From Contusions to Fatal Atlanto-Occipital Dislocations: The Clinical Spectrum of Pediatric Horse-Related Trauma over 22 Years

Background: Pediatric horse-related trauma ranges from minor soft-tissue injuries to potentially fatal trauma. Existing studies often focus on hospitalized patients or selected injury patterns, while broader clinical data remain limited. This study aimed to characterize injury mechanisms, patterns, treatment requirements, and outcomes. Methods: This retrospective cohort study included patients younger than 19 years treated at a Level I trauma center between 2002 and 2023. Demographics, injury mechanisms, injury patterns, treatment, hospitalization, and outcomes were analyzed. Results: A total of 593 patients with 650 injury events were included (mean age at first presentation, 13.0 ± 3.8 years; 90.9% female). Falls predominated (69.8%), followed by kicks (15.2%) and bites (4.6%). Contusions were most frequent (38.5%), followed by fractures (24.5%) and head injuries (16.6%). Injury mechanism was significantly associated with injury pattern (p < 0.001; Cramér’s V = 0.43), and age differed across major injury categories (p < 0.001). Hospital admission was required in 17.4% of events and operative treatment in 5.2%. Fractures (aOR, 5.43; p < 0.001) and head injuries (aOR, 8.85; p < 0.001) were independently associated with hospital admission. Follow-up beyond the initial presentation was documented in 236 of 650 events (36.3%). Among the 234 non-fatal events with documented follow-up, 83.3% were free of complaints; these outcome data should be interpreted as conditional on follow-up availability and subject to potential attrition bias. Two of 593 patients (0.3%) died following atlanto-occipital dislocations after falls involving stirrup entrapment and dragging. Conclusions: Pediatric horse-related trauma comprises distinct mechanism-specific injury patterns. Although most injuries were managed without hospitalization or surgery, fractures and head injuries accounted for a disproportionate treatment burden, while rare complex mechanisms resulted in fatal craniocervical trauma.