title: School playground surfacing and arm fractures in children: a cluster randomized trial comparing sand to wood chip surfaces.
abstract: BACKGROUND
  The risk of playground injuries, especially fractures, is prevalent in children, and can result in emergency room treatment and hospital admissions. Fall height and surface area are major determinants of playground fall injury risk. The primary objective was to determine if there was a difference in playground upper extremity fracture rates in school playgrounds with wood fibre surfacing versus granite sand surfacing. Secondary objectives were to determine if there were differences in overall playground injury rates or in head injury rates in school playgrounds with wood fibre surfacing compared to school playgrounds with granite sand surfacing.
  
  
  RESULTS
  The cluster randomized trial comprised 37 elementary schools in the Toronto District School Board in Toronto, Canada with a total of 15,074 students. Each school received qualified funding for installation of new playground equipment and surfacing. The risk of arm fracture from playground falls onto granitic sand versus onto engineered wood fibre surfaces was compared, with an outcome measure of estimated arm fracture rate per 100,000 student-months. Schools were randomly assigned by computer generated list to receive either a granitic sand or an engineered wood fibre playground surface (Fibar), and were not blinded. Schools were visited to ascertain details of the playground and surface actually installed and to observe the exposure to play and to periodically monitor the depth of the surfacing material. Injury data, including details of circumstance and diagnosis, were collected at each school by a prospective surveillance system with confirmation of injury details through a validated telephone interview with parents and also through collection (with consent) of medical reports regarding treated injuries. All schools were recruited together at the beginning of the trial, which is now closed after 2.5 years of injury data collection. Compliant schools included 12 schools randomized to Fibar that installed Fibar and seven schools randomized to sand that installed sand. Noncompliant schools were added to the analysis to complete a cohort type analysis by treatment received (two schools that were randomized to Fibar but installed sand and seven schools that were randomized to sand but installed Fibar). Among compliant schools, an arm fracture rate of 1.9 (95% confidence interval [CI] 0.04-6.9) per 100,000 student-months was observed for falls into sand, compared with an arm fracture rate of 9.4 (95% CI 3.7-21.4) for falls onto Fibar surfaces (p< or =0.04905). Among all schools, the arm fracture rate was 4.5 (95% CI 0.26-15.9) per 100,000 student-months for falls into sand compared with 12.9 (95% CI 5.1-30.1) for falls onto Fibar surfaces. No serious head injuries and no fatalities were observed in either group.
  
  
  CONCLUSIONS
  Granitic sand playground surfaces reduce the risk of arm fractures from playground falls when compared with engineered wood fibre surfaces. Upgrading playground surfacing standards to reflect this information will prevent arm fractures.
  
  
  BACKGROUND
  Current Controlled Trials ISRCTN02647424.
authors.affiliation: Division of Orthopaedic Surgery, Hospital for Sick Children, Toronto, Ontario, Canada. andrew.howard@sickkids.ca
authors.forename: Andrew W
authors.initials: AW
authors.lastname: Howard
authors.forename: Colin
authors.initials: C
authors.lastname: Macarthur
authors.forename: Linda
authors.initials: L
authors.lastname: Rothman
authors.forename: Andrew
authors.initials: A
authors.lastname: Willan
authors.forename: Alison K
authors.initials: AK
authors.lastname: Macpherson
mesh_terms: D001134:Arm Injuries / Q000453:epidemiology*; D002170:Canada / Q000453:epidemiology; D002648:Child; D016000:Cluster Analysis; D006259:Craniocerebral Trauma / Q000453:epidemiology; D050723:Fractures, Bone / Q000453:epidemiology*; D006801:Humans; D018570:Risk Assessment; D012574:Schools; D012822:Silicon Dioxide; D013499:Surface Properties; D014934:Wood
chemical_list: D012822:Silicon Dioxide