Abstract
Objectives
In competitive motocross, children as young as 4 years old race in groups on motorized off‐road bikes on uneven terrain. We aimed to describe pediatric injuries occurring during an annual week‐long certified amateur motocross competition between 2011 and 2021. Secondarily, we compared injury characteristics and medical evaluation by age.
Methods
This retrospective analysis of injuries sustained by children during an annual motocross competition included children <18 years who received care for an event‐related injury within either of the two large regional hospital systems between 2011 and 2021. Data were collected through electronic health record review and analyzed with descriptive statistics. We used chi‐square and Fisher exact tests to compare findings by age (young child less than 12 years vs. adolescent 12 years or older).
Results
Over the 10‐week study period (1 week per year for each of 10 years), 286 encounters were made by 278 children. Nearly all children (280/286, 98%) underwent imaging; most had at least one traumatic finding (71.7% of x‐rays, 62.4% of computed tomography [CT] scans). Ninety‐three children (32.5% of 286) sustained multisystem injuries. Emergency department procedures included one endotracheal intubation, one thoracostomy, 46 closed reductions, and 37 procedural sedations. Twenty‐eight children (9.8% of 286) required operative intervention. Overall, 25.5% of children (73/286) were hospitalized and one adolescent died. Adolescents were more likely than young children to undergo CT imaging (40.1% vs. 26.8%, p = 0.042) and have multisystem injuries (36.3% vs. 23.2%, p = 0.045). There was no difference in hospitalization or operative intervention by age.
Conclusion
This comprehensive assessment of injuries sustained by children during competitive motocross demonstrates significant morbidity and mortality. Findings have implications for families who consider participation and health systems in regions where competitions occur.
Keywords: motorcross injuries, pediatric, trauma
1. INTRODUCTION
1.1. Background and importance
Competitive motocross is an international sport with riders as young as 4 years old racing at high speed in groups of 20–40 riders on motorized off‐road dirt bikes on uneven and obstacle‐laden terrain. 1 , 2 Certified competitions require participants to wear shatterproof eye protection, full face helmets, and chest and back protection; yet serious injuries still occur. 3 Medical personnel in regions where certified competitions are held may need to respond to an increased number of injured pediatric patients during the times when competitions occur, as up to 5%–10% of children competing in certified events may sustain an injury requiring medical evaluation. 4 However, investigations of pediatric injuries from motocross often focus on specific injury type or include children who are participating recreationally and may have different risks and mechanisms of injury. 5 , 6 , 7 , 8 The few studies that seek to provide comprehensive evaluations of injuries sustained by children during competition are limited by small numbers and may not fully capture the scope of injury. 4 , 9 , 10 , 11
1.2. Goals of this investigation
We aimed to assess the characteristics of traumatic pediatric injuries occurring during a certified annual week‐long international amateur motocross competition between 2011 and 2021. Secondarily, we compared injury characteristics and evaluation between adolescents (13 years and older) and children (12 years and younger).
2. METHODS
2.1. Study design and setting
This is a retrospective analysis of injuries sustained by children during an annual international week‐long motocross competition, one of four major events on the amateur motocross circuit, with approximately 750 participants under age 18 each year. 2 , 12 Children (<18 years) were eligible for inclusion if they were evaluated for traumatic injuries sustained in motocross competition during the week of the event each year between 2011 and 2021 at an emergency department (ED) within either of two large hospital systems in the region, UF Health and HCA North Florida Hospital. UF Health is an academic medical center that serves as the region's only Level 1 trauma center and children's hospital ED, which has approximately 26,000 annual pediatric ED visits and 200 annual pediatric top‐level trauma alerts. HCA North Florida has one hospital‐based community ED. Between the two hospital systems, there are also five freestanding EDs in the region. Together, the one community ED and five freestanding EDs have approximately 16,000 pediatric visits annually. Within these two hospital systems, the UF Health trauma center and children's hospital is the only one with inpatient and subspecialty services and serves as a referral center for all pediatric care in the region. All transferred patients with traumatic injuries come through the ED prior to hospital admission. Outside of these two hospital systems, there are several small urgent care centers but no other EDs within 25 miles of the motocross track.
2.2. Participants
Potentially eligible participants were identified if (1) they were less than 18 years old at the time of ED visit, (2) they had a visit to a participating ED during the week of the motocross competition any year between 2011 and 2021, and (3) they had at least one ED diagnosis code for a traumatic injury (Supporting Information Appendix 1). Repeat visits by the same participant were excluded if they were for the same injury as the index visit but were included if they were for the evaluation of a newly sustained injury. Trained physicians then reviewed the medical record of each potentially eligible patient to determine if the injury had occurred while participating in motocross; those that had were eligible for inclusion in the study. Children who were initially seen at a participating community or freestanding ED (i.e., not the children's hospital Level 1 trauma center) and subsequently transferred to the children's hospital Level 1 trauma center were only included for the receiving visit at the trauma center.
2.3. Data collection
For each participant, we collected data on demographics, pre‐hospital and hospital care, and injury diagnoses. Demographics (age, sex, and year of injury) and ED disposition were directly abstracted from the electronic health record (EHR) and entered into a central REDCap database. 13 Age was categorized as adolescent (older than 12 years) or young child (12 years or younger). 14 Based on the state and country listed in the EHR under current address, participants were categorized as from Florida, an out of state location (further categorized by US Census region), or an international location. 15 Emergency medicine physicians (E.B., K.R., T.S., C.K.H., C.K.G., R.H., and D.M.) used a standardized data collection form to collect data related to pre‐hospital and hospital management (mode of ED arrival, respiratory support, imaging, and procedures) and injury diagnoses through manual review of clinician documentation and radiology reports in the EHR; these were then entered into the REDCap database by selecting from predetermined lists of management strategies and diagnoses, with an opportunity to select “other” within each category and provide a free text response (Supporting Information Appendix 2). A random 10% of charts were independently reviewed by a second physician investigator blinded to the first reviewer's abstraction. For physician‐abstracted variables, we calculated Cohen's kappa to assess interrater reliability. 16 Variables with a kappa <0.6 were not included for analysis (Supporting Information Appendix). We subsequently categorized injuries based on anatomic location (head and face; neck and back; chest and thorax; abdomen; pelvis and genitourinary; upper extremity; and lower extremity), with a separate category for soft tissue injuries (defined as a superficial contusion, abrasion, sprain, burn or any laceration not involving a solid organ) of any location. We considered participants to have sustained “multisystem injuries” if they had more than one injury and if those injuries occurred in separate anatomic locations; superficial soft tissue injuries were not included in this diagnosis.
2.4. Data analyses
We analyzed data with descriptive statistics, including proportions for categorical variables and medians with interquartile ranges for non‐normally distributed continuous data. We used chi‐square and Fisher exact tests to compare findings by age (adolescent or young child). This study was approved by the institutional review boards at both participating institutions.
3. RESULTS
Over the 10‐week study period, there were 286 included encounters (median 26 encounters per 1‐week period each year, range 11–51) made by 278 children. Most encounters (254/286, 88.8%) took place at the trauma center and children's hospital ED; 16 of these 254 children (6.3%) were transferred in from another ED. Most encounters were made by children who were from out of state (241/286, 84.3%), including 22 (7.7%) from international locations. The youngest patient was 5 years old and 28.7% (82/286) of patient encounters were for patients under 13 years old. Table 1 shows additional demographic characteristics of the sample.
TABLE 1.
Demographics of children evaluated for injuries sustained during competitive motocross.
| Patient characteristics, No. (%) |
Adolescent (n = 204) |
Younger child (n = 82) |
Total (n = 286) |
|---|---|---|---|
| Median age in years (IQR) | 15 (14–16) | 11 (10–12) | 14 (12–16) a |
| Male | 187 (91.7) | 77 (93.9) | 264 (92.3) |
| Location of origin b | |||
| Florida | 29 (14.2) | 16 (19.5) | 45 (15.7) |
| Non‐Florida South | 73 (35.8) | 37 (45.1) | 110 (38.5) |
| Northeast | 22 (10.8) | 9 (11.0) | 31 (10.8) |
| Midwest | 39 (19.1) | 13 (15.9) | 52 (18.2) |
| West | 23 (11.3) | 2 (2.4) | 25 (8.7) |
| International | 17 (8.3) | 5 (6.1) | 22 (7.7) |
| Missing | 1 (0.5) | 0 | 1 (0.4) |
| Means of arrival | |||
| Personal vehicle | 113 (55.4) | 46 (56.1) | 159 (55.6) |
| Emergency medical services | 80 (39.2) | 31 (37.8) | 111 (38.8) |
| Interfacility transfer | 11 (5.4) | 5 (6.1) | 16 (5.6) |
Note: Adolescent is defined as 13 years or older, younger child defined as 12 years old or younger.
Abbreviation: IQR, interquartile range.
Age (in years) in sample include the following: 5 (n = 2), 7 (n = 2), 8 (n = 8), 9 (n = 7), 10 (n = 15), 11 (n = 18), 12 (n = 21), 13 (n = 28), 14 (n = 38), 15 (n = 45), 16 (n = 38), 17 (n = 32).
Based on United States Census Bureau regions.
The Bottom Line
This retrospective analysis assessed injuries sustained by children and adolescents participating in an annual competitive motocross competition. Our findings demonstrate that children participating in this annual motocross competition risk sustaining an injury requiring hospital evaluation and many require interventions, including fracture reduction, procedural sedation, and surgical operations that themselves carry risk. These serious injuries occur despite regulations requiring protective gear for all competitors and horsepower limitations for younger riders. Our study also highlights areas in which clinicians and hospital leaders at nearby hospitals can focus their attention when preparing for these large‐scale, time‐limited events.
Table 2 shows the details of injury diagnoses in participants. Of the 286 encounters, the most commonly diagnosed injuries were clavicle fractures (46, 16.1%), long bone arm fractures (63), and concussions (37). Children sustained multisystem injuries in 93 encounters (32.5%), which occurred more commonly in adolescents compared to young children (36.3% vs. 23.2%, p = 0.045).
TABLE 2.
Injuries sustained by children during competitive motocross.
| Injuries, No. (%) |
Adolescent (n = 204) |
Younger child (n = 82) |
Total (n = 286) |
|---|---|---|---|
| Any soft tissue injury a | 92 (45.1) | 35 (42.7) | 127 (44.4) |
| Head and face injuries | |||
| Concussion | 27 (12.7) | 10 (12.2) | 37 (12.9) |
| Intracranial hemorrhage | 4 (2.0) | 2 (2.4) | 6 (2.1) |
| Diffuse axonal injury | 2 (1.0) | 0 | 2 (0.7) |
| Facial fracture | 0 | 5 (6.1) | 5 (1.7) |
| Dental injury | 1 (0.5) | 2 (2.4) | 3 (1.0) |
| Neck and back injuries | |||
| Vertebral fracture | 11 (5.4) | 1 (1.2) | 12 (4.2) |
| Spinal cord injury | 2 (1.0) | 1 (1.2) | 3 (1.0) |
| Vertebral artery injury | 1 (0.5) | 0 | 1 (0.4) |
| Chest and thorax injuries | |||
| Rib fracture | 6 (2.9) | 2 (2.4) | 8 (2.8) |
| Pulmonary contusion | 13 (6.4) | 1 (1.2) | 17 (5.9) |
| Pneumothorax | 13 (6.4) | 3 (3.7) | 16 (5.6) |
| Pneumonitis | 1 (0.5) | 0 | 1 (0.4) |
| Scapula fracture | 12 (5.9) | 2 (2.4) | 14 (4.9) |
| Sternoclavicular dislocation | 1 (0.5) | 0 | 1 (0.4) |
| Abdominal injuries | |||
| Hepatic laceration | 3 (1.5) | 1 (1.2) | 4 (1.4) |
| Splenic laceration | 1 (0.5) | 0 | 1 (0.4) |
| Renal laceration | 1 (0.5) | 0 | 1 (0.4) |
| Adrenal hemorrhage | 1 (0.5) | 1 (1.2) | 2 (0.7) |
| Pelvic injuries | |||
| Pelvic fracture | 6 (2.9) | 0 | 6 (2.1) |
| Hip dislocation | 1 (0.5) | 0 | 1 (0.3) |
| Upper extremity injuries | |||
| Clavicle fracture | 32 (15.7) | 14 (17.1) | 46 (16.1) |
| Long bone fracture (humerus, radius, ulna) | 42 (20.6) | 21 (25.6) | 63 (22.0) |
| 1 (0.5) | 1 (1.2) | 2 (0.7) | |
| Carpal fracture | 4 (2.0) | 1 (1.2) | 5 (1.7) |
| Metacarpal fracture | 3 (1.5) | 0 | 3 (1.0) |
| Finger fracture | 4 (2.0) | 1 (1.2) | 5 (1.7) |
| Shoulder dislocation | 5 (2.5) | 2 (2.4) | 7 (2.4) |
| Acromioclavicular separation | 1 (0.5) | 0 | 1 (0.3) |
| Finger dislocation | |||
| Lower extremity injuries | |||
| Long bone fracture (femur, tibia, fibula) | 32 (15.6) | 15 (18.3) | 47 (16.4) |
| Foot fracture | 2 (1.0) | 1 (1.2) | (1.0) |
| Knee dislocation | 2 (1.0) | 0 | 2 (0.7) |
| Ankle dislocation | 1 (0.5) | 0 | 1 (0.3) |
| Multisystem injury b | 74 (36.3) | 19 (23.2) | 93 (32.5) |
Note: Injuries listed include those that were identified during data abstraction and do not include injury types that were not identified (Supporting Information Appendix 2). The total is more than the sample size as study participants could have more than one injury type.
Defined as a superficial contusion, abrasion, laceration, sprain, or burn.
Defined as involvement of two or more body groups using the categories listed in the table above (not including superficial soft tissue injuries).
A total of 111 encounters (38.8%) arrived via ambulance, including one adolescent received cardiopulmonary resuscitation (CPR) on scene and had a supraglottic airway placed before ED arrival and one adolescent underwent endotracheal intubation before ED arrival. Table 3 shows the details of injury evaluation and management after ED arrival. Children in nearly all encounters (270/286, 94.4%) underwent imaging, most of whom had at least one traumatic finding on plain radiography (202, 75.0%). Of the 104 CT scans performed, 63.5% had a traumatic finding. Procedures performed in the ED included one endotracheal intubation, one thoracostomy, 46 closed reductions, and 37 procedural sedations. In 28 encounters (9.8% of 286), the injured child underwent a surgical procedure in the operating room (OR). Procedures in the OR included open reduction and internal fracture fixation (n = 30), pelvic angiogram and embolization of arterial bleed (n = 1), laminectomy for spinal cord decompression (n = 1), and complex laceration repair (n = 1). Overall, 25.5% of children (73/286) were hospitalized, including seven (2.4% of 286 encounters) requiring intensive care. There was one inpatient adolescent death secondary to severe spinal cord injury. Adolescents were more likely than young children to undergo CT imaging (41.1% vs. 26.8%, p = 0.032). There was no difference in hospital admission or operative procedures by age.
TABLE 3.
Evaluation and management of children with injuries from competitive motocross.
| Evaluation and management, No. (%) |
Adolescent (n = 204) |
Younger child (n = 82) |
Total (n = 286) |
|---|---|---|---|
| Imaging obtained in the ED | |||
| CT | 82 (40.1) | 22 (26.8) | 104 (36.4) |
| X‐ray | 193 (94.6) | 75 (91.5) | 268 (93.7) |
| Ultrasound a | 24 (11.8) | 3 (3.7) | 27 (9.4) |
| Procedure in the ED | |||
| Laceration repair | 4 (2.0) | 9 (11.0) | 13 (4.5) |
| Wound debridement | 1 (0.5) | 0 | 1 (0.3) |
| Closed reduction – fracture | 26 (12.7) | 17 (20.7) | 43 (15.0) |
| Closed reduction – dislocation | 3 (1.5) | 0 | 3 (1.0) |
| Arthrocentesis | 0 | 1 (1.2) | 1 (0.3) |
| Nerve block | 2 (1.0) | 0 | 2 (0.7) |
| Hematoma block | 4 (2.0) | 2 (2.4) | 6 (2.1) |
| Procedural sedation | 21 (10.3) | 16 (19.5) | 37 (12.9) |
| Transfusion of blood products | 1 (0.5) | 0 | 1 (0.3) |
| Needle decompression thoracostomy | 1 (0.5) | 0 | 1 (0.3) |
| Tube thoracostomy | 1 (0.5) | 0 | 1 (0.3) |
| Endotracheal intubation | 1 (0.5) | 0 | 1 (0.3) |
| Procedure in the operating room | 21 (10.3) | 7 (8.5) | 28 (9.8) |
| Disposition from the ED | |||
| Admit to non‐intensive care unit | 50 (24.5) | 16 (19.5) | 66 (23.1) |
| Admit to intensive care unit | 6 (2.9) | 1 (1.2) | 7 (2.4) |
| Discharge | 145 (71.1) | 65 (79.3) | 210 (73.4) |
| Eloped/left against medical advice | 3 (1.5) | 0 | 3 (1.0) |
Abbreviations: CT, computed tomography; ED, emergency department.
This included bedside ultrasound with FAST (focused assessment with sonography in trauma) as well as radiology performed abdominal, retroperitoneal, and extremity ultrasounds.
4. LIMITATIONS
Our study is limited by classification bias of retrospectively collected data. However, we designed our protocol with multiple rigorous steps to minimize this bias. 17 Our analysis does not include injuries that were not brought to medical attention or were treated outside of these two hospital systems; however, given that the two included hospital systems represent all emergency care locations in the region of the motocross park, these are expected to be of low severity. We also may have missed any fatalities that occurred on site and were not brought to the hospital. We chose not to include measures of injury severity, instead focusing on clinically applicable data related to injury assessment and management. As such, our study provides data on child injuries and associated clinical resource use that may be more meaningful to ED and hospital leaders in regions with amateur competitions. Future studies should focus on identifying participant and race characteristics that are associated with injury severity.
5. DISCUSSION
This comprehensive assessment of injuries sustained by children during competitive motocross demonstrates the significant morbidity and mortality that can result from this sport. Findings have implications not only for children and parents who are considering competitive motocross participation, but also for organizational leadership of health systems in regions where competitions occur.
Adolescents who participate in high school sports experience injuries during competition at a rate of five injuries per 1000 athlete‐exposures, with approximately 7% of these requiring surgery. 18 As we do not know the exact number of competition participants each year, we cannot calculate a rate of injury. However, our findings suggest that children participating in this annual motocross competition risk sustaining an injury requiring hospital evaluation and many require interventions, including fracture reduction, procedural sedation, and surgical operations that themselves carry risk. These serious injuries occur despite regulations requiring protective gear for all competitors and horsepower limitations for younger riders. Our findings also demonstrate that even young children, and not only adolescents, sustain serious injuries during competitions. This demonstrated risk to young riders can be used to support advocacy efforts to consider raising the minimum age at motocross competitions, especially given existing literature to demonstrate cognitive ability to comprehend risk develops in early to middle adolescence. 19 , 20 Beyond consideration of age limits, there is also a demonstrated need to improve safety standards for adolescent competitors who were more likely to suffer multisystem injuries.
Our findings also show the substantial impact that amateur motocross competitions can have on nearby health systems. The large influx of injured pediatric patients impacts local emergency medical services and EDs, as well as hospital radiology and surgical subspecialty resources. In preparation for this, our hospital increases pediatric procedural sedation capacity by increasing ED physician staffing during the week of this event each year. However, many motocross competitions occur in rural regions, where nearby hospitals may not have the capacity to increase their already limited resources for pediatric trauma care. 2 , 21 Our study highlights areas in which ED clinicians and hospital leaders at such hospitals can focus their attention when preparing for these large‐scale, time‐limited events. In particular, coordinating such efforts with a pediatric readiness coordinator may be particularly important for children competing in these amateur events. 22
Overall, our findings are of critical importance to inform advocacy efforts to improve safety standards at motocross competitions, enhance readiness in hospitals where competitions occur, and improve parent education regarding the significant health risks associated with competitive motocross for children.
AUTHOR CONTRIBUTIONS
Erin B. Bruney, Carolyn K. Holland, Colleen K. Gutman, and Tricia Swan conceptualized and designed the study. Erin B. Bruney and Colleen K. Gutman designed the data collection instrument. Erin B. Bruney, Kalei M. Rollins, Carolyn K. Holland, Robyn Hoelle, David Martin, Colleen K. Gutman, and Tricia Swan collected data. Erin B. Bruney and Colleen K. Gutman carried out data analyses. Erin B. Bruney drafted the initial manuscript. Colleen K. Gutman and Tricia Swan supervised study conduct. All authors critically reviewed and revised the manuscript for important intellectual content, approved the final manuscript as submitted, and agreed to be accountable for all aspects of the work.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflicts of interest.
Supporting information
Supporting Information
ACKNOWLEDGMENTS
Colleen K. Gutman was supported by NIH/NCATS (KL2TR001429). The NIH/NCATS had no role in the design and conduct of the study.
Biography
Erin Bruney, MD, is a Pediatric Emergency Fellow in the Department of Emergency Medicine at the University of Florida in Gainesville, FL, USA.
Bruney EB, Rollins KM, Holland CK, et al. Racing to disaster: A 10‐year retrospective analysis of pediatric competitive motocross injuries. JACEP Open. 2024;5:e13267. 10.1002/emp2.13267
Colleen K. Gutman and Tricia Swan contributed equally as co‐senior authors.
Present address:
Tricia Swan, AdventHealth Ocala, Ocala, FL, USA.
Prior presentation: These data have been presented, in part, at the 2023 Pediatric Academic Societies Annual Meeting (Washington, DC), the 2023 Society for Academic Emergency Medicine Annual Meeting (Austin, TX), and the 2023 University of Florida College of Medicine Research Day (Gainesville, FL).
Marianne Gausche‐Hill, MD
REFERENCES
- 1. McIntosh AL, Christophersen CM. Motocross injuries in pediatric and adolescent patients. JAAOS—J Am Acad Orthop Surg. 2018;26(5):162‐165. doi: 10.5435/JAAOS-D-16-00405 [DOI] [PubMed] [Google Scholar]
- 2. American Motorcyclist Association. 2019. Accessed February 26, 2024. https://americanmotorcyclist.com/motocross‐arenacross/ [Google Scholar]
- 3. Stiles R, Benge C, Stiles PJ, et al. Evaluation of protective equipment used among motorbike riders. Kans J Med. 2018;11(2):44‐47. [PMC free article] [PubMed] [Google Scholar]
- 4. Prabhakaran S, Silagy AW, Campbell NA, Flanagan PV, Campbell IA. Paediatric injuries during the Australian Junior Motocross Championship treated at a rural centre. Med J Aust. 2018;208(6):270‐270. doi: 10.5694/mja17.01123 [DOI] [PubMed] [Google Scholar]
- 5. Pomerantz WJ, Gittelman MA, Smith GA. No license required: severe pediatric motorbike‐related injuries in Ohio. Pediatrics. 2005;115(3):704‐709. doi: 10.1542/peds.2004-1304 [DOI] [PubMed] [Google Scholar]
- 6. Larson AN, Stans AA, Shaughnessy WJ, Dekutoski MB, Quinn MJ, McIntosh AL. Motocross morbidity: economic cost and injury distribution in children. J Pediatr Orthop. 2009;29(8):847. doi: 10.1097/BPO.0b013e3181c1e2fa [DOI] [PubMed] [Google Scholar]
- 7. Kennedy RD, Potter DD, Osborn JB, et al. Childhood motocross truncal injuries: high‐velocity, focal force to the chest and abdomen. BMJ Open. 2012;2(6):e001848. doi: 10.1136/bmjopen-2012-001848 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Daniels DJ, Clarke MJ, Puffer R, Luo TD, McIntosh AL, Wetjen NM. High occurrence of head and spine injuries in the pediatric population following motocross accidents. J Neurosurg Pediatr. 2015;15(3):261‐265. doi: 10.3171/2014.9.PEDS14149 [DOI] [PubMed] [Google Scholar]
- 9. Dick CG, White S, Bopf D. A review of the number and severity of injuries sustained following a single motocross event. J Orthop. 2014;11(1):23‐27. doi: 10.1016/j.jor.2013.12.012 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Williams BA, McFadden JP, Teurlings TL, Blakemore LC. Pediatric injuries at an annual motocross competition: rates and severity. J Pediatr Orthop. 2017;37(3):e168. doi: 10.1097/BPO.0000000000000849 [DOI] [PubMed] [Google Scholar]
- 11. Arena CB, Holbert JA, Hennrikus WL. Injuries in the competitive paediatric motocross athlete. J Child Orthop. 2017;11(3):175‐179. doi: 10.1302/1863-2548.11.160262 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12. Mini O's Race Info . Accessed January 3, 2024. https://resultsmx.com/minio/raceorder.asp?e=235&r=dl
- 13. Harris PA, Taylor R, Minor BL, et al. The REDCap consortium: building an international community of software platform partners. J Biomed Inform. 2019;95:103208. doi: 10.1016/j.jbi.2019.103208 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14. Alderman EM, Breuner CC, Committee on Adolescence , et al. Unique needs of the adolescent. Pediatrics. 2019;144(6):e20193150. doi: 10.1542/peds.2019-3150 [DOI] [PubMed] [Google Scholar]
- 15. United States Census Bureau . Geographic levels. Census.gov. Accessed March 25, 2023. https://www.census.gov/programs‐surveys/economic‐census/guidance‐geographies/levels.html [Google Scholar]
- 16. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159‐174. doi: 10.2307/2529310 [DOI] [PubMed] [Google Scholar]
- 17. Gilbert EH, Lowenstein SR, Koziol‐McLain J, Barta DC, Steiner J. Chart reviews in emergency medicine research: where are the methods? Ann Emerg Med. 1996;27(3):305‐308. doi: 10.1016/S0196-0644(96)70264-0 [DOI] [PubMed] [Google Scholar]
- 18. Collins C, Anderson M, Burus T. National High School Sports‐Related Injury Surveillance Study: 2022–23 School Year. Datalys Center Sports Injury Research and Prevention. [Google Scholar]
- 19. Mann L, Harmoni R, Power C. Adolescent decision‐making: the development of competence. J Adolesc. 1989;12(3):265‐278. [DOI] [PubMed] [Google Scholar]
- 20. Weithorn LA, Campbell SB. The competence of children and adolescents to make informed treatment decisions. Child Dev. 1982;53(6):1589‐1598. [PubMed] [Google Scholar]
- 21. Pilkey D, Edwards C, Richards R, Olson LM, Ely M, Edgerton EA. Pediatric readiness in critical access hospital emergency departments. J Rural Health. 2019;35(4):480‐489. doi: 10.1111/jrh.12317 [DOI] [PubMed] [Google Scholar]
- 22. Foster AA, Hoffmann JA. Saving children's lives by improving pediatric readiness for emergency care. JAMA Netw Open. 2023;6(1):e2250951. doi: 10.1001/jamanetworkopen.2022.50951 [DOI] [PubMed] [Google Scholar]
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Supplementary Materials
Supporting Information