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PEDIATRICS Vol. 111 No. 1 January 2003, pp. 163-166

Acute Backpack Injuries in Children

Brent M. Wiersema, DO*, Eric J. Wall, MD{ddagger} and Susan L. Foad, MPH{ddagger}

* Bi-County Community Hospital, Department of Orthopaedic Surgery, Warren, Michigan
{ddagger} Cincinnati Children’s Hospital, Department of Pediatric Orthopaedic Surgery, Cincinnati, Ohio

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   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Objective. To identify the most common mechanisms and sites of injury associated with book backpacks in school-aged children, who present to the emergency department. This should help with the development of backpack injury prevention strategies.

Design. A descriptive analysis of The National Electronic Injury Surveillance System (NEISS) of the US Consumer Product Safety Commission (CPSC) National Injury Information Clearinghouse data on backpacks.

Setting. One hundred emergency department departments throughout the United States that participate in NEISS data collection served as the setting.

Participants. All children between 6 and 18 years old who were recorded in the NEISS database with a backpack-related injury were studied.

Methods. Patients were identified by review of the NEISS data from 1999–2000. We separated patient data by age, sex, location of injury, and mechanism of injury.

Results. There were 247 children with backpack injuries. The mean age was 11.8 years, and 50% were male. The most common injury location was the head/face (22%) followed by the hand (14%), wrist/elbow (13%), shoulder (12%), and foot/ankle (12%). The back ranked sixth (11%). Of these back injuries, 59% were associated with carrying a backpack. The most common mechanism for injury was tripping over the backpack (28%), followed by wearing (13%), and getting hit by the backpack (13%).

Conclusions. Although the CPSC data on backpack injuries is frequently quoted in articles relating backpacks with back injury, 89% of backpack injuries in our study do not involve the back. Our study does not support the hypothesis that back injury is the major problem with book backpacks in the emergency department setting.

Key Words: backpacks • back pain • NEISS data

Abbreviations: CPSC, Consumer Product Safety Commission • NEISS, National Electronic Injury Surveillance System


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Backpacks have become the mainstay of transporting books and goods for school-aged children. Recently there has been growing concern among health care professionals, parents, and educators that backpacks are damaging the back.1–3 The issue of back pain with backpack use is controversial within the scientific literature with some studies finding no association4–6 and some finding an association.7–10 We recently studied a group of school-aged children who presented to a pediatric orthopedic office complaining of back pain, and found that only 1 of 346 patients attributed their back pain to a book backpack.5 The US Consumer Product Safety Commission (CPSC) reported that backpacks were associated with an estimated 12 688 injuries between 1999 and 2000.11,12 Several articles and Web sites have cited the CPSC data on book backpack injuries as evidence that backpacks cause injury.2,3,13 It is assumed in the medical and lay community that the most common injury associated with backpacks is related to the back. We felt the CPSC data required additional investigation because it was at odds with our own findings. The purpose of our study was to identify the most common sites and mechanisms of acute injuries associated with backpacks in school-aged children by analyzing the CPSC data.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Data for this study was drawn from the National Electronic Injury Surveillance System (NEISS) of the US CPSC National Injury Information Clearinghouse in Washington, DC. It is an electronic database that complies injury information from selected US hospitals with 24-hour emergency departments. The overall injury estimates are derived from injuries treated in 100 hospital emergency departments that participate in the NEISS. The NEISS estimates are calculated using data from a sample of hospitals, which are statistically representative of institutions with emergency departments located within the United States and its territories. The national estimate is a projection of the total US hospital emergency department treated injuries based on the number of such injuries reported.14

The data we reviewed was obtained from the 1999 and 2000 annual data. There were 12 688 estimated injuries associated with bookbags or back carriers, excluding infant-carriers and camping backpacks. The subject sample count included 342 patients. Only school-aged children 6 to 18 years old were reviewed, which further narrowed the sample size to 247. Demographic data on our sample of 247 school-aged children with acute backpack injuries is reported in Table 1. Each case reviewed contained information of the patient’s age, sex, diagnosis, body part injured, as well as a specific comment on the injury.


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  		TABLE 1. Demographic Information

 
We separated the school-aged case reports based on the location of injury and the mechanism of injury. Specifically, we divided the body parts into the following 11 areas: hip, knee, leg, foot/ankle, shoulder, wrist/elbow, hand, head/face, neck and back, and other. The "other" category included injuries that did not fit in the above areas, such as smoke inhalation from a backpack fire, vaginal tear from landing on a backpack, etc.

The 3 main injury mechanisms associated with the standard use of backpacks were wearing, lifting, or taking off a backpack. The 3 most common nonstandard use mechanisms were tripping over the backpack, reaching into the backpack, or getting hit with the backpack by another person.

Our institutional review board reviewed this study and granted exemption (CHMC #02–1-15X).


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 CONCLUSION
 REFERENCES
 
Location of Injury
The most common location for injury in our sample of 247 children was the head and face, representing 22% of total injuries, with a laceration to the head/face being the most common injury in this group (Fig 1). Injuries to the hand involved 14% of the children with such injuries as punctured fingers from pencils, jammed fingers while reaching for books in the backpack, and fractures from the backpack falling on the user’s hand. Wrist/elbow injuries occurred in 13%, with wrist sprains being the most common type of injury. The shoulder was injured in 12% of the children, with shoulder strains being the most common shoulder injury. Injuries to the foot/ankle involved 12% of all injures, with ankle sprains being the most common injury in this group. The back was the sixth most common injury site of injury and only accounted for 11% of all reported acute backpack injuries in this study, with lumbar strain being the most common back injury. Neck injury represented 6% of injuries, with neck strain the most common injury. Rare sites of injury were the knee 3%, the hip 2%, and leg 2%. The "other" category consisted of 5% of the injuries.



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  		Fig 1. Location of injuries.

 
Mechanism of Injury
The most common backpack mechanism of injury was tripping over the backpack, occurring in 28% of the 247 study children (Table 2). Thirty-nine percent of all tripping incidents occurred at school and 17% occurred at home. The location of the incident was not noted in 44% of the injuries. Tripping incidents typically resulted from the backpack lying on the ground. The mechanism of tripping over a backpack primarily caused injury to the foot/ankle (31%) or wrist/elbow (20%), but only caused 1 of the 27 back injuries.


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  		TABLE 2. Mechanism of Injury Breakdown

 
Getting hit by a backpack was the mechanism of injury involved in 13% of the total injuries sustained by book backpack use. Sixty-five percent of these injuries were caused by a child being hit by another person. A number of these injuries occurred on accident but for the majority of these incidents the backpack was used as a weapon. Twenty-six percent of the injuries were sustained at school and 16% occurred at home. The head/face was the location hit most commonly. There were no hitting injuries reported to the back.

Injuries associated with actually wearing a backpack occurred in 13% of the total children. Sixteen patients stated their injury involved the back, with 8 involving the shoulder, and 4 involving the neck. Surprisingly, the combination of wearing a backpack and sustaining an injury to the back only represented 6% of the total injuries in this study.

Lifting the backpack to put it on was the cause of 8% of all injuries and involved the shoulder in half of the cases. Lifting a backpack resulted in injury to the back in <1% of the total injuries. Taking off the backpack and reaching into the backpack were the least common mechanisms of injury at 2% each, and neither had a reported injury occurring to the back. Injuries from taking off the backpack always involved the upper extremity.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
CONCLUSION
 REFERENCES
 
School-aged children use backpacks for transporting books and goods to school 80% to 94% of the time.5,6,15,16 Some health care workers, school administrators, and legislators have recommended that book backpack use should be restricted or eliminated. The CPSC data has been cited as evidence that school backpacks are dangerous, causing 12 688 injuries in the years 1999 and 2000 and it is frequently assumed that the most common injury relates to the back.11,12,14 Our study of the CPSC data shows that only 11% of all acute backpack injuries are related to the back.

In an article in Time magazine, Dr Ian Smith uses the NEISS data from 2000 and states "there were 5900 kids treated for sprains and strains directly caused by backpacks" and describes how to avoid such problems by adjusting your backpack, reducing the load, and organizing the weight within the backpack.2 These injuries may be sprains and strains but they are not occurring predominantly to the back. The American Academy of Orthopaedic Surgeons has also focused on backpacks and back pain. They have an online fact sheet for parents regarding back pain and its association with backpacks and their injury prevention tips state to "use hip straps for heavier weights and use both of the backpack straps."3 Following these recommendations would only eliminate <11% of backpack injuries requiring emergency department visits.

The most common injuries were to the head/face comprising 21% of all backpack-related injuries. Being hit by a backpack or tripping over a backpack caused 70% of injuries in this largest group. As would be expected, the standard use of lifting and wearing a backpack caused none of the injuries to the head and face. Backpack injury prevention strategies should include the important mechanisms of being hit by a backpack and tripping over a backpack.

Hand injuries accounted for 14% of all backpack injuries in the study. These included punctures and foreign body injury from reaching into the backpack as well as jammed fingers and fractures from tripping over a backpack. Lifting or taking off a backpack caused only 3 out of the 34 hand injuries, and none were attributable to wearing a backpack. There were 33 injuries to the wrist/elbow associated with backpack use and tripping over a backpack caused nearly half of these injuries.

It is reported that the shoulder, not the back, is the musculoskeletal "weakest link" that limits load carriage with backpacks.17 Our study supports this finding through analysis of the injuries caused by wearing, lifting, or taking off a backpack. These standard use mechanisms of a backpack caused 19 shoulder injuries versus only 18 back injuries. Surprisingly, only 2 these back injuries were sustained while lifting a backpack and 10 shoulder injuries were sustained lifting a backpack. It appears that it would be more productive to teach children correct shoulder-lifting techniques than back-lifting techniques.

Only 23% of the total injuries in the study were caused by mechanisms involving the standard use of a backpack (wearing, lifting, and taking off). The standard use of a backpack produced the most shoulder and back injuries in this study (19 and 18, respectively). Wearing a backpack made up 13% of the total injuries reported. More specifically, wearing a backpack and sustaining a back injury represented only 6% of the total reported injuries in this study.

The "nonstandard" use of a backpack (tripping, hitting, etc) resulted in 77% of all backpack injuries that required an emergency department visit. This result shows that the actual use of a backpack is not exceptionally dangerous, and efforts should be directed toward educating children on proper backpack safety habits rather than restricting loads and redesigning backpacks. Current recommendations to reduce potential backpack injury, such as reducing backpack weight,3 rolling backpacks,13 and adjusting weight distribution within backpacks would,2 at best, eliminate only 23% of the injuries in this study. Recommending that children put their backpacks in a safe place so they do not trip over them, and not to use them as a weapon to hit another person, could eliminate >40% of backpack injuries presenting to the emergency department.

This study is limited in that it focuses primarily on acute backpack injuries that generate an emergency department visit; however, several of the patients in the study had chronic complaints. This study would miss minor acute injuries and would miss most chronic injuries that would be diagnosed and treated elsewhere, such as a physician’s office. Because we have no follow-up data, we cannot state the true severity or time to resolution of these injuries. The CPSC data did not distinguish between single-strap versus double-strap backpack use so we cannot comment on this issue.


   CONCLUSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
REFERENCES
 
The CPSC NEISS data on backpack injuries reveals very few injuries to the back caused by wearing a backpack (6%). The most common site of injury is the head/face with the back ranking sixth. The most common mechanism of injury is tripping over a backpack. Public health officials should expand their backpack safety initiatives to cover injuries caused by tripping over a backpack and being hit by a backpack.


   FOOTNOTES
 
Received for publication Mar 18, 2002; Accepted Aug 21, 2002.

Address correspondence to Eric J. Wall, MD, Department of Pediatric Orthopaedic Surgery, 3333 Burnet Ave, Bldg C, MLC 2017, Cincinnati, OH 45229. E-mail: eric.wall{at}chmcc.org


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 

  1. Iyer SR. Musculoskeletal pain in school children. In: Proceedings of the International Ergonomics Association 2000; Human Factors Ergonomics Society; Congress, pp. 5.419–5.422. Washington, DC: 2000
  2. Smith I. Schooling on backpacks. Time.2001158
  3. Kids and backpacks. Available at: www.aaos.org Accessed August 12, 2002
  4. Troussier B, Davoine P, de Gaudemaris R, Fauconnier J, Phelip X. Back pain in school children. A study among 1178 pupils. Scand J Rehabil Med.1994; 26 :143 –146[ISI][Medline]
  5. Spears JD, Wall EJ, Mehlman CT, Crawford AH. Backpacks and back pain: where’s the epidemic? Presented at the American Academy of Pediatrics Annual Meeting; October 20–24, 2001; San Francisco, CA. J Pediatr Orthop.In press
  6. Grimmer K, Williams M. Gender-age environmental associates of adolescent low back pain. Appl Ergon.2000; 31 :343 –360[CrossRef][ISI][Medline]
  7. Kruse RW, Sheir-Neiss GI, Rahman T, Jacobsen L, Pelli J. Backpack use as a risk factor in children’s back pain. Presented at the American Academy of Orthopaedic Surgeons Annual Meeting; 2002; Dallas, TX. Poster No. 264
  8. Skaags DL, D’Ambra P, Early SD, Tolo VT. Association of backpack and scoliosis with carrying a backpack in 1,020 children. Presented at the Scoliosis Research Society Annual Meeting; September 18–21, 2000; Cairnes, Australia. Paper No. 47
  9. Skaags DL, Early SD, D’Ambra P, Tolo VT. The association of back pain and carrying a backpack in school children. Presented at the Pediatric Orthopaedic Society of North America Annual Meeting; May 2–5, 2001; Cancun, Mexico. Paper No. 21
  10. Viry P, Creveuil C, Marcelli, C. Nonspecific back pain in children. A search for associated factors in 14-year-old schoolchildren. Rev Rhum Engl Ed.1999; 66 :381 –388[Medline]
  11. National Electronic Injury Surveillance System. Washington, DC: US Consumer Product Safety Commission; 2000
  12. National Electronic Injury Surveillance System. Washington, DC: US Consumer Reports Product Safety Commission; 2001
  13. Backpacks on a roll. Available at: http://www.consumerreports.com Accessed August 12, 2002
  14. National Electronic Injury Information Clearinghouse Reported Incidents: Book Bags or Bag Carriers: 1999–2000. Washington, DC: US Consumer Product Safety Commission; 2001
  15. Pascoe DD, Pascoe DE, Wang YT, Shim DM. Kim CK. Influence of carrying book bags on gait cycle and posture of youths. Ergonomics.1997; 40 :631 –641[Medline]
  16. Whitfield J, Legg S, Hedderley D. The weight and use of schoolbags in New Zealand secondary schools. Ergonomics.2001; 44 :819 –824[Medline]
  17. Vacheron JJ, Poumarat G, Chandezon R, Vanneuville G. The effect of loads carried on the shoulders. Mil Med.1999; 164 :597 –599[Medline]
PEDIATRICS (ISSN 1098-4275). ©2003 by the American Academy of Pediatrics



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