A 7-year-old male came to clinic after falling off monkey bars at school 45 minutes previously. He had no loss of consciousness and was otherwise well. The pertinent physical exam showed a well-appearing child with normal growth parameters who was holding his left arm. There was pain in the mid shaft with a small amount of generalized swelling. The rest of his examination was negative.
The radiologic evaluation revealed the diagnosis of a non-displaced diaphyseal fracture of the radius. The patient was casted and had followup arranged with orthopedics. This was the second fracture from the same playground in a few weeks. The physician asked the child about the playground and found out that there was little wood mulch under the structures, so he contacted the school about the playground conditions. He was told that the playground had been recently inspected and additional mulch was ordered. He recommended that in the meantime that the structure not be used and alternative activities be provided for the children. The principal said that he appreciated the telephone call and would take the recommendation back to the school district to see if the mulch could be available sooner.
About 200,000 children are injured each year on playgrounds costing an estimated 1.2 billion dollars. Most of the playground injuries are at schools and daycare centers and gender rates and age rates depend on the study. More injuries occur in the summer months. Rates of severe injuries varies depending on classification and the specific study conducted. Fractures, lacerations, contusion/abrasion, and strains/sprains all are common injuries. Falls contribute to about 80% of injuries. Between 1990-2000, 147 children died from playground injuries – 82 from strangulation and 31 from falls. The number decreased from 2001-2008 to 40 deaths with 27 due to strangulation and 7 due to head injury. Climbing equipment and swings cause the most equipment-related injures.
The National Program for Playground Safety has a quick checklist for parents.
The S.A.F.E. checklist stands for
“Supervision is present, but strings and ropes aren’t.
Adult presence is needed to watch for potential hazards, observe, intercede and facilitate play when necessary. Strings on clothing or ropes used for play can cause accidental strangulation if caught on equipment.
All children play on Age-appropriate equipment.
Preschoolers, ages 2 – 5, and children ages 5 – 12, are developmentally different and need different equipment located in separate areas to keep the playground safe and fun for all.
Falls to surface are cushioned.
Nearly 70 percent of all playground injuries are related to falls to the surface. Acceptable surfaces include hardwood fiber/mulch, pea gravel, sand and synthetic materials such as poured-in-place, rubber mats or tiles. Playground surfaces should not be concrete, asphalt, grass, blacktop, packed dirt or rocks.
Equipment is safe.
Check to make sure the equipment is anchored safely in the ground, all equipment pieces are in good working order, S-hooks are entirely closed, bolts are not protruding, there are no exposed footings, etc.”
More extensive checklists include:
- Adult Supervision
- Supervise children while they play.
- Make sure the equipment is age-appropriate.
- Remove drawstrings, bicycle and sports helmets, necklaces, hoods, etc. that can get caught on equipment. No drawstrings as they can potentially strangle a child especially on clothing for the head, but also on waistbands. Alternatives are to cut the strings just long enough to tie and then to also sew the drawstring in the center of the clothing so it cannot be pulled out too long.
- Never attach or allow children to attach, ropes, jump ropes, clotheslines, or pet leashes to play equipment; children can strangle on these.
- Report problems to the appropriate person so the they can be repaired.
- Surfaces around playground equipment should be filled with at least 12 inches of loose fill, such as wood chips, mulch, sand, pea gravel, or shredded rubber. Rubber matting that has been approved and installed correctly is also appropriate.
- Material that may have been moved during normal use should be replaced at frequent intervals. Dirt, asphalt and concrete are not appropriate surfaces but can “filled in” with appropriate materials. Specific information can be found in the CPSC public playground safety handbook.
- Chromated copper arsenate or CCA is a chemical that helps prevent wood rot. It was used from the 1930’s to around 2003/4 in the United States. It can be difficult to tell if the wood is treated or not, so contacting the manufacturer may be necessary. If unsure, assume it is and appropriate removal should be done.
- Most stationary equipment should have a “use-zone” of at least 6 feet in all directions. For swings, the use zone extends back and forth and at least twice the height of the suspending bar.
- Stationary equipment more than 30 inches high should be spaced at least 9 feet apart from another piece of equipment.
- Any equipment openings should be less than 3.5 inches apart or more than 9 inches to prevent body part entrapment
- Guardrails should surround all elevated platforms and ramps beginning at 29 inches of height.
- Check for sharp edges or pointed edges on the equipment. Wood equipment should be without splinters or rot. Check the temperature of the equipment to prevent burn injuries.
- Check for dangerous hardware such as open “S” hooks (more than a dime width) or protruding bolts (more than 2 bolt threads).
- Playground Area
- Check for trip hazards such as rocks, tree roots, concrete footings etc.
- Check for hazards such as broken glass or metal on the ground.
The Consumer Product Safety Commission has two handbooks available on home playground safety and public playground safety
Questions for Further Discussion
1. Name some health issues that playgrounds help to treat or prevent?
2. Where can you find the legal requirements for playgrounds in your state or location?
3. Where can you find certified playground safety inspector?
- Disease: Fractures | School Health Child Safety
- Symptom/Presentation: Upper Extremity Trauma
- Specialty: General Pediatrics | Preventive Medicine and Health Maintenance | Orthopaedic Surgery and Sports Medicine
- Age: School Ager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Fractures
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Centers for Disease Control. Playground Injuries: Fact Sheet. Available from the Internet at http://www.cdc.gov/HomeandRecreationalSafety/Playground-Injuries/playgroundinjuries-factsheet.htm statistics (rev. 1/19/2009, cited 11/4/11)
National Safety Council. Playground Safety. Available from the Internet at www.nsc.org/news_resources/resources/documents/playground_safety.pdf (rev. 4/2009, cited 11/4/11)
National Program for Playground Safety. Research – Injuries. Available from the Internet at http://www.playgroundsafety.org/research/index.htm (rev. 2006, cited 11/4/11)
National Program for Playground Safety. Quick Checklist for Parents. Available from the Internet at http://www.playgroundsafety.org/safety/checklist.htm (rev. 2006, cited 11/4/11)
Consumer Product Safety Commission. Is Your Home Playground a Safe Place to Play? Available from the Internet at http://www.cpsc.gov/CPSCPUB/PUBS/Pg1.pdf (cited 11/4/11)
Consumer Product Safety Commission. Outdoor Home Playground Safety Handbook. Available from the Internet at http://www.cpsc.gov/cpscpub/pubs/324.pdf (rev. 2009, cited 11/4/11)
Consumer Product Safety Commission. Public Playground Safety Handbook. Available from the Internet at http://www.cpsc.gov/CPSCPUB/PUBS/325.pdf (rev. 11/2010, cited 11/4/11)
Consumer Product Safety Commission. Tips for Public Playground Safety. Available from the Internet at http://www.cpsc.gov/CPSCPUB/PUBS/Playfct.pdf (cited 11/4/11)
Consumer Product Safety Commission. Chromated Copper Arsenate (CCA) – Treated Wood Used in Playground Equipment. Available from the Internet at http://www.cpsc.gov/phth/ccafact.html (cited 11/4/11)
University of Michigan. Playground and Outdoor Play Safety. Available from the Internet at http://www.med.umich.edu/yourchild/topics/outdoor.htm (rev. 2008, cited 11/4/11)
Injury Free Coalition for Kids. Parents Playground Injury Prevention Checklist. Available from the Internet at http://www.injuryfree.org/resources/PlaygroundInjuryPreventionChecklist.pdf (cited 11/4/11)
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.
26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital