Irreducible extremity fractures in pediatric and adolescent rodeo-related trauma: A retrospective case series

Abstract

Purpose:

Although most pediatric extremity fractures can be managed with closed reduction, even when operative fixation is required, youth rodeo exposes participants to high-energy livestock-related trauma that may produce fracture patterns associated with failed closed reduction. This study described operative management and fracture irreducibility in pediatric and adolescent extremity injuries sustained during organized rodeo participation.

Methods:

A retrospective case series was performed at a Level I pediatric trauma center. Patients aged ≤18 years who sustained injuries during organized rodeo participation between November 2017 and December 2023 were identified through trauma registry review. Demographics, injury characteristics, operative management, and intraoperative findings were recorded. Fractures were classified as irreducible when documented closed reduction attempts failed, and open reduction was required to obtain satisfactory alignment.

Results:

Forty-one patients with rodeo-related injuries were identified. Orthopedic injuries occurred in 21 patients (51.2%), including 18 extremity fractures (43.9%). Thirteen of eighteen extremity fractures (72.2%) were managed operatively. Open reduction after unsuccessful closed reduction attempts was required in 5 of 13 operatively treated fractures (38.5%), representing 27.8% of all extremity fractures. Irreducible injuries included femoral shaft fractures, elbow fracture-dislocations, Monteggia injuries, proximal humerus fractures, and both-bone forearm fractures.

Conclusion:

Pediatric and adolescent rodeo-related extremity fractures were frequently managed operatively, and open reduction was required in a substantial proportion of surgically treated cases. These findings should be interpreted descriptively because no matched comparison cohort was available.

Significance of study:

This single-center series suggests that failed closed reduction may occur in several pediatric and adolescent rodeo-related extremity fracture patterns.

Level of evidence:

IV (Therapeutic Case Series)

Keywords

pediatric trauma rodeo injuries fracture irreducibility open reduction high-energy mechanisms extremity fractures

Introduction

Most pediatric extremity fractures can be managed successfully with nonoperative treatment or closed reduction. This is largely attributable to the thick periosteum in children, which helps maintain alignment, along with reliable healing potential and substantial remodeling capacity.¹ Even when surgery is required, femoral shaft and diaphyseal forearm fractures are commonly treated with flexible intramedullary nails following successful closed reduction.^2–8 In published pediatric cohorts, open reduction is necessary in only a minority of operatively treated fractures, generally reported between 5% and 25% depending on fracture type and study population.^2–8

When closed reduction is unsuccessful, operative findings often include periosteal interposition, muscle entrapment, or incarcerated fracture fragments preventing satisfactory alignment.^2,3,9–11 Although well described, these patterns are uncommon in general pediatric trauma populations, where most injuries result from falls and recreational activities. The extent to which the injury mechanism influences the likelihood of successful closed reduction remains unclear. High-energy trauma involving axial loading, rotational forces, and abrupt deceleration may result in greater displacement and soft-tissue disruption, making closed reduction more difficult to achieve. As a result, fracture behavior in high-energy settings may differ from what is routinely seen in general pediatric cohorts.

Organized youth rodeo represents one such high-energy environment. Participation begins at a young age under national governing associations.^12,13 Rough stock events, including bull and bronco riding, expose competitors to large animal mass, repetitive acceleration–deceleration, rotational forces, and high-energy falls. Injury rates have been reported at approximately 8.2 per 1000 competitor exposures, with greater severity observed in rough stock events than in timed events.¹⁴ Prior systematic reviews and pediatric series have shown that extremity injuries are common and frequently require operative treatment in this population,^15–17 and trauma-center data confirm a meaningful injury burden associated with rodeo participation.¹⁸ Broader sports injury literature also emphasizes the magnitude of force transmission in animal-related athletic activities.¹⁹

Although the epidemiology of rodeo injuries has been described, the frequency of irreducible fractures in this setting remains unclear. The purpose of this study was to describe operative treatment and irreducible fractures in pediatric and adolescent extremity injuries sustained during organized rodeo participation, with particular attention to the fracture patterns and intraoperative findings in fractures requiring open reduction.

Methods

Institutional review board approval was obtained with waiver of informed consent. This was a retrospective study using a prospectively maintained institutional trauma registry, supplemented by a retrospective review of the electronic medical record, operative reports, and radiographs at a pediatric Level I trauma center.

The institutional trauma registry was queried to identify patients 18 years of age or younger who sustained animal-related injuries between November 2017 and December 2023 using ICD-9 and ICD-10 external cause codes. Medical records were then reviewed to determine whether the injury occurred during organized youth rodeo participation. After application of inclusion and exclusion criteria, 41 patients were included in the final analysis (Figure 1).

Figure 1.

Flow diagram of cohort identification and classification of pediatric and adolescent organized rodeo–related injuries.

Organized rodeo participation was defined as injury sustained during a sanctioned youth rodeo event, including rough stock and timed competitions. Injuries occurring outside structured rodeo events, such as recreational livestock exposure, were excluded. Patients without an orthopedic injury were retained in the overall cohort description but excluded from the orthopedic injury analysis.

Electronic medical records, emergency department documentation, inpatient records, operative reports, and radiographs were reviewed. Demographic variables included age and sex. Injury variables included Injury Severity Score (ISS), fracture location, fracture pattern, associated injuries, event type, and orthopedic follow-up duration. Follow-up duration was defined as the interval from the index injury encounter to the last documented orthopedic follow-up visit and was recorded for patients with orthopedic injuries, including the extremity-fracture subgroup. Operative variables included the indication for surgery, the fixation method, documentation of closed reduction attempts, intraoperative findings, and the requirement for open reduction.

Fractures were categorized as irreducible when operative documentation indicated that closed reduction attempts were unsuccessful, and open reduction was required to obtain satisfactory alignment. Operative reports were reviewed for documentation of periosteal interposition, muscle entrapment, fragment incarceration, or buttonholing. Fractures treated through an open approach for visualization or definitive fixation alone were not included in this category. Irreducibility classification was based on the documented need for open reduction rather than the definitive fixation construct.

Continuous variables are presented as means with standard deviations or medians with interquartile ranges (IQR), as appropriate. Categorical variables are presented as counts and percentages. Comparisons between patients 12 years of age or younger and older than 12 years were performed using Fisher’s exact test. Statistical significance was defined as p < 0.05.

Results

During the study period, 41 pediatric patients sustained rodeo-related injuries (Table 1). The mean age was 13 ± 4 years (range, 4–18 years), and 32 patients (78.0%) were male. Rough stock events accounted for 29 injuries (70.7%), timed events for 9 (22.0%), and 3 injuries involved large stock animals without documented event classification. The mean Injury Severity Score (ISS) was 7 ± 5, and three patients (7.3%) had an ISS > 15. Nineteen patients (46.3%) required hospital admission, including three who required intensive care.

Table 1.

Demographic and event characteristics (n = 41).

Variable	Value
Age, years	13 ± 4 (range, 4–18)
Male	32 (78.0)
Female	9 (22.0)
Race
White	41 (100)
Payer
Public	22 (53.7)
Private	17 (41.5)
Self	2 (4.9)
Event type
Rough stock	29 (70.7)
Timed	9 (22.0)
Unspecified	3 (7.3)
Injury characteristics
ISS	7 ± 5
ISS > 15	3 (7.3)
Orthopedic injuries	21 (51.2)
Extremity fractures	18 (43.9)
Operative fractures	13/18 (72.2)
Irreducible fractures	5/13 (38.5)
Hospital admission	19 (46.3)
ICU admission	3 (7.3)

Data are presented as mean ± SD or n (%). Injury categories are not mutually exclusive.

ICU, intensive care unit; ISS, injury severity score.

Orthopedic injuries were identified in 21 patients (51.2%; 95% CI, 36.5–65.7) (Table 2). Median orthopedic follow-up was 9.6 weeks (IQR, 4.9–34.7), and mean follow-up was 19.3 ± 19.2 weeks (range, 1.7–59.3). Eighteen patients (43.9%; 95% CI, 29.9–59.0) sustained extremity fractures, all of which were closed. Fracture locations included the proximal humerus, distal humerus (including supracondylar fractures), elbow fracture-dislocations, diaphyseal forearm fractures, femoral shaft fractures, tibial shaft fractures, and foot fractures. Three additional patients sustained pelvic ring and/or spinal fractures.

Table 2.

Distribution of Injuries in pediatric and adolescent rodeo trauma (n = 41).

Injury category	Value, n (%)
Non-orthopedic injuries
Craniofacial	12 (29.3)
Thoracoabdominal	6 (14.6)
Minor soft tissue	6 (14.6)
Multisystem	6 (14.6)
Orthopedic injuries
Total	21 (51.2)
Spine/pelvic fractures	3 (7.3)
Extremity fractures	18 (43.9)
Follow-up, weeks, median (IQR)	9.6 (4.9–34.7)
Extremity fracture subgroup (n = 18)
Age ≤ 12 years	10 (55.6)
Age > 12 years	8 (44.4)
Follow-up, weeks, median (IQR)	9.4 (4.2–31.9)
Extremity fracture distribution (n = 18)
Proximal humerus	4 (22.2)
Distal humerus	1 (5.6)
Supracondylar humerus	3 (16.7)
Elbow fracture-dislocation	1 (5.6)
Monteggia injury (Bado III)	1 (5.6)
Both-bone forearm fracture	1 (5.6)
Distal radius	2 (11.1)
Subtrochanteric femur	1 (5.6)
Femoral shaft	2 (11.1)
Tibia-fibula shaft	1 (5.6)
Metatarsal	1 (5.6)

Data are presented as mean ± SD or n (%). Follow-up was defined as the interval from index injury encounter to the last documented orthopedic follow-up.

Seventeen patients (41.5%) underwent operative intervention (Table 3). Among patients with extremity fractures, 13 of 18 (72.2%; 95% CI, 49.1–87.5) were treated surgically. Operative rates did not differ between patients ≤ 12 years of age and >12 years (70.0% vs 75.0%, Fisher’s exact test, p > 0.99). Within the extremity-fracture subgroup, median follow-up was 9.4 weeks (IQR, 4.2–31.9), and mean follow-up was 18.2 ± 18.1 weeks (range, 1.7–59.2). Mean follow-up among operatively treated extremity fractures was 23.3 ± 19.0 weeks (range, 1.7–59.2). Procedures included open reduction and internal fixation (n = 5), rigid intramedullary nailing (n = 3), closed reduction and percutaneous pinning (n = 3), flexible intramedullary nailing (n = 1), and closed reduction under general anesthesia (n = 1).

Table 3.

Operative Management of Pediatric and Adolescent Rodeo Injuries (n = 41).

Variable	n/N (%)
Overall operative management (n = 41)
Any surgery	17/41 (41.5)
Craniofacial	2/12 (16.7)
Thoracoabdominal	1/6 (16.7)
Spine/pelvis	1/3 (33.3)
Extremity fractures	13/18 (72.2)
Extremity fracture operative treatment by age (n = 18)
Age ≤ 12 years	7/10 (70.0)
Age > 12 years	6/8 (75.0)
Operative extremity fracture procedure type (n = 13)^a
Open reduction and internal fixation	5 (38.5)
Rigid intramedullary nailing	3 (23.1)
Closed reduction and percutaneous pinning	3 (23.1)
Flexible intramedullary nailing	1 (7.7)
Closed reduction under general anesthesia	1 (7.7)
Irreducible fracture characteristics (n = 5)^b
Total	5/13 (38.5)
Proportion of all extremity fractures	5/18 (27.8)
Age ≤ 12 years	1/7 (14.3)
Age > 12 years	4/6 (66.7)
Plate fixation among fractures requiring open reduction	2/5 (40.0)

Fisher’s exact test for operative treatment by age (age ≤ 12 years vs age > 12 years), p > 0.99. ^bFisher’s exact test for irreducible fracture by age among operatively treated extremity fractures, p = 0.103.

Among operatively treated extremity fractures, 5 of 13 (38.5%; 95% CI, 17.7–64.5) required open reduction after unsuccessful closed reduction attempts (Figure 2). Two of these five fractures underwent plate fixation. This represented 27.8% of all extremity fractures (95% CI, 12.5–50.9) and 12.2% of the overall cohort. Four of the five irreducible fractures occurred in patients older than 12 years, although this difference was not statistically significant (1/7 vs 4/6, Fisher’s exact test, p = 0.10). These fractures involved multiple anatomic regions, including femoral shaft fractures, elbow fracture-dislocations, Monteggia injuries, proximal humerus fractures, and diaphyseal both-bone forearm fractures. Operative findings included muscular interposition in femoral shaft fractures, incarceration of the medial epicondyle in elbow fracture-dislocations, radial head entrapment in Monteggia injuries, metaphyseal displacement in proximal humeral fractures, and radial shaft buttonholing through the flexor pollicis longus in forearm fractures.

Figure 2.

Preoperative radiographs of the five irreducible extremity fractures in this series required open reduction after unsuccessful closed reduction attempts. (a) Elbow fracture-dislocation with an incarcerated fracture fragment. (b) Bado III Monteggia injury. (c) Diaphyseal both-bone forearm fracture. (d) Proximal humeral metaphyseal fracture. (e) Femoral shaft fracture.

Discussion

In this series, pediatric and adolescent extremity fractures sustained during organized rodeo participation were frequently treated operatively, and more than one-third of surgically managed fractures required open reduction after unsuccessful closed reduction attempts. Although the number of irreducible fractures was small, these injuries occurred across multiple anatomic regions and were associated with intraoperative findings known to impede closed reduction. In the absence of a matched same-center comparison cohort with other high-energy mechanisms, these findings should be interpreted as descriptive. Even so, the observed proportion of open reduction remains clinically relevant in the context of general pediatric fracture care.

In general pediatric cohorts, most long-bone fractures can be reduced closed, even when operative fixation is required. Flexible intramedullary nailing of femoral shaft fractures is commonly performed following successful closed alignment, with open reduction reported in approximately 5% to 20% of cases.^2–4 Similarly, diaphyseal both-bone forearm fractures treated with elastic stable intramedullary nailing are most often managed with closed techniques, with open reduction reported in 10% to 25%, depending on fracture characteristics.^5–8 Closed reduction in the emergency department is also successful in the majority of pediatric fractures.²⁰ Relative to these general pediatric reports, the proportion observed in the present cohort was substantial; however, this study cannot determine whether rodeo-related injuries carry a higher risk of irreducibility than other high-energy mechanisms treated at our institution.

Two findings merit emphasis. First, 72.2% of extremity fractures required operative treatment, consistent with the injury severity within this cohort. This differs from the pediatric mutton bustin’ series by Schultz et al., in which 15% of patients underwent surgery, although that study involved younger children and sheep-riding rather than organized rough stock competition.¹⁷ Second, 5 of 13 operatively treated extremity fractures required open reduction after failed closed reduction. Four of these five injuries occurred in patients older than 12 years, although this difference was not statistically significant (1/7 vs 4/6, Fisher’s exact test, p = 0.10). Irreducible fractures were identified in femoral shaft fractures, elbow fracture-dislocations, Monteggia injuries, proximal humeral fractures, and diaphyseal forearm fractures, suggesting that this pattern was not confined to a single fracture type.

Rodeo participation represents a high-energy mechanism. Rough stock events involve large animal mass, abrupt acceleration and deceleration, rotational forces, and high-energy falls. Prior studies have shown greater injury severity in rough stock compared with timed events,¹⁴ and pediatric series and systematic review data indicate that extremity injuries are common and often require operative management in this population.^15–17 Trauma-center data further support a meaningful injury burden associated with rodeo participation.¹⁸ In that context, markedly displaced rodeo-related fractures may present increased difficulty with closed reduction.

Operative reports in this series support this explanation. Findings included muscular interposition in femoral shaft fractures, incarceration of the medial epicondyle in elbow fracture-dislocations, radial head entrapment in Monteggia injuries, metaphyseal displacement in proximal humeral fractures, and radial shaft buttonholing through the flexor pollicis longus in forearm fractures. These mechanisms are established causes of failed closed reduction. Although this study cannot establish a mechanism-specific causal relationship, the recurrence of these barriers across fracture types supports careful operative planning when treating displaced rodeo-related extremity injuries.

From a clinical standpoint, surgeons often anticipate successful closed reduction in femoral shaft, forearm, and selected elbow fractures.^2–8 In rodeo-related injuries, that expectation may not always hold. Awareness of a meaningful frequency of irreducible patterns may assist with preoperative counseling, operating-room planning, and preparation for the possibility of open reduction when satisfactory alignment cannot be obtained closed.

From an injury-prevention standpoint, current rulebooks from major youth rodeo governing associations indicate that safety requirements vary by organization and event. In the National High School Rodeo Association rulebook, bull riding requires a functional helmet with a full-face mask and a chin strap, and state- or provincial-sanctioned rodeos are expected to maintain a safety plan identifying emergency response resources; National Finals additionally require on-site physician coverage and ambulances.¹³ In the National Little Britches Rodeo Association rulebook, general contestant attire permits either a Western hat or a safety helmet, and non-member participation requires signed consent documentation.¹² Although the present study did not evaluate event-level compliance with these requirements, the findings support continued attention to protective equipment, event preparedness, and injury prevention in youth rodeo participation.

This study has several limitations. The design was retrospective, using a prospectively maintained trauma registry supplemented by chart, operative report, and radiographic review. As the only pediatric Level I trauma center in the state, more severe injuries may be overrepresented, and less complex fractures may have been managed elsewhere. The sample size was limited, and fracture heterogeneity precluded bone-specific analysis. Most importantly, a matched comparison cohort of patients with similar fractures sustained through other high-energy mechanisms, such as pedestrian-struck trauma or motor vehicle collisions, was not available. Accordingly, we cannot determine whether the observed rate of open reduction was specific to rodeo participation or reflected high-energy referral patterns more broadly. In addition, although follow-up duration was recorded, the study was not designed to assess long-term functional, radiographic, or patient-reported outcomes or to capture the specific governing-association rule set in effect at the time of each injury or event-level compliance with safety, protective-equipment, consent, or emergency-preparedness requirements.

Despite these limitations, this case series demonstrates that pediatric and adolescent rodeo-related extremity fractures can involve substantial operative burden and mechanically irreducible patterns across multiple fracture types. These observations provide clinically relevant detail in a sparsely described pediatric injury setting and support future multicenter and same-institution comparative studies.

Conclusion

Pediatric and adolescent rodeo-related extremity fractures in this series showed a substantial operative burden, with open reduction required in more than one-third of surgically treated fractures after unsuccessful closed reduction attempts. The recurrence of mechanically irreducible patterns across multiple anatomic regions suggests that these injuries may present distinct operative challenges. While no matched comparison cohort was available, these findings support careful preoperative planning and operative preparedness when managing pediatric and adolescent rodeo-related extremity trauma.

Supplemental Material

sj-pdf-1-cho-10.1177_18632521261453206 – Supplemental material for Irreducible extremity fractures in pediatric and adolescent rodeo-related trauma: A retrospective case series

Supplemental material, sj-pdf-1-cho-10.1177_18632521261453206 for Irreducible extremity fractures in pediatric and adolescent rodeo-related trauma: A retrospective case series by Taylor E. Arnold, Jack A. Nolte, Derek J. Krinock, Hannah R. Branton, Brien M. Rabenhorst, Deidre L. Wyrick and Scott J. Schoenleber in Journal of Children's Orthopaedics

Footnotes

Author contributions

Conceptualization: SS, TA, JN, DK, DW

Methodology: TA, SS, DW

Data curation: DK, JN, SS

Formal analysis: TA, JN, SS

Investigation: TA, JN, DK, SS

Writing – original draft preparation: TA

Writing – review and editing: SS, TA, JN, DK, HB, BR, DW

Supervision: SS

All authors approved the final manuscript.

All authors meet the ICMJE criteria for authorship and take responsibility for the integrity of the work.

Ethical approval

This retrospective case series was approved by the Arkansas Children’s Hospital Institutional Review Board (IRB 287103). The requirement for written informed consent was waived owing to the retrospective study design. The study was conducted in accordance with the Declaration of Helsinki.

Data availability statement

The data that support the findings of this study are available from the corresponding author upon reasonable request. Access to the dataset is subject to institutional review board regulations and institutional data sharing policies.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Taylor E. Arnold

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