (n=106), with the remaining (23) being other. Nearly half (47.1%) of all injuries occurred in the Waikato DHB and kicks and knocks were more common there than in other regions.

The mean ISS for all events was 5 (median ISS=4, IQR=1), while only 6.6% were major events (ISS>12). There was no significant relationship between having a major or non-major admitted trauma for children compared to adults. However, there was a significant relationship between gender and having a major or non-major admitted trauma (Chi Square test, χ2=15.3, df=1, P<0.0001).

Approximately 20.4% (143 patients) of those injured also had a secondary mechanism of injury, of which over half of these injuries (55%) were in direct contact with the horse, eg, kicked, trampled or knocked. The most frequent secondary mechanisms were being trampled on and being knocked; 22.4% and 23.8% respectively. Of all those with a secondary mechanism nearly three quarters (73.4%) occurred following a fall.

The number of equine-related trauma events by five-year age band and gender are shown in Figure 1.

Figure 1: Age and gender distribution for all equine-related trauma events in the Midland Region over the five-year period (2012–2016).  

For the majority of age bands under 60 years, females suffered substantially more trauma events than males with peaks occurring at different age bands across gender. A Chi Square test showed no significant relationship between gender and falls, but there was a significant relationship between gender and non-fall equine injury (χ2=6.232, df=1, P=0.01). Over the five-year period, there was a slight increase annually (non-significant) in the number of equine injuries ranging from 139 in 2012 to 147 in 2016. Average monthly event volumes varied significantly across the year (χ2=39, df=11, P<0.05) ranging from 7 during July to 18 during January (across the five years, July = 35 events, December = 91 events). Events also varied significantly across the days of the week (χ2=26, df=6, P=0.0002), a weekday daily average of 18 events and during the weekends there were 27 and 23 such events, respectively. However, this pattern was more pronounced for females than males.

There were no fatalities in this cohort and 88 patients (12.5%) were diagnosed with a TBI, with two-thirds being female (67.0%). Nearly 14% (12) of all TBIs had a serious or severe AIS score of 3–4. TBI events by mechanism were as follows: fall from horse 70 (79.5%), kicked 9 (10.2%), and knocked 4 (4.5%). There were a total of 65 individual skull and jaw fractures diagnosed (13 vault of skull, 8 base of skull, mandible 14, orbit & zygoma 15, maxilla and nose 15).

Nearly half of individual injuries were to extremities (arm/hand/shoulder 24.5% and leg/foot 22.8%) with injuries to thorax, head, face and spine each approximately 10%. The remaining body regions (abdomen/pelvis, external and neck) together made up less than 10% of all injuries. When broken down by mechanism, the pattern by body region was generally consistent with the overall mechanism data (see Table 1). Of note was that over a quarter of injuries to the face (26.9%), and 35.2% of abdominal injuries, resulted from kicks. Additional examination of injuries to the body regions (Table 2) shows that two-thirds of all upper extremity injuries scored 2 (moderate). The most severely injured body region was the thorax, with over 40% of thoracic injuries ranging from AIS 3 (serious) and above. Most thoracic injuries were caused by fall from horse (78.9%). Injuries to the spine also tended to be more serious. Counter to this, injuries to the face, neck and external areas tended to be minor, AIS 1.

Table 1: Equine-related trauma (events, %) in Midland Region* 2012–2016, by mechanism.

*Excludes Tairawhiti DHB, late addition to Midland Trauma Registry.

Table 2: Equine-related trauma (Events, %) in Midlands* 2012–2016, Body region injuries by AIS Severity score, n=1,472.

*Excludes Tairawhiti DHB, late addition to Midland Trauma Registry.

Further examination of the data showed that those who fell from the horse, or were kicked or knocked, received a more severe injury score (AIS), with the majority scoring AIS 2 and above. The most severely injured (AIS 4–5) fell from or were knocked by the horse. For each remaining mechanism, more than half of the injuries were minor (AIS 1).

Direct costs could only be calculated for patients admitted to hospitals within Waikato DHB and was estimated to be NZ$2.6 million for 332 costed patients (100% of all patients were costed), shown in Table 3.

Table 3: Equine-related trauma, total in-hospital costs (NZ$, rounded) to Waikato DHB (2012–2016) by mechanism (332 costed patients).

The costliest 10% of cases accounted for 36.9% of the overall cost ($929,285) while the average cost per case (where costed) was NZ$7,805. Injuries to males cost more on average ($8,901) than females ($7,391). Adult injuries made up 92.5% of the costed patients and were more expensive on average than children. Lastly, over three quarters (76.3%) of the total cost came from recreational equine injuries.

Discussion

The findings here are that majority of riders (70%) are injured through falling, and are female, with the most injured body regions being extremities (limbs) which is all supported by past research in New Zealand,8,17,18 and abroad.5 It is unsurprising that females dominated the injury statistics here as they have also been found to have much higher engagement in equestrian activities than males in New Zealand;1 of those participating in horse-riding in the previous 12 months, 70% were female. Females were also younger on average than their male counterparts with an early peak for 10–14 year-olds, similar to that found by others in New Zealand.17,18 Thus, this research shows little change in the pattern of equine-related injuries in New Zealand.

Another group at risk of injures are working males, who are more frequently kicked than injured by other mechanisms. This was also found by John et al.8 Additionally, gender was significantly related to having a major or non-major admitted trauma, and male injuries cost more on average than females for those hospitalised in the Waikato DHB. Further work should aim to determine the relationships and causes between gender and severity (major versus non-major admitted) and mechanism for equine-related trauma. If working males are at greater risk of equine injury, prevention strategies should include workplace health and safety frameworks, as suggested by Chapman and Thompson.23

A positive and surprising finding was the lack of hospital fatalities in the five-year study period. In New Zealand, Bentley et al (2006) reported three deaths nationwide resulting from horse riding in one year,16 while Northey (2003) reported 16 fatalities over seven years.17 Research conducted in the 1990s in New Zealand24 found higher National rates of fatalities due to equine-related injuries, 54 in a 10-year period (death rate of 0.17 in 100,000 persons per year), and even higher was found by Hume and Marshall (1994) (death rate of 0.64 in 100,000 persons per year).25 However, both these studies included coronial data. Injury severity may also be decreasing in New Zealand with the mean ISS here (5) being considerably lower, and less patients being severely injured (ISS>12), than that found previously,4,6,10,13,26,27 but is similar to one New Zealand study.8 Days spent in hospital (LOS) was also found to be lower here (mean 3.4, median two days) than reported previously.7,8,10,26,27 Given lower injury severity, LOS and fatality rate, it is encouraging that injury prevention strategies and public safety messages may be impacting on those who spend time around horses, but further research is needed to confirm this.

While no significant differences were found between ethnic groups of this injured cohort, 15.1% were Māori (n=106), which is much higher than reported horse riding participation rates for adult Māori in New Zealand (4%).1 Although Northey (2003) found lower rates of injured Māori (11%) than here, she found that injuries among Māori men were particularly higher than females.17 Māori are also overrepresented in sports-related TBI14 and have also been found to have higher rates of major trauma injury.28 The difference in participation versus proportion of Māori injured here may be accounted for by the fact that although few Māori participate in horse riding, more might work in the horse industry in non-riding positions, ie, farrier, stable hand etc. More investigations are needed to confirm this.

Recent US research suggests that over a quarter of equine-related injuries occur while unmounted.6,7 This is in line with the present findings and other New Zealand-based research.18 Although a recent study in the UK found only 12% of those injuries were unmounted5 similar to that of another New Zealand study (15%).17 The differences in those unmounted across these studies may be due to being a different population that has a higher rural proportion with more exposure to horses. Unfortunately, the data fields did not allow accurate analysis of location of injury and so this area requires further investigation. However, given that over a quarter of those injured here were off the horse, ie, bystanders or handlers, these groups of people should be targeted for future injury prevention efforts as well as others who spend time around horses.29

Our findings suggest that although equine-related injuries only made up 3.5% of all trauma admissions during the study period, the financial burden and impact on morbidity is extensive. The average hospitalisation cost is more than 2.5 times that reported in 2003.18 Unfortunately, due to the level of details available, the present study was unable to determine which injuries were due to other people, such as bystanders, handlers or other equestrians. Head injuries (10.3%) and TBIs (12.5%) continue to be a concern.14

The study is unique in that it utilises a continuous dataset that represents all hospitalised in-patients of all ages and injury severity within a New Zealand health region, including estimates of the significant burdens of cost and bed utilisation. The Midland Region is also representative of New Zealand as a whole in terms of demography and rurality.20 This study does not represent a population sample of all equine-related injuries because it does not include non-admitted persons, nor pre-hospital deaths from equine injuries. Notwithstanding these limitations, this study provides an up-to-date account of the rate and pattern of equine-related injuries that can now be used for targeted interventions and health service planning.

Conclusions

Females and falls continue to dominate in equine-related injuries posing significant cost and public health burden. However, these results indicate that injury prevention strategies may be impacting on those who work with or ride horses, as the severity of equine-related injuries is less than previously reported. While the rate of Māori injured is much higher than reported participation levels, additional research is required to better understand the causative reasons. Further work should also extend to describing the causation of equine injuries in more detail within the at-risk groups to help reduce this significant and potentially preventable burden on the health system, patients and the community.

‍