Unveiling the Upper-Extremity Morbidities of Utility-Terrain Vehicles in Pediatric Riders

Abstract

Purpose: Off-road vehicles including all-terrain vehicles (ATVs) and utility-terrain vehicles (UTVs) are preventable sources of pediatric upper-extremity (UE) trauma. We hypothesized that UE traumas from UTV accidents in children would be associated with more mutilating hand injuries, amputations, surgeries, and longer hospital and intensive care unit (ICU) admissions compared to ATVs.

Methods: Pediatric cases of UE injury because of the use of an ATV or UTV at a trauma I center were identified using International Classification of Disease 9/10 codes and EPIC Boolean logic from 2010 to 2021. Findings were analyzed with Fisher exact tests, multivariate analysis of variance, analysis of variance with post hoc analyses, and multiple linear regressions.

Results: Retrospective review identified 42 patients from 5 states (ATV = 25; UTV = 17). Pediatric UTV riders had triple the amount of UE vascular compromise and sustained nearly 7-times more partial hand amputations. No significant differences in time spent in the hospital or ICU were observed based on vehicle type; however, young riders of UTVs required 1.5 additional reconstructive surgeries compared to young riders of ATVs.

Conclusion: Accidents caused by UTVs often lead to devastating UE injuries in pediatric riders. Hand surgeons are in a unique position to serve as forerunners to ensure pediatric rider safety and care for the devastating traumas produced by off-road vehicle accidents.

Type of study/level of evidence: Therapeutic IV.

Keywords: ATV; Hand trauma; Mutilating hand injury; Side-by-side; UTV.

Figure 1

A photo of the side-by-side utility-terrain vehicle (UTV). UTVs are characterized by the presence of four wheels, a roll-over protection system over the top of the vehicle, rider seatbelts, a steering wheel, and foot pedals for accelerating. Image courtesy of Ty Call, MD.

Figure 2

This image is a prototypical example of a thumb-sparing, transmetacarpal trauma that is commonly seen in young riders of UTV accidents. This patient was a 5-year-old girl who sustained a near partial hand amputation, with the volar skin as the only intact region following the trauma. Her operative course included fixation of metacarpals 2–5, repair of the majority of her extrinsic extensor and flexor tendons to digits 2–5, revascularization of the third and fourth common digital arteries, repair of two dorsal hand veins, and the repair of several digital nerves. Through the efforts of hand surgery and hand therapy, the need for a partial hand amputation was mitigated and the patient’s most recent DASH (Disabilities of the Arm, Shoulder, and Hand) score was 25.

Figure 3

These radiographs are of a 12-year-old girl who sustained multiple open fractures after a UTV ROE. The patient was riding passenger, directly behind the driver in a four-seater UTV. During the ROE, the patient stuck her hand outside the vehicle to brace for impact. Amputations to the thumb, index, middle, and small fingers were performed as replantation was unfeasible due the extensive crush-avulsion trauma to the soft tissues.

Figure 4

A comparison by vehicle type. A Average days spent in the hospital. B Average days spent in the ICU. C Number of upper extremity surgeries.

Figure 5

This patient was a 13-year-old girl who sustained a crush-avulsion injury to her right index finger following a utility-terrain vehicle roll-over event. The patient was initially treated at an outside hospital that was not a part of the American Society for Surgery of the Hand/American College of Surgeons (ASSH/ACS) National Hand Trauma Center Network. Image A depicts the hand at presentation to our ASSH/ACS Hand Trauma Center 24 hours after injury, with vascular compromise evident in the right index finger. The delay in appropriate microvascular treatment contributed to the need for amputation.

Figure 6

This patient was a 13-year-old girl who sustained a degloving, lacerating trauma to her left forearm and hand following a utility-terrain vehicle roll-over event. At presentation to our Hand Trauma Center, she had multiple metacarpal fractures, greenstick fractures of the distal radius and ulna, and a had a large portion of the palmar skin degloved (Image A and Image B). Bony and soft tissue traumas were addressed in a single operation (Image C). Image D shows the patient three months after her initial reconstruction. A subsequent Z-plasty was performed to release the scar contracture. At final follow-up 21 months after surgery, the patient was doing well without ongoing concerns.