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. 2015 Jun 30;3(1):3–9. doi: 10.1002/ams2.118

Horse kick injury mimicking a handle bar injury or a hidden speared injury

Yasumasa Oode 2, Tetsuro Maruyama 1, Masayuki Kimura 1, Toru Fukunaga 1, Kazuhiko Omori 2, Youichi Yanagawa 2,✉
PMCID: PMC5667223  PMID: 29123740

Abstract

A 16‐year‐old male was transported to our emergency department after he was kicked in the abdomen by a horse. He was diagnosed with injury of the liver and abdominal rectus muscle, and was cured by observational treatment. An Ichushi search was undertaken to identify articles published from 1983 to 2013 using the key words “horse” and “trauma”. We found 13 cases that described horse‐related injuries and summarized these cases, including our case. There were 10 males, three females and one patient of an undescribed sex. The patients ranged in age from 16 to 58 years old, with an average age of 33 years. The injured sites were predominantly the face (mandible) and upper abdomen, indicating that a projecting part of the body may be more likely to be injured. Cardiac rupture, aortic head injury, or lethality induced by a horse kick have not been reported in Japan, but such injuries have been reported in other countries. Ten of 15 cases (67%) required surgical treatment for severe injuries. Horse kick injuries tend to be severe, because the transfer of energy from the end of the hoof, with a small cross‐sectional area, to a small field, leads to internal organic injuries that are more severe than predicted, similar to a handlebar injury. Accordingly, we advocate the close observation of patients with horse kick injuries, which may be regarded as being similar to blunt stab wounds or hidden speared injuries.

Keywords: Handle bar injury, hidden speared injury, horse kick injury, liver injury, observation

Introduction

Injuries caused by horses are rare.1, 2 Most cases are injuries due to a fall from a running horse, which is equivalent to a high energy accident. The other mechanisms of injuries include those due to a kick or bite, or being dragged.1, 2, 3, 4, 5 We herein present a rare case of injury induced by a horse kick and a review of published reports.

Case

A 16‐year‐old male was kicked in the abdomen by a horse when he performed warm‐up exercises prior to participating in an equestrian event. He was transported to Numazu City Hospital by a helicopter emergency medical service due to severe abdominal pain. He had asthma and was being treated with fluticasone/salmeterol. On arrival, he was alert with a blood pressure of 150/94 mmHg, a heart rate of 72 b.p.m., a 99% SpO2 under room air, and a body temperature of 37.4°C. He had right hypochondrial pain, a scabbing wound induced by the horse kick (Fig. 1), and tenderness without peritoneal irritation signs.

Figure 1.

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Abdominal appearance on arrival of a 16‐year‐old male patient who was kicked in the abdomen by a horse. The patient had a scabbing wound induced by the horse kick.

Other findings were: white blood cell count, 16,500/μL; hemoglobin, 11.5 g/dL; platelets, 43.0 × 104/μL; total protein, 7.2 g/dL; aspartate aminotransferase, 181 IU/L; alanine aminotransferase, 144 IU/L; glucose, 98 mg/dL; blood urea nitrogen, 14.7 mg/dL; creatinine, 0.75 mg/dL; sodium, 143 mEq/L; potassium, 4.5 mEq/L; chloride, 103 mEq/L; creatine phosphokinase, 343 IU/L; C‐reactive protein, <0.1 mg/dL; and troponin T, negative. A urinary occult blood examination was negative. An electrocardiogram was also negative for abnormalities.

An abdominal echo revealed a highly echoic area at segments 5 and 8 of the liver, with fluid retention at the rectovesical pouch (Fig. 2). His hepatic lesion corresponded to a type IIIa hepatic injury according to the classification of the Japanese Association for the Surgery of Trauma. A plain trunk computed tomography scan also showed the same lesion. He was diagnosed with injury of the liver and abdominal rectus muscle, and was admitted to the hospital for observation and fasting because his vital signs were stable. His symptoms and signs improved day by day, and a repeated abdominal echo showed decreasing fluid at the rectovesical pouch. After confirming decreases in the aspartate aminotransferase and alanine aminotransferase levels, he was discharged to home.

Figure 2.

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Results of abdominal ultrasound on arrival of a 16‐year‐old male patient who was kicked in the abdomen by a horse. The scan revealed a high‐echoic area at segments 5 and 8 of the liver (the left side, arrowed), with fluid retention at the rectovesical pouch (the right side, arrowed).

Discussion

An Ichushi search (Japana Centra Revuo Medicine), which collects summaries of Japanese medical articles, was undertaken to identify articles published between 1983 and 2013 using the key words “horse” and “trauma”. We found eight articles and two abstracts, including 13 cases that described horse‐related injuries.5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 We summarized these cases, including our present case, in Table 1. The patients included 10 males, three females, and one of undescribed sex. They ranged in age from 16 to 58 years, with an average age of 33 years. The injured sites were predominantly the face (mandible) and upper abdomen. One case was injured by a front hoof,8 but most cases were induced by kicks from the rear legs. A projecting part of the body may be more likely to be injured, because the rear legs of a horse kick upward.

Table 1.

Summary of horse kick injuries reported in Japan

Ref. Age, years Sex Injured site Treatment
6 20s M Rupture of the small intestine Surgical repair
6 60s F Liver injury Observation
6 30s M Rupture of the small intestine Surgical repair
7 20 M Mandibular fracture Internal fixation
7 ND ND Maxillary fracture ND
8 37 F Mandibular fracture, neck sprain Intermaxillary anchorage
9 29 M Pancreatic injury Letton–Wilson procedure
10 54 M Pancreatic injury Necrotomy and drainage
11 28 M Rupture of the duodenum Surgical repair
12 37 M Rupture of the duodenum Surgical repair
13 23 M Ascending colon injury Surgical repair
14 20 F Mandibular and cervical fractures Internal fixation
15 58 M Paniculitis Surgical removal
Present 16 M Liver injury Observation
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F, female; M, male; ND, not described; Ref., reference number.

Our search of published work using the key words “horse” and “kick” on PubMed identified 48 reports; of these, 34 reported treatment of humans and 14 reported treatment of horse injuries. Of the 34 reports of humans, one treated a patient with an ovarian tumor who had a past history of a horse kick injury that was not related to the ovarian tumor. Among the 33 human reports of a horse kick injury, 20 were case reports, while the other 13 included one prospective study, seven retrospective studies, three surveys using questionnaires, and two reviews.4, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47 The case reports are summarized in Table 2,16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 and all reports other than case reports are summarized in Table 3.4, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47 Cardiac rupture and/or lethal head injuries induced by horse kicks have not been previously reported in Japan, although these injuries have been documented in other countries.18, 37

Table 2.

Published case reports of horse kick injuries

No. Lead Reporter Patient age, years Sex Diagnosis Outcome
 1 Sarin 43 M Blunt aortic rupture Survived
 2 Gorman 43 F Right ventricular rupture Survived
 3 Ebert 13 F Left ventricular rupture Death
 4 Alami 35 M Right atrial rupture Survived
 5 Skene 47 F Pericardial effusion Survived
 6 Byrne 63 M Tricuspid regurgitation and right‐to‐left intra‐atrial shunt Survived
 7 Tatabe 22 M Tricuspid insufficiency Survived
 8 Knobloch 29 F Tricuspid insufficiency Survived
 9 Benitez 47 M Complete heart block Survived
10 Pérez de Juan Romero 21 M Myocardial infarction Survived
11 Ogawa 56 M Cranial penetration injury Survived
12 Downar 49 F Streptococcal meningitis after head trauma Survived
13 Martins 45 M Dentoalveolar and mandibular body fractures Survived
14 Kannan 42 M Facial injury Survived
15 Andratschke ND ND Arteriovenous fistula of the orbit Survived
16 Freitas 6 M Multiple avulsions of deciduous teeth Survived
17 Steinhorst 12 F Orbital fractures and blunt eye trauma Survived
18 Lodder 34 F Rupture of the thyroid gland Survived
19 Méndez‐Gallart 8 M Duodenal rupture Survived
20 Horwitz 8 M Major hepatic injury Survived
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F, female; M, male; ND, not described in abstract.

Table 3.

Published reports of horse‐related injuries including kicks, excluding case reports

No. Lead Reporter Design Total no. of patients Average patient age, years Range of patients' ages, years Sex (%male) Mortality, n (%) Subject Main results
 1 Balakrishnan Retrospective 20 22 5–48 2 (10) 0 (0.0) Liver trauma after falling from or being kicked; treated in the regional hepatopancreaticobiliary unit at a tertiary referral center Only 2 patients required laparotomy and liver resection, remaining 18 were successfully managed conservatively, early CT imaging is advised
 2 Carmichael Retrospective 284 37.2 ND 145 (51) 3 (1.0) Horse‐related injuries in a single Level I trauma center Most injuries occurred due to falling off while riding (54%) or kick (22%)
Extremity fracture (33%) and head injury (27%)
Mounted equestrians more commonly incurred injury to the chest and lower extremity
Unmounted equestrians incurred injury to the face and abdomen
Head trauma frequency was equal between mounted and unmounted equestrians
3 deaths, 2 of which were due to severe head injury from a kick
 3 Zhang Retrospective 149 ND 5–65 91 (61.0) ND Cranio‐facial injuries caused by animals in southern‐central part of China Bite was the predominant mechanism of injury, followed by kick, fall, trample, knock, and scratch
 4 Eckert Prospective 24 22.6 7–34 2 (8.3) 0 (0.0) Equestrian injuries caused by horse kicks; multicenter study including 9 trauma centers in Hamburg, Germany All accidents (100%) occurred while the equestrians were handling or grooming the horse
16 riders (66.7%) suffered orbital, midface, or mandible fractures; 8 riders (33.3%) had injuries on other parts of the body
 5 Kiuru Retrospective 46 30 16–55 3 (6.5) 1 (2.1) Horse‐riding accidents treated in a single Level I trauma center Falling off a horse (72%), horse kick (11%), and crushing injury caused by a falling horse (13%)
5 head, 3 facial, 13 spine, 5 body, 2 pelvic, and 3 lower extremity trauma. Multiple injuries were seen in 5 (11%) patients. In 21 patients (46%) multi‐slice CT examination was normal
In 1 patient the injuries were lethal (head trauma)
 6 Exadaktylos Retrospective 17 36 16–74 6 (35.2) 0 (0.0) Horse kick injury in Switzerland 8 of 17 patients sustained contusions of the extremities, the back, and the trunk. In 9 patients an isolated facial injury was diagnosed
The equestrian community may underestimate the risk of severe injuries attributable to hoof kicks, especially while handling the horse
 7 Costa Retrospective 1 (13) <3 ND ND ND Ventricular assist devices in pediatric cardiac surgery Cardiac trauma induced by horse kick
 8 Busch Retrospective 11(134) ND ND ND 0 Blunt bovine and equine trauma treated in a single Level II trauma center Fall from horse in 45 patients, animal assault in 42, animal kick in 39, and animal‐drawn vehicle in 8
 9 Meredith Questionnaire ND ND ND ND ND Horse‐related facial injuries in riding school Falls were perceived to be the most common cause of facial injury (41%), ahead of horse kicks (9%)
10 Jäggin Questionnaire ND ND ND ND ND Questionnaires to 700 veterinary practitioners concerning horse kick injury Severe injuries incurred by veterinarians in recent years were few
11 Giebel Questionnaire 155 ND ND ND 1 (0.6) Equestrian accidents in children younger than 16 years in Germany The typical patient profile was that of young female equestrian with little experience and little weekly riding practice, without practicing falling‐exercises and warming up, often using different horses
Falling of the horse (64.9%) and falling with the horse (5.7%) were accidents of special significance. Kick by horse's hoof (11.8%), being stepped by horse (3.8%), horsebite (7.3%) and injuries of horse's bridle had their own patterns of injuries. Injuries of the distal parts of the upper extremity are preeminent in falling of the horse, whilst in falling with the horse head injuries and shoulder injuries are preeminent. Remarkably often horse kicks were causing dangerous head injuries (41.6%). One fatal accident happened in handling a horse
12 Bury Review ND ND ND ND ND Animal‐related fatalities Blunt force injuries characteristically involve larger animals such as cattle or horses that may kick, crush, or trample a victim causing head and facial injuries
Farm workers in particular are at high risk of lethal injuries involving the head and torso
13 Jagodzinski Review ND ND ND ND ND Horse‐related injuries in children Estimated 13,400 emergency department visits nationwide for horse‐related injuries among children younger than 15 years
Most serious injuries occur when a rider is thrown form a horse, which is often accompanied by being dragger or crushed by the horse. Hoof kick injuries to an unmounted child represent about 30% of horse‐related injuries and may result in more severe injury
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ND, not described.

In a case report concerning hepatic injury, Horwitz et al. reported the successful treatment of an 8‐year‐old male with a devitalized right lobe of the liver and avulsion of the right hepatic vein using venovenous bypass to obtain a stabilized circulation and bloodless operative field.35 Balakrishnan et al. reported 20 cases of hepatic injury induced by horse kicks or falls from horses.36 All patients had right‐sided rib fractures, and computed tomography indicated laceration of the liver in 12 patients, contusion in three patients, and subcapsular hematoma in two patients. Only two patients required laparotomy and liver resection; the remaining 18 were successfully managed conservatively, similar to the present case.

Carmichael et al. reported the largest series (284 cases) of horse‐related injuries to date.37 In that report, most injuries occurred due to falling off while riding (54%) or sustaining a kick from the horse (22%), resulting in extremity fractures (33%) and head injury (27%). Mounted equestrians more commonly incurred injury to the chest and lower extremities, whereas unmounted equestrians received injuries to the face and abdomen, primarily due to horse kicks, similar to the above Japanese series. There were three deaths, two of which were the result of severe head injuries from kicks.

One of the reasons for this is that horse kick injuries tend to be severe, because the transfer of energy from the end of the hoof, with a small cross‐sectional area, to a small field, leads to internal organ injuries that are more severe than predicted, similar to a handlebar injury.48, 49 Accordingly, we advocate the close observation of patients with horse kick injuries, which may be regarded as being similar to blunt stab wounds or hidden speared injuries.

Conflict of Interest

None.

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