2013

http://informahealthcare.com/bijISSN: 0269-9052 (print), 1362-301X (electronic)

Brain Inj, 2013; 27(12): 1450–1453! 2013 Informa UK Ltd. DOI: 10.3109/02699052.2013.823664

ORIGINAL ARTICLE

Recreational-related head injuries in Qatar

Ashok Parchani1,2, Ayman El-Menyar2,3, Hassan Al-Thani1, Mazin Tuma1,2, Ahmad Zarour1, Husham Abdulrahman1,Ruben Peralta1, Mohammad Asim3, & Rifat Latifi1,2,4

1Section of Trauma Surgery, Hamad General Hospital, Doha, Qatar, 2Clinical Medicine, Weill Cornell Medical College, Doha, Qatar,3Clinical Research, Section of Trauma Surgery, Hamad General Hospital, Doha, Qatar, and 4Department of Surgery, University of Arizona,

Tucson, AZ, USA

Abstract

Background: The incidence of recreation related-injuries (RRI) among the physically activepopulation is increasing. This study aimed to analyse frequency and characteristics of RRI inQatar.Methods: A retrospective chart review was conducted for all patients with head injuries whosustained a RRI and were admitted to the trauma unit between 2008–2011. Patients’demographics, injuries, complications and mortality were analysed.Results: Of 1665 cases of head injury, 107 (6.4%) had RRI. The majority of cases were males withmean age of 27� 12, injury severity score of 14� 8 and head abbreviated injury score of3.2� 0.9. Mechanisms of injury included All-Terrain Vehicle, Jet-skiing, football and water-boat.Patients sustained RRI mainly had contusion followed by subarachnoid haemorrhage, subduraland epidural haematoma. Upper extremities and the chest were the most frequently associatedinjuries. Severe head injuries were observed in 18% of patients with Glasgow Coma Score58.Median length of stay was 4 (1–67) days. The incidence of RRI was highest amongst Asians(66%) and nationals (23%). The overall mortality among patients with RRI was 7%.Conclusion: RRI causes significant morbidity and mortality. An urgent need is recommended forlegislative amendment and public awareness for safety regulations during recreational activitiesinvolving potential risk of trauma.

Keywords

All-terrain vehicle, head injury, sports,recreational activities

History

Received 24 December 2012Revised 10 June 2013Accepted 21 June 2013Published online 7 August 2013

Introduction

Several studies from developed countries have highlighted a

substantial impact of sports and recreation-related head

injuries on public health [1–3]. According to the Center for

Disease Control and Prevention (CDC) report, the annual

incidence of sports and recreation-related head injuries

constituted 5% of the total sports-related injuries in the US

[4]. After motor vehicle crashes, sports-related injuries were

the second most common cause of concussions among

adolescents in the US [2]. Recreation and sports involving

all-terrain vehicles (ATVs), bicycling and playground activ-

ities possesses greater risk of traumatic head injuries and

admissions to the emergency department [4]. Recently ATVs

have gained increased popularity for the sports and recreational

activities worldwide. Extensive studies have reported poor

safety compliance during recreational activities responsible for

significant head injuries among the young male population [5–

8]. These studies also demonstrated higher rates of alcohol

intoxication and its contribution to ATV crashes [7, 8].

Generally, head, orthopaedic and facial injuries require

emergency services after an ATV crash [9]. Russell et al. [10]

found a greater association between severe closed head

injuries and paraplegia during ATV crashes. A recent study

from Qatar showed that ATV crashes are responsible for

severe injuries causing death and permanent disability [11].

Prior data showed that helmet use for all riders might reduce

the risk of death by 42% and the risk of non-fatal head injury

by 64%, respectively [12]. A population-based study from

the US found that states without ATV safety legislation had

a fatality rate of 0.17 per 100 000 persons, compared with

0.08 deaths per 100 000 persons in States with helmet and

other safety regulations [13]. Therefore, authorities in the US

have enacted helmet laws and restricted driving or riding

ATVs for children 516 years of age [13]. The information

regarding RRI in the Middle East is lacking and only

supported by a few small observational studies. Therefore,

more studies are needed to analyse the magnitude of RRI

causing significant morbidity and mortality, particularly

among a young age population, and to provide future

directions for implementation of injury prevention pro-

grammes. Herein, the aim is to analyse the incidence and

characteristics of RRI in Qatar, a rapidly developing country

in the Middle East.

Correspondence: Ashok Parchani, MD, Assistant-Director TICU,Sec t ion o f Tr a um a Surge r y, D ep a r tm en t o f S u rge r y,Hamad General Hospital, Doha, Qatar. Tel: 0974-55254263. Fax:+97444394031. Email: traumaresearch@hmc.org.qa

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Methods

A retrospective chart review was conducted for all patients

with head injury who sustained RRI and were presented to the

only level I Trauma Center in Qatar and admitted to the

trauma intensive care unit at the Hamad General Hospital

between January 2008 and July 2011. Patient charts were

reviewed for demographics such as age, gender, nationality,

details of injuries, Glasgow Coma Score (GCS), Injury

Severity Score (ISS), head abbreviated injury score (AIS),

interventions, complications, intensive care unit (ICU) length

of stay, use of protective devices and mortality. Further, as the

age group less than 30 years ideally constituted a physically

active population which is more likely to be involved in risky

leisure activities, therefore, this study has arbitrarily classified

age into two categories, i.e.530 and �30 years for the sake of

analysis.

IRB approval was received from the Medical Research

Center at Hamad Medical Corporation, Qatar to complete the

study, ensuring that the research met ethical standards.

Data were presented as proportions or mean� standard

deviation (SD), median and range as appropriate. Mortality,

ISS and GCS were compared between the age groups

(530 years and �30 years) using the student t-test for

continuous variables and Pearson chi-square (�2) test for

categorical variables. A significant difference was considered

when the p-value was less than 0.05. Data analysis was

carried out using the Statistical Package for Social Sciences

version 18 (SPSS Inc., Chicago, IL).

Results

Of the total 1665 cases of head injury, 107 (6.4%) were

identified as recreational-related (RRI). The majority of those

patients were males (87%), with an average age of 26.7� 12

years, ranging from 2–56 years (Figure 1). The most common

mechanism of injury was All-Terrain Vehicle (ATV; 90%),

followed by Jet-skiing (5%), football (3%) and waterboat (2%)

(Figure 2).

After initial trauma admission at the emergency depart-

ment, 39% were transferred to the ICU and 11% were shifted

to the operating room for emergency craniotomies (Figure 3).

Patterns of RRI mainly included contusion (29%), subarach-

noid haemorrhage (26%), subdural (25%) and epidural

haematoma (23%), respectively (Figure 4). The mean ISS

was 14� 8, whereas the head AIS was 3.2� 0.9. Severe head

injuries were observed in 18% of patients with GCS58. The

median length of ICU stay was 4 (1–67) days. The incidence

of RRI were highest amongst Asians (66%) followed by

nationals (23%) and Arabs (non-national; 11%) (Figure 5).

Ethanol intoxication was found in 10% of the patients of

Asian ethnicity. Moreover, severity (ISS & GCS) and

outcome were comparable according to the age (530 vs

�30 years) (Table I). The overall mortality in this study was

7% (5% in age530 and 10% in age �30).

Discussion

This is the first report from the Middle East that focuses on

the demographics and characteristics of patients with sports

and recreation-related head injuries (RRI). RRI causes

Series1, OR,11%

Series1, ICU,39%

Series1, Ward,50%

Figure 3. Emergency department disposition.

Series1, Jetship, 5%

Series1, ATV,90%

Series1,Boat, 2%

Series1,Football, 3%

Figure 2. Mechanism of injury.

Series1, SDH,25% Series1, EDH,

23%

Series1,Contusion, 29%

Series1, SAH,26%

Series1, IVH, 4%

Series1, ICH, 1%

Figure 4. Head injury types.

Series1, < 16yrs, 21%

Series1, 16-30 yrs, 40%

Series1, 31-45 yrs, 32%

Series1, > 46yrs, 7%

Figure 1. Age distribution.

DOI: 10.3109/02699052.2013.823664 Head injuries in sports 1451

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significant morbidity and mortality in Qatar, which is largely

neglected due to paucity of information. In this study, 6% of

patients who sustained a head injury had RRI with an overall

mortality rate of 7%. Physically active young males were

frequently involved in RRI injuries in the current study. These

findings are consistent with earlier studies from Canada and

the US [14–16]. Further, the type of recreational activities

differs according to the socio-cultural and geographic condi-

tions. An earlier study from Australia found a significant

correlation between geographic site and hospitalization with

sports-related injury, after adjusting for confounding factors

[17]. Harris et al. [15] reported hockey, cycling and skiing as

the most common sport and recreation-related activities that

are involved in severe head injuries which needs emergency

services. Qatar is a small peninsula (1.8 million people)

mostly comprised of sand deserts with surrounding coastal

areas. So, in this study, ATV (90%) and water-sports (7%)

were found to be the most common recreational sports

related-activities involving head injury. In addition, �3% of

the cases had football-related injuries, which might suffer

from under-reporting of sports-related injuries in the study.

ATVs are used largely as recreational vehicles; therefore,

safety should be a priority. From the early 1970s, ATVs have

been recognized as a significant cause of both morbidity and

mortality in children [18]. Adolescents and children primarily

of male gender have been associated with a higher risk of

injury [18, 19]. These findings are also consistent with these

reports. Traumatic head and facial injuries were the major

RRI in this series followed by injuries to the upper extremity

and chest, which is consistent with the previously reported

injury patterns [20–22].

Bowman et al. [20] showed that ATV riders without a

helmet suffered severe head injuries which require neurosur-

gical interventions. In addition, a higher number of ATV

riders without a helmet were admitted to the ICU, had longer

hospital length of stay and were shifted mainly to the acute

care rehabilitation facilities [20]. A study from California

recorded detectable alcohol levels in 21% of the patients

admitted with ATV injuries, of them 66% had alcohol levels

higher than the permissible limit for driving [23]. A Canadian

report showed that a large number of patients that sustained

head injury (67%) while riding an ATV had detectable blood

alcohol concentrations [22]. In contrast, only 10% of the

patients admitted with ATV injuries had detectable alcohol

levels in this study.

This study also confirms a high rate of severe injuries due

to RRI; as 39% of the cases requiring admission were

transferred to the intensive care unit and 11% of cases were

shifted to the operating room directly from the emergency

department. The majority (90%) of this cohort had ATV-

related injuries. Pelletier et al. [22] described the risk

of morbidity and mortality during ATV crashes. They

found significantly higher mortality in those who ride an

ATV without a helmet. Keenan and Bratton [24] also reported

a 6.5% mortality rate among young ATV riders who sustained

severe head injuries. The same study reported that 19% of

children who died from head injury were wearing helmets

while ATV riding [24]. Helmets may offer insufficient

protection in some situations, because ATVs are heavy and

can attain a relatively higher speed. Therefore, a selection of

helmets designed for off-road vehicles with additional

protection for the eyes and face provides more safety. In

addition, other protective gear such as over-the-ankle boots,

gloves, goggles and protective clothing should be used while

riding an ATV.

Population-based analysis on ATV-related deaths in the US

showed that states without any ATV safety legislation have a

collective death rate twice that of states with any safety

legislation [25, 26]. To date there is no legislation in Qatar

regarding the recreational activities such as a minimum

permissible age limit, compulsory helmet use, mandatory

training, licensing and registration or prohibition of three-

wheeled ATVs. Reports from the developed countries found

that the use of a helmet during an ATV ride decreases the risk

of head injuries and deaths [22, 26]. So, there is an urgent

need for legislative amendments for development and imple-

mentation of safety regulations for sports and recreational

activities in this community.

ATV riding is the most popular recreational sport in Qatar,

which is performed in sand dunes located outside the city.

Such recreational activities are away from the civil society,

which makes it difficult to monitor. Also, legal safety

regulations for an ATV are not yet strictly implemented.

However, there is a well-designed curriculum for obtaining a

driving license for a motor vehicle in Qatar. Therefore, a strict

implementation of off-road vehicle legislation is extremely

important. The legislation should dictate the minimum age to

operate ATVs, restricting passengers to the number for which

the vehicle is designed and mandate the use of helmets

specifically designed for off-road vehicles. The high inci-

dence of ATV-related head injuries in this study advocates

mandatory training for ATV riding, license restrictions based

on age, penalties for non-safety compliance and regulation for

joyrides. Also, there is a strong need for public awareness

Series1,Nationals, 23% Series1, Arabs

(Non-nationals),11%

Series1, Asians,66%

Figure 5. Nationality distribution.

Table I. Severity and outcome according to age.

530 years(61%)

�30 years(39%) p-Value

ISS, Median (Range) 10 (4–42) 10 (4–38) 0.51GCS, Median (Range) 15 (3–15) 15 (3–15) 0.98Head AIS, Median (Range) 3 (2–5) 3 (2–5) 0.99LOS, Median (Range) 5 (1–67) 4 (1–36) 0.10Mortality 5% 10% 0.23

ISS, Injury Severity Score; GCS, Glasgow Coma Score.

1452 A. Parchani et al. Brain Inj, 2013; 27(12): 1450–1453

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regarding the aggressive behaviour in leisure activities,

alcohol use and associated risks.

In addition, mapping of accident sites is essential to

identify the hotspots involved in ATV crashes. Also, special

attention and monitoring is needed in such hotspots during

weekends by the traffic department to promote safer recre-

ational sports. Further, it is the prime responsibility of parents

or caregivers as a member of the community to take all

essential precautionary measures to avoid ATV crashes.

Riding adult ATVs by young children or teenagers should

be discouraged by the family.

One of the limitations of the present study is the

retrospective nature, which lacks information regarding

potentially important risk factors such as driver’s behaviour

and type of ATV accidents. Another limitation is the small

number of cases for recreational-related head injuries.

Conclusions

Accidents during recreational activities, particularly ATV

crashes, are not uncommon. RRIs pose a significant threat to

the safety of the young population due to lack of safety

awareness and under-reporting of these incidences. Since

recreational activities are site-specific, it is possible to

implement and monitor safety regulations with customized

injury prevention initiatives in specified regions. This study

recommends an urgent need for legislative amendment and

public awareness for safety regulations during recreational

activities involving potential risk of injuries. Such strategies

should be actively promoted and implemented. In addition,

active community effort and monitoring by the parents is

needed for safe outdoor recreation, thus reducing the burden

on the healthcare system from injuries sustained from

recreational activities.

Acknowledgement

We thank all the Trauma surgery staff and Miss Monira

Mollazehi from database registry for their kind co-operation.

IRB approval was received from the Medical Research Center

at Hamad Medical Corporation, Qatar to complete the study

ensuring that the research met ethical standards.

Declaration of interest

The authors report no conflicts of interest. The authors alone

are responsible for the content and writing of the paper.

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