1. Galen Cummings DO – MountainView Regional Medical Center
2. Jordan Johnson DO – MountainView Regional Medical Center

ABSTRACT

Introduction
There are more than 15,000 golf cart-related injuries resulting in Emergency Department (ED) visits each year in the United States. To date, there have been no specific analyses of serious orthopedic injury frequency, demographics, locations, or affected populations. Variable safety and operational requirements play a role in the increasing incidence of major injuries. The objective of this study is to estimate the national orthopedic injury burden and review current regulations on the state and federal level.

Methods
Data extracted from the National Electronic Injury Surveillance System (NEISS) was compiled and retrospectively analyzed for patients of all ages who were treated in EDs following golf cart-related fracture, amputation, dislocation, or death between 2012 and 2021. Golf cart safety equipment and operational regulations on a federal and state level were reviewed and summarized.

Results
Between 2012 and 2021, an estimated 35,453 (95% CI = 20,530-50,375) patients visited EDs in the United States for treatment of golf cart-related orthopedic injury. Fracture was the most commonly sustained injury, constituting 93% of injuries (934 of 1004 in our sample). Dislocations represented 6% (61 of 1004). Amputations represented the remaining 1% (9 of 1004). Children sustain a disproportionate number of injuries (37% overall, 39% of fractures). Cart operation regulation and safety requirements are minimal and highly variable. 

Conclusions
The rate of US golf cart-related injury continues to increase in parallel with increasingly widespread golf cart use. Regulatory efforts remain inadequate and inconsistent across jurisdictions. Awareness and advocacy for improved safety equipment and public use guidelines should be considered to reduce golf cart-related orthopedic morbidity.

Keywords: Golf cart, fracture, amputation, dislocation

INTRODUCTION
Golf cart use and popularity has continued to increase over the last several years. They have become an increasingly widespread and established choice for moving people in multiple settings beyond the golf course, including around sporting events, schools, certain communities, hospitals, airports, and prisons. Several states also allow use of golf carts for transportation on public roads. Golf carts are considered by many to be safe and relatively harmless vehicles that are highly practical for their ability to navigate multiple terrains with reduced size, minimal noise, and general ease of use (5,8)  

Despite their obvious utility and benign appearance, it has been noted by several authors in recent years that golf carts are involved in a significant number of injuries and occasional fatalities annually (1,3,5-8,10-17). The yearly injury figures have increased steadily over the last 3 decades from approximately 6,000 emergency department visits in 1990 to 18,000 in 2015 (5,16). More recent national analyses of the available data have estimated well over 150,000 total emergency department visits due to golf cart-related injuries between 2007 and 2017 (5).

Relatively lax and highly varied laws regarding the use, operation, and required safety features of golf carts have very likely played a role in injury figures. While some “low-speed vehicles,” or LSVs, are mandated to meet certain federal safety standards and pass inspection, rules regarding golf carts and other such slow-moving, off-road vehicles are much more inconsistent or nonexistent (5). At the state level, laws and regulations regarding operation are highly variable. Valid driving licenses are only required in certain states and municipalities. The requirements for safety equipment also vary widely with regard to laws requiring functioning lights, signals, or seatbelts. Many jurisdictions have no requirements at all for safety features (4,8). Inexperienced operators with inadequate safety equipment contribute to severe injury incidence nationwide (10,15,16).

There has been substantial and robust analysis of the impact of golf-cart-related injuries leading to emergency department visits in general, but no specific investigation of associated major orthopedic injuries in particular (1,3,5-8,10-17). The last nationwide evaluation of all golf cart-related injuries by type, incidence, and rate of occurrence was published five years ago by Horvath, et al (5). They reported on all golf cart-related injuries that were evaluated in an ED setting, including sprains, and lacerations (5). In this paper, we will focus on major skeletal injuries in particular, such as fracture, dislocation, amputation, and death in an attempt to highlight the role of these vehicles in cases involving severe morbidity and mortality.

METHODS
The National Electronic Injury Surveillance System (NEISS) is a statistically valid surveillance and follow-back system in which the United States Consumer Product and Safety Commission (CPSC) collects data on consumer-product-related injuries that occur in the United States. The CPSC makes probability estimates of these injuries based on data collected from a number of participating representative hospitals in the United States (US) and its territories. These participating hospitals report each product-related emergency department (ED) visit including patient demographic data as well as details of the injury and involved products.

In this study, we queried the NEISS database for major skeletal injuries presenting to US emergency departments involving golf carts from the years 2012-2021. The authors reviewed the data for patient demographics, injury type, body part injured, injury location, and ED disposition. Data was cross-checked and confirmed using the column in the original data from NEISS which gives a brief summary for each patient encounter. All recorded injuries involved operation or care of a golf cart by the patient being treated or another individual. These injuries were categorized and counted. The authors evaluated totals and trends across the data. Descriptive reports of these data are given in this report.

The authors reviewed state laws for golf cart use in public settings using the Golf Cart Resource, which is available online (4). This resource provides summaries of the available laws and regulations for the majority of US states. We summarized our findings in Appendix 1.

RESULTS
In our review of the data, there were a total of 1004 major orthopedic injuries between 2012 and 2021 involving golf carts that resulted in fracture, amputation, dislocation, or death. The average patient age was 38.21 years old over the studied time period, and fairly consistent from year to year (range: 32.19-41.98 years). Pediatric average age was found to be 10.46 years of age (patients <18 years), adult average age was 55.36 years of age (patients >/=18). See Table 1.

Ethnicities involved were reported to NEISS as 56% “white”, 4.5% “black”, 0.5% “Hispanic”, and “not specified” for the remaining 39% of patients. See Table 2. Men constituted 553 of the injured parties (56%), and women 437 (44%). See Table 3. Alcohol (31 cases), drugs (4 cases), or both (3 cases) were involved in a minority of injuries, but it should be noted that these substances were not consistently included in the datasets until 2019 and these figures are therefore not generalizable across the data.

The most common severe orthopedic injury was fracture. This represented 93% of major orthopedic injuries (934/1004) overall. 39% of the fractures were sustained by pediatric patients (362/934) and 61% by adults (572/934). There were 9 total amputations (7 adult, 2 pediatric). Of these amputations, 7 were of the upper extremity, 2 were of the lower. Adults sustained 55 of the 61 total dislocations, the majority of these (27/55) occurring in the upper extremity, 15 in the hip, and 13 in the lower extremity. There were 3 upper extremity dislocations (50%) and 3 hip dislocations (50%) reported in the pediatric population. See Table 4.

The locations where patients sustained golf cart-related injuries were identified as “home” in 94 cases, once on the “farm,” 54 on the “street,” 41 in “public,” once involving a mobile home, 3 at school, 308 in the sporting setting including on golf courses, and 485 were listed as “unknown” in the database. See Table 5.

Disposition from emergency departments was “discharge home” in 662 of 987 encounters. 325 total patients were admitted from the ED to the hospital. Of these, 88 patients were pediatric (27%) and 237 were adults (73%). In the aggregated data between 2012 and 2021, there were no reported fatalities within the emergency departments reporting.

A detailed review of golf cart regulations by state was undertaken and findings are summarized in Appendix 1. Some of the key findings include: 11 states limit golf cart top speeds to 20-25mph, 21 states require basic features such as headlights and brake/tail lights, 5 states require seatbelts, 19 states allow golf carts to be operated on public roads with posted speed limits of 25-35mph (4).

DISCUSSION
From 2012 to 2021, there were 1004 emergency department visits reported to the NEISS following severe orthopedic injuries sustained while operating or caring for a golf cart. This represents an estimated 35,453 (95% CI = 20,530-50,375) total ED visits nationwide for treatment of fracture, dislocation, or amputation during the 10-year study period between 2012 and 2021 (2). While this is a small fraction of the estimated 12,000-18,000 ED visits per year (approximately 150,000 total visits in the study period) due to all golf cart-related injuries, it does represent a significant and increasing number of severe skeletal injuries from the use of such innocuous vehicles (9,12). A bimodal distribution of these injuries in the pediatric and mature adult populations has been noted in a number of previous works on the topic (5,8,9). Our observations are broadly consistent with these findings, though there remains a consistent, robust prevalence of injuries across the entire age spectrum with increasing incidence over the years analyzed. The popularity and availability of these vehicles in ever-widening applications and locales enables increased access, subsequently leading to additional injury potential. See Tables 6 and 7.

The role of improving the available safety features on golf carts has been studied and many of the injury narratives and mechanisms reviewed in our analysis support previous authors’ conclusions: Rear-facing seating, inadequate or absent seat belt restraints, lack of four-wheel brakes, and open-air cabin design have all been shown to contribute to injuries sustained (5, 13).  Ejection and falls from moving carts are among the most common mechanisms observed (12,17). Many of these frequently-encountered injuries would have benefitted from improved enclosure, restraint of passengers, better braking, and/or improved cornering stability (13). Certainly, some incidents involving golf carts, such as collision with standard passenger vehicles on public roads, are difficult  to mitigate even with the addition passive personal protective gear or improved drivability. These injuries tend to be quite severe, but are fortunately relatively rare in our data and across the general US (1,3,11).

Highly variable local and federal laws regarding the required safety equipment for the use and operation of golf carts beyond the links was also reviewed here. As demonstrated in Appendix 1, the laws from state to state are highly varied. Fewer than half of states (24 in total) require the driver of a golf cart to possess a valid driver’s license or operator’s permit and insurance to use the vehicles on public thoroughfares. Further regulation is frequently defined at the municipal government level and many states also defer to local guidelines for safety equipment and usage rules (4). Case series have noted severe injuries and deaths, especially from golf cart-versus-automobile wrecks on public streets (1,3,11). This suggests that present safety equipment requirements and usage laws are inadequate in several jurisdictions.

Our analysis builds upon the growing body of literature regarding the capacity for occupant injury with golf cart use, especially with broadening use that includes driving among full-size passenger vehicles (1,3,11). In specific evaluation of rates and demographics of those sustaining serious orthopedic injury, we have found that fracture is by far the most common, most often occurring in adults, and is increasing in frequency. See Table 6. We have further stratified this data by anatomical location of the fracture in Table 7. Children in other studies of all golf cart-related injuries, including those sustaining non-orthopedic injuries, comprise 30-40% of the reported injuries. This is a rate that is near double that of adults (8). Interestingly, these general injury figures in the pediatric population are broadly consistent with our observation that serious pediatric orthopedic injuries accounted for 37% of the total number analyzed. See Table 4.

Limitations: As with other studies utilizing the NEISS reporting database, there are some inherent limitations to our analysis. This is a retrospective review that relies, in part, upon very short narratives and limited coding specificity that can limit the granularity of the data and potentially lead to bias from reporter or reviewer. Prior to 2019, the system only allowed for a single diagnosis code to be entered for a patient, which could generate additional reporting bias with polytraumatized patients. NEISS is also a measure of a representative sampling of visits to emergency departments, which likely underestimates the true number of injuries due to those seeking care in other settings, or not seeking formal care at all (2). Pre-hospital and post-ED mortality is also unaccounted for in the NEISS data reporting tool.

CONCLUSION
The incidence of golf cart-related serious orthopedic injuries has been on a steady upward trajectory over the last several years. There have been good quality studies published outlining steps that can be taken by manufacturers and users to increase safety in golf carts, but given the lack of consistent governmental regulation of this sector of vehicles, morbidity and mortality figures associated with their increasing use continue to rise (13,14). Addressing lax regulation at the state government level, particularly in those states with limited regulation and where golf carts are allowed to comingle with passenger car traffic would likely prove beneficial for the population utilizing these machines. Additional research should analyze the severity of pre-hospital and post-ED treatment, outcomes, morbidity, mortality, and cost of golf-cart related injuries in the US.

DISCLOSURES
The authors or their immediate family members have no financial conflicts of interest to report. No outside funding was utilized for this research.

Tables 1-2 | Tables 3-4 | Tables 5-6 | Table 7

REFERENCES

1. Castaldo JE, Raquet B, Robert, VandeWeerd C. 2020. “Analysis of Death and Disability due to Golf Cart Crashes in The Villages, Florida: 2011-2019.” Traffic Injury Prevention 21 (7): 437–41.
2. Consumer Product Safety Commission. National Electronic Injury Surveillance System 2002-2021. NEISS Online Database. Published April 2022. Accessed November 18, 2022. https://www.cpsc.gov/cgibin/NEISSQuery/home.aspx
3. Garay M, Silver J, Reynolds AW, Hess J, Armstrong D, Hennrikus W. 2022. “Golf Cart Injuries in Children: The Experience of Trauma Centers in a Single State in the USA.” Journal of Pediatric Orthopaedics Part B 31 (1): E44–48.
4. “Golf Cart State Laws and Regulations.” n.d. Golf Cart Resource. https://golfcartresource.com/golf-cart-state-laws-regulations/#nostate.
5. Horvath KZ, McAdams RJ, Roberts KJ, Zhu M, McKenzie LB. 2020. “Fun Ride or Risky Transport: Golf Cart-Related Injuries Treated in U.S. Emergency Departments from 2007 through 2017.” Journal of Safety Research 75 (December): 1–7.
6. Kelly EG. 1996. “Major Injuries Occurring during Use of a Golf Cart.” Orthopedics 19 (6): 519–21; discussion 521–23.
7. Linnaus ME, Ragar RL, Garvey EM, Fraser JD. 2017. “Injuries and Outcomes Associated with Recreational Vehicle Accidents in Pediatric Trauma.” Journal of Pediatric Surgery 52 (2): 327–33.
8. McGwin G, Zoghby JT, Griffin R, Rue LW. 2008. “Incidence of Golf Cart-Related Injury in the United States.” Journal of Trauma – Injury, Infection and Critical Care 64 (6): 1562–66.
9. Miller BL, Waller JL, McKinnon BJ. 2011. “Craniofacial Injuries due to Golf Cart Trauma.” Journal of Otolaryngology – Head & Neck Surgery = Le Journal D’oto-Rhino-Laryngologie et de Chirurgie Cervico-Faciale 144 (6): 883–87.
10. Miller B, Yelverton E, Monico J, Replogle W, Jordan JR. 2016. “Pediatric Head and Neck Injuries due to Golf Cart Trauma.” International Journal of Pediatric Otorhinolaryngology 88 (September): 38–41.
11. Passaro KT, Cole TB, Morris PD, Matthews DL, Mac Kenzie WR. 1996. “Golf Cart Related Injuries in a North Carolina Island Community, 1992-4.” Injury Prevention: Journal of the International Society for Child and Adolescent Injury Prevention 2 (2): 124–25.
12. Sciarretta JD, Harris T, Romano A, Davis BD, Pepe A. 2016. “Golf Cart-Related Injuries: A Community at Risk.” The American Surgeon 82 (1): E36–37.
13. Seluga KJ, Baker LL, Ojalvo IU. 2009. A parametric study of golf car and personal transport vehicle braking stability and their deficiencies. Accident Analysis and Prevention, 41(4), 839–848.
14. Simpson B, Shepard S, Kitagawa R. 2019. “Golf Cart Associated Traumatic Brain Injury.” Brain Injury: [BI] 33 (11): 1476–78.
15. Starnes JR, Unni P, Fathy CA, Harms KA, Payne SR, Chung DA. 2018. “Characterization of Pediatric Golf Cart Injuries to Guide Injury Prevention Efforts.” The American Journal of Emergency Medicine 36 (6): 1049–52.
16. Tracy BM, Miller K, Thompson A, Cooke-Barber J, Bloodworth P, Clayton E, Boswell W. 2020. “Pediatric Golf Cart Trauma: Not Par for the Course.” Journal of Pediatric Surgery 55 (3): 451–55.
17. Watson DS, Mehan TJ, Smith GA, McKenzie LB. 2008. “Golf Cart-Related Injuries in the U.S.” American Journal of Preventive Medicine 35 (1): 55–59.
18. White LC, McKinnon BJ, Hughes CA. 2013. “Etiologies of Pediatric Craniofacial Injuries: A Comparison of Injuries Involving All-Terrain Vehicles and Golf Carts.” International Journal of Pediatric Otorhinolaryngology 77 (3): 414–17.

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