Article, Emergency Medicine

Dodgeball-related injuries treated at emergency departments

a b s t r a c t

Background: There is little published information on injuries from playing dodgeball. This investigation described dodgeball-related injuries among children and adults managed at emergency departments (EDs).

Methods: Cases were dodgeball-related injuries reported to the National Electronic Injury surveillance System (NEISS) during 2001-2018. Cases were divided into patients age 0-19 years (children) and patients age 20 years or greater (adults).

Results: A total of 5533 dodgeball-related injuries were identified, resulting in a national estimate of 185,382 injuries. Children accounted for 167,766 (90.5%) and adults for 17,617 (9.5%) of the injuries. For both age groups, the number of injuries increased during 2001-2006 then fluctuated but did not demonstrate any clear trend during 2007-2018. The highest proportion of children were treated on Friday (21.8%) while the highest proportion of adults were treated on Saturday (20.2%). While 57.8% of child injuries occurred at school, 46.7% of adult injuries occurred at a sports or recreational facility. The more common reported types of injuries among children and adults, respectively, were sprain or strain (30.7% vs 38.5%), fracture (24.7% vs 23.9%), contusion or abrasion (16.3% vs 7.5%), and dislocation (3.0% vs 11.7%). The most frequently Affected body parts among children and adults, respectively, were the upper extremity (50.4% vs 46.3%), head and neck (22.8% vs 15.4%), and lower extremity (21.4% vs 31.5%).

Conclusion: The majority of dodgeball-related injuries occurred among children. Children and adults tended to differ with respect to when and where the injuries occurred as well as the type of injury.

(C) 2019

  1. Introduction

Children in and out of school in the United States (US) play a wide variety of games and sports (e.g., baseball, football, basket- ball, soccer, kickball), among which is dodgeball. Dodgeball is a team sport played by two teams. Players throw balls and try to hit opponents while avoiding being hit themselves. The objective is to eliminate all of the members of the opposing team by hitting them with thrown balls, catching a ball thrown by an opponent, or violation of the rules by an opponent. The sport is played infor- mally in schools and elsewhere under varying rules and formally as an international sport.

In recent years, concerns have been raised about playing of dodgeball in schools, relating to issues such as bullying and injury. In 2006, the National Association for Sport and Physical Education (NASPE) issued a position statement that dodgeball was not an appropriate activity for K-12 school physical education programs [1]. Dodgeball has been banned in some US schools [2,3].

q This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

E-mail address: [email protected]

In contrast, dodgeball has become increasingly popular among adults [3]. In 2014, the Sport and Social Industry Association reported that adult dodgeball participation had grown 20% annu- ally over the previous three years [4]. According to an article pub- lished in 2018, 30,000-50,000 adults played organized dodgeball in the US [5]. To put this in perspective, a study by the Sports and Fitness Industry Association provided the number of persons in the US in 2018 participating in a variety of other Team sports, including basketball (24.2 million), tennis (17.8 million), baseball (15.9 million), soccer (11.4 million), court volleyball (6.3 million),

lacrosse (2.1 million), and rugby (1.6 million) [6].

There is limited published information on injuries that occur while playing dodgeball, consisting primarily of case reports [7,8]. The objective of this study was to describe dodgeball- related injuries reported to US emergency departments (EDs).

  1. Methods

The data source for this investigation was the National Elec- tronic Injury Surveillance System (NEISS) operated by the US Con- sumer Product Safety Commission (CPSC). The NEISS collects data

https://doi.org/10.1016/j.ajem.2019.10.043

0735-6757/(C) 2019

on consumer product-related injuries in the US from the EDs of approximately 100 hospitals as a probabilistic sample of the more than 5000 US hospitals with EDs. The NEISS is a stratified sample based on ED size and geographic location. Information collected include the patient’s age, sex, race, ethnicity, injury diagnosis, body parts affected, and location where the injury occurred, among others [9]. NEISS data are publically available and de-identified; therefore, the study is exempt from institutional review board approval. The NEISS database has been used extensively to investi- gate sports-related injuries [10-16].

Cases were dodgeball-related injuries reported to NEISS during 2001-2018. Although the NEISS includes two numeric fields for coding the product involved in the injury, and there are product codes for particular sports, there is no product code specific to dodgeball. However, the NEISS contains two narrative text fields providing a brief summary of the circumstances of the injury. These narrative fields have been used in previous studies to iden- tify cases [17-20]. For the present study, the author first identified all records where the Narrative_1 and Narrative_2 text fields con- tained the terms ”dodge” and ”ball.” The author then individually reviewed the Narrative_1 and Narrative_2 text fields of the result- ing records to determine whether the injury appeared to be related to dodgeball. In order for an injury to be considered related to dodgeball, the patient must have been directly injured by the dodgeball (e.g., ”hit by dodgeball”) or injured while playing a dodgeball game (e.g., ”twisted knee while playing dodgeball,” ”fell on hand while playing dodgeball”). Any records where it was clear that the injury was not related to dodgeball were excluded. For example, a record where the injury was caused when the patient ”dodged a ball” other than a dodgeball were excluded from the study. No further quality check was performed for inclusion or exclusion of a record. Because of the potentially different trends in dodgeball participation among children and adults, the cases were divided into two age groups: patients age 0-19 years (chil- dren) and patients age 20 years or greater (adults).

The distribution of cases (reports) by treatment year, month,

and day of week; patient age and sex; injury location; type of injury; body part injured; and disposition was determined for the two age groups. The weighted estimates (the sum of the numbers in the Weight number field) based on the sample weight assigned to each case based on the inverse probability of the hospital being selected for the NEISS sample and 95% confidence interval (CIs) also were calculated. The CPSC considers an estimate unstable and potentially unreliable when the number of records used is less than 20, the estimate is less than 1200, or the coefficient of varia- tion (CV) exceeds 33% [9]. Thus, the estimates for some of the vari- able subgroups may be unstable and potentially unreliable.

  1. Results

Of the 5551 records initially identified as having ”dodge” and ”ball” in the narrative, 5533 dodgeball-related injury records were included in the study, resulting in a national estimate of 185,382 dodgeball-related injuries (95% CI 156,133-214,632) during 2000-2018. Over 90% of the patients were children and 9.5% were adults (Table 1). Among children, 53.2% of the patients were age 6- 12 years. Among adults, 47.3% were age 20-29 years and the num- ber declined with increasing age.

Fig. 1 shows the annual estimate of dodgeball-related injuries. For all age groups, the estimate increased during 2001-2006. After- ward, the annual estimate fluctuated but did not demonstrate any clear trend. During 2006-2018, the mean annual injury estimate was 11,529 (95% CI 8555-14,503) for all persons, 10,321 (95% CI

7589-13,052) for children, and 1208 (95% CI 565-1852) for adults.

Table 2 presents the distribution of dodgeball-related injuries by various circumstances of the injury. For both age groups, the majority of patients were male with the male:female ratio being

2.3:1 for children and 2.0:1 for adults. Although injuries were trea- ted every day of the week, the highest proportion of injuries among children were treated on Friday while the highest proportion of injuries among adults were treated on Saturday. Among children, the majority of injuries occurred at school; among adults, the high- est proportion of injuries occurred at sports or recreational facilities.

Table 3 shows the type of injury and patient disposition. For both age groups, the most common types of injury were sprain or strain followed by fracture; however, the third most common type of injury was contusion or abrasion among children and dis- location among adults. Among children, the most frequently affected body part was the upper extremity followed by the head or neck and lower extremity; among adults, the most frequently affected body part was the upper extremity followed by the lower extremity and head or neck. For both age groups, the majority of patients were treated or examined at the ED and released.

  1. Discussion

This study described dodgeball-related injuries treated at US EDs. Such information is important because of concerns raised over the playing of dodgeball in school as well as the increasing popu- larity of the sport among adults. There is little published informa- tion on these injuries; thus, this study adds to the limited information on the topic.

Using NEISS data, this study found an estimated 185,382 dodgeball-related injuries treated at US EDs during 2000-2018.

Table 1

Patient age of dodgeball-related injuries treated in United States emergency departments, National Electronic Injury Surveillance System, 2001-2018.

Patient age (years)

No.

Est.

No.

%

No.

%

95% CI

00-05

62

1.1

1488

0.8

767-2210

06-12

2885

52.1

89,184

48.1

73,509-104,859

13-19

2117

38.3

77,093

41.6

63,229-90,958

20-29

237

4.3

8340

4.5

6017-10,663

30-39

129

2.3

4984

2.7

3394-6575

40-49

68

1.2

2506

1.4

1513-3498

50-59

27

0.5

1434

0.8

727-2140

60-69

6

0.1

264

0.1

70+

2

0.0

89

0.0

00-19

5064

91.5

167,766

90.5

140,921-194,610

20+

469

8.5

17,617

9.5

13,474-21,759

Total

5533

185,382

156,133-214,632

No. = Number of cases or reports.

Est. = Weighted estimate (sum of the Weight field). 95% CI = 95% confidence interval.

Fig. 1. Annual estimated number of dodgeball-related injuries treated in United States.

Table 2

Patient demographics and injury circumstances of dodgeball-related injuries treated in United States emergency departments, National Electronic Injury Surveillance System, 2001-2018.

Variable

Patient age 0-19

years

Patient age 20

+ years

No.

%

Est.

%

No.

%

Est.

%

Sex

Male

3535

69.8

117,574

70.1

315

67.2

11,671

66.2

Female

1529

30.2

50,192

29.9

154

32.8

5946

33.8

Month of treatment

January

396

7.8

12,747

7.6

36

7.7

1188

6.7

February

431

8.5

13,545

8.1

41

8.7

1435

8.1

March

497

9.8

16,092

9.6

47

10.0

1729

9.8

April

519

10.2

16,044

9.6

52

11.1

2006

11.4

May

606

12.0

21,001

12.5

46

9.8

1786

10.1

June

317

6.3

10,872

6.5

30

6.4

1360

7.7

July

277

5.5

7615

4.5

39

8.3

1520

8.6

August

282

5.6

9271

5.5

27

5.8

1036

5.9

September

409

8.1

12,749

7.6

45

9.6

1422

8.1

October

465

9.2

16,116

9.6

39

8.3

1547

8.8

November

487

9.6

18,524

11.0

34

7.2

1042

5.9

December

378

7.5

13,191

7.9

33

7.0

1544

8.8

Day of week of treatment

Sunday

341

6.7

11,801

7.0

63

13.4

2411

13.7

Monday

668

13.2

20,956

12.5

59

12.6

2102

11.9

Tuesday

780

15.4

24,490

14.6

59

12.6

2623

14.9

Wednesday

895

17.7

30,332

18.1

54

11.5

2160

12.3

Thursday

918

18.1

30,807

18.4

77

16.4

2441

13.9

Friday

1062

21.0

36,614

21.8

68

14.5

2323

13.2

Saturday

400

7.9

12,766

7.6

89

19.0

3556

20.2

Incident location

School

2784

55.0

96,938

57.8

25

5.3

1134

6.4

Sports/recreation facility

923

18.2

29,649

17.7

222

47.3

8233

46.7

Home

245

4.8

9119

5.4

51

10.9

2093

11.9

Other public property

124

2.4

4546

2.7

24

5.1

1250

7.1

Street

12

0.2

398

0.2

7

1.5

224

1.3

Unknown

976

19.3

27,116

16.2

140

29.9

4683

26.6

Total

5064

167,766

469

17,617

No. = Number of cases or reports.

Est. = Weighted estimate (sum of the Weight field).

This number is much smaller than the estimated number of inju- ries related to basketball (9,539,923), baseball (2,693,778), soccer (3,669,908), and volleyball (1,018,732) during 2001-2018 in the NEISS database. This might be expected considering that the num- ber of participants in these other sports is likely much higher than for dodgeball [6].

Although the majority of patients were children, particularly age 6-12 years, almost 10% were adults, indicating that dodgeball-related injuries are not limited to a particular age group. The estimated annual number of injuries increased among both children and adults during 2001-2006 but remained relatively steady after 2006. Considering recent concerns regarding children

Table 3

Type of injury and patient disposition of dodgeball-related injuries treated in United States emergency departments, National Electronic Injury Surveillance System, 2001-2018.

Variable Patient age 0-19 years Patient age 20 + years

No.

%

Est.

%

No.

%

Est.

%

Injury

Sprain, strain

1337

26.4

51,455

30.7

189

40.3

6780

38.5

Fracture

1327

26.2

41,392

24.7

109

23.2

4210

23.9

Contusion, abrasion

784

15.5

27,353

16.3

37

7.9

1317

7.5

Internal injury

354

7.0

10,318

6.2

10

2.1

490

2.8

Laceration

299

5.9

8863

5.3

19

4.1

858

4.9

Concussion

284

5.6

6380

3.8

14

3.0

582

3.3

Dislocation

137

2.7

5037

3.0

52

11.1

2055

11.7

All other

542

10.7

16,968

10.1

39

8.3

1324

7.5

Body part affected

Upper extremity

2432

48.0

84,486

50.4

222

47.3

8156

46.3

Head, neck

1300

25.7

38,293

22.8

67

14.3

2717

15.4

Lower extremity

1038

20.5

35,977

21.4

152

32.4

5549

31.5

Trunk

270

5.3

8317

5.0

28

6.0

1195

6.8

Entire body, unknown

24

0.5

693

0.4

0

0.0

0

0.0

Disposition

Treated/examined and released

4951

97.8

16,5310

98.5

458

97.7

17,181

97.5

Treated and transferred

3

0.1

203

0.1

0

0.0

0

0.0

Treated and admitted/hospitalized

63

1.2

1250

0.7

7

1.5

225

1.3

Held for observation

18

0.4

255

0.2

0

0.0

0

0.0

Left without being seen

26

0.5

729

0.4

4

0.9

211

1.2

Unknown

3

0.1

19

0.0

0

0.0

0

0.0

Total

5064

167,766

469

17,617

No. = Number of cases or reports.

Est. = Weighted estimate (sum of the Weight field).

playing dodgeball, resulting in the sport being banned in some schools, it might be expected that the annual number of injuries among children might decrease. Moreover, the increasing popular- ity of dodgeball among adults might be expected to result in a rise in injuries among adults. However, neither trend was observed. There are various reasons why the concerns regarding children playing dodgeball did not translate into a major decline in the number of children playing the sport. The number of schools ban- ning dodgeball may be small, children may play dodgeball away from school, or there may be an increase in the number of children playing dodgeball in schools without a ban. Information on the annual number of children and adults playing dodgeball would be helpful for more clearly evaluating annual trends; however, such information was not available.

Differences were observed between the two age groups with respect to the circumstances of the injury. Most of the children were injured at school while the greatest proportion of adults were injured at sports or recreational facilities. Additionally, children were more often treated on Friday while adults were more often treated on Saturday. It may be that children are more likely to play dodgeball on Friday than other days of the school week. And adults may be more likely to play dodgeball on weekends, when they are off work, and at facilities where teams can come together to play. While the type of dodgeball-related injuries were most often sprain or strain followed by fracture for both age groups, the third most common type of injury was contusion or abrasion among children and dislocation among adults. Moreover, the most fre- quently affected body part was the upper extremity followed by the head or neck and lower extremity in children but the upper extremity followed by the lower extremity and head or neck in adults. These differences in injury patterns may reflect age differ- ences in the manner in which dodgeball is played, susceptibility to particular injuries, or likelihood to be seen at an ED for a partic- ular injury. Adults may play dodgeball differently than children do. Adults may throw the ball harder or their older body may be more likely to suffer an injury if the person trips or falls. Children may be more likely to be taken to an ED for a particular type of injury, such

as a contusion or abrasion, that adults might manage at home or with a private physician.

This study has limitations. Cases were identified by searching for ”dodge” and ”ball” in the electronic record narrative. Moreover, the narrative of the records was reviewed by a single person (the author) and the decision to consider a given record as related to dodgeball was subjective and based on the limited information in the narrative. Dodgeball-related injuries where ”dodge” and ”ball” were not documented in the narrative, or where the narrative did not clearly indicate that the injury was related to dodgeball, would not have been included in this investigation. Also, only those inju- ries treated at an ED were included. The number of dodgeball- related injuries not seen at an ED is unknown. Furthermore, the NEISS database is a consumer product-related injuries database. So there may be some skepticism regarding its utility for analysis of sports-related injuries. However, the NEISS database has been used extensively for other sports-related injury investigations [10-16]. Investigation of dodgeball-related injuries from other data sources might prove useful to provide a more complete view of these injuries.

  1. Conclusion

The majority of dodgeball-related injuries occurred among chil- dren. After increasing during 2001-2006, the annual estimated number of injuries remained relatively stable. Children and adults tended to differ with respect to when and where the injuries occurred as well as the type of injury. However, most patients of both age groups were treated and released from the ED. The results of this study, particularly the age-related differences, may be use- ful for planning education, prevention, and management of dodgeball-related injuries.

Declaration of Competing Interest

None.

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