Abstract
Background: Recreational motorized vehicles, including all-terrain vehicles (ATVs), dirt and motor bikes, snowmobiles, and e-scooters, are an increasingly recognized source of severe trauma among children. Adult provincial data from Alberta demonstrate high morbidity, mortality, and more than $6 million in acute care costs from ATV-related injuries over a decade; however, pediatric injury patterns remain under-characterized despite rising exposure. Methods: We conducted a retrospective cohort study of pediatric patients presenting with major trauma (Injury Severity Score > 12) to the Stollery Children’s Hospital between December 2019 and June 2023. Recreational motorized vehicle-related cases were analyzed for demographics, injury mechanisms, injury severity, hospital resource utilization, and clinical outcomes. Available Abbreviated Injury Scale data were reviewed descriptively for a subset of ATV-related injuries. Results: Of 345 pediatric major trauma cases, 55 (16%) involved recreational motorized vehicles, accounting for 17% of major blunt trauma presentations. ATVs were the most common mechanism (58%), followed by dirt/motor bikes (23.6%), snowmobiles (14.5%), and e-scooters (3.6%). Patients were predominantly male (72.7%) with a mean age of 13.1 years. Operative intervention was required in 58.2% of cases, 30.9% required pediatric intensive care unit admission, and mortality was 5.5%. Helmet status was incompletely documented; only 36.4% of patients were recorded as wearing helmets. Children from rural regions accounted for 43.6% of injuries. In the ATV subset with available AIS data, head, facial, and extremity injuries were most common, and all patients sustained at least one serious injury (AIS ≥ 3). Conclusions: Recreational motorized vehicles represent a substantial and preventable cause of severe pediatric trauma in Alberta. When contextualized with adult provincial data demonstrating significant mortality and healthcare costs, these findings support strengthened injury-prevention strategies, improved safety enforcement, and evidence-informed policy approaches.
1. Introduction
Recreational motorized vehicles, including all-terrain vehicles (ATVs), motorized dirt bikes, snowmobiles, and more recently, e-scooters, are widely used across Canada for leisure, transportation, and, in rural settings, occupational activities, with Alberta consistently ranking among the top provinces for ownership per capita [1]. Steady growth in off-road vehicle sales and recreational participation across the country has increased youth access to high-powered machines, often in settings where safety legislation and enforcement vary widely [1]. These vehicles are associated with high-energy transfer, rollover dynamics, and ejection mechanisms that frequently result in multisystem pediatric trauma [2,3,4].
ATVs in particular pose unique hazards due to their inherent instability, high centers of gravity, wide turning radii, and acceleration and vehicle weight relative to rider size and strength [5]. Multiple studies have demonstrated that children lack the physical, cognitive, and perceptual abilities needed to safely operate these vehicles, making them specifically vulnerable when operating adult-sized, high-powered machines, riding without helmets, or using these vehicles unsupervised [2,3,6,7]. Crash dynamics commonly involve rollovers, ejections, or collisions with stationary objects; mechanisms strongly associated with severe head, spine, thoracic, and extremity trauma [5,8].
The burden of these motorized recreational vehicles extends beyond the pediatric population. Alberta consistently reports some of the highest ATV-related injury and mortality rates nationwide. In an Alberta population-based study over 10 years, Krauss et al. identified 459 cases of severe ATV-related trauma in individuals 18 years or older, with a mortality rate of 17% and acute care costs exceeding $6 million for hospital admissions alone [8]. During that period, ATV crash incidence increased steadily, with injury patterns dominated by head and cervical spine trauma, high rates of alcohol involvement and low helmet use—all factors strongly predictive of mortality [8]. These findings underscore that, in Alberta, motorized off-road vehicle injuries are common, severe, costly and heavily influenced by modifiable behaviors.
In contrast, Alberta-specific pediatric data is limited. Pediatric studies from Ontario, Nova Scotia, and Newfoundland have consistently described high-risk mechanisms, preventable injury patterns, and low protective equipment compliance among injured children [3,4,5,6]. Yet Alberta, a province with high ATV use, large rural populations, and permissive regulations, remains underrepresented in the pediatric trauma literature. Notably, Alberta has no minimum age for operating an ATV on private land, no standardized training requirements, and historically limited enforcement of helmet laws in off-road environments [2]. These regulatory gaps may contribute to preventable injuries among children and adolescents, particularly in rural areas where recreational motorized vehicle use is common and trauma resources may be distant.
At the Stollery Children’s Hospital in Edmonton, Alberta, one of Canada’s largest pediatric trauma centers, clinicians have observed an apparent rise in major injuries linked to recreational motorized vehicles in recent years. These injuries frequently require multidisciplinary management, including neurosurgery, orthopedics, general surgery, and PICU admissions. National pediatric trauma databases capture overall trends in blunt trauma, but there is a lack of detail when it comes to describing Alberta specific patterns, mechanisms, and outcomes for motorized off-road vehicle incidents. Understanding these patterns is essential for informing prevention strategies, guiding legislative reform, and supporting public health initiatives tailored to regional needs.
To address this gap, we conducted a retrospective cohort study of pediatric major trauma involving recreational motorized vehicles presenting to the Stollery Children’s Hospital between December 2019 and June 2023. This study aims to:
- Describe the epidemiology, mechanisms, and clinical severity associated with ATVs, dirt/motor bikes, snowmobiles, and e-scooters;
- Evaluate hospital resource utilization, including operative intervention and PICU admission; and
- Contextualize pediatric findings within known adult provincial data and provincial policy limitations;
By pairing contemporary pediatric outcomes with established adult data, this analysis aims to provide a comprehensive, province-level perspective on motorized recreational vehicle injuries and highlight opportunities for prevention and legislative action.
2. Methods
2.1. Study Design and Setting
We conducted a retrospective cohort study of pediatric patients presenting to the Stollery Children’s Hospital in Edmonton, AB, Canada, with major trauma related to recreational motorized vehicle (RMV) use. The Stollery is a tertiary pediatric trauma center and the primary referral site for complex pediatric injuries across central and northern Alberta, parts of British Columbia and Saskatchewan, and the Northwest Territories, with nearly 55,000 emergency department visits annually.
2.2. Study Population
All patients aged 0–17 years with an Injury Severity Score (ISS) > 12 who sustained RMV-related injuries between December 2019 and June 2023 were eligible for inclusion. RMVs included ATVs, motorized dirt bikes, snowmobiles, and e-scooters.
Cases were excluded if:
- The mechanism did not involve an RMV;
- ISS was ≤12;
- Documentation was incomplete following transfer;
- The child died at the scene.
2.3. Data Sources and Variables
Data was abstracted from the trauma registry and verified against electronic medical records. Variables collected included demographics, helmet use, alcohol involvement, mechanism, time and location of injury, ISS, trauma team activation, operative management, surgical specialties involved, PICU admission, length of stay, and mortality. Available Abbreviated Injury Scale (AIS) body-region and severity data were reviewed descriptively for a subset of ATV-related injuries with sufficiently complete anatomic injury coding in the trauma registry. AIS body-region and severity were analyzed at the patient level, with each patient counted once per injured region and classified by maximum AIS severity.
2.4. Geographic Classification
Patient residence was categorized as rural or urban based on the forward sortation area of the recorded postal code. Rural residence was defined as postal codes beginning with “T0,” corresponding to rural and small community regions within Alberta. All remaining postal codes were categorized as urban. This classification was used to examine the geographic distribution of injuries and contextualize access to trauma care.
2.5. Statistical Analysis
Descriptive statistics were used to summarize the cohort. Continuous variables were expressed as means with standard deviations or medians with interquartile ranges. Categorical variables were summarized as counts and percentages. No imputation was performed.
2.6. Ethics Approval
The study was conducted in accordance with the Declaration of Helsinki and approved by the University of Alberta Research Ethics Board (REB# Pro00154881; 7 July 2025). Patient consent was waived due to the retrospective nature of the study and use of de-identified data.
3. Results
Among 345 pediatric major trauma patients (ISS > 12) identified during the study period (December 2019–June 2023), 55 (16%) sustained injuries related to recreational motorized vehicles (RMVs), accounting for 17% of major blunt trauma presentations. Most RMV-injured patients were male (40/55, 72.7%), with a mean age of 13.1 years. Injury mechanisms included ATVs (32/55, 58%), motorized dirt bikes (13/55, 23.6%), snowmobiles (8/55, 14.5%), and e-scooters (2/55, 3.6%). Rural residence accounted for 24/55 cases (43.6%). Demographic, mechanism, and clinical characteristics of the RMV cohort are summarized in Table 1.
Table 1.
Demographic, event, and clinical characteristics of pediatric patients with RMV-related major trauma (n = 55).
Helmet status was recorded as helmet worn in 20/55 patients (36.4%), no helmet in 21/55 (38.2%), unknown in 7/55 (12.7%), and missing/not documented in 7/55 (12.7%). Alcohol involvement was recorded as present in 5/55 patients (9.1%), absent in 28/55 (50.9%), and missing/not documented in 22/55 (40.0%). Crash location was recorded as off-road in 23/55 patients (41.8%), public road in 7/55 (12.7%), track in 4/55 (7.3%), and unknown in 21/55 (38.2%). Children were documented as the driver in 39/55 cases (70.9%).
Injuries were severe (mean ISS 21.0) and frequently involved multisystem trauma. More than half of the patients required operative intervention (58.2%), including damage-control procedures (18.2%). Among those undergoing surgery, orthopedic procedures were most common (35.5%), followed by neurosurgical (22.6%) and plastic surgery procedures (22.6%), with smaller contributions from multispecialty (12.9%), vascular (3.2%), and general surgery (3.2%) interventions. Ventilation duration and transfusion or massive transfusion protocol utilization were not consistently captured in the trauma registry and therefore could not be reliably analyzed. PICU admission was required in 17/55 patients (30.9%). Median hospital and PICU lengths of stay were 6 and 5 days, respectively. Mortality was 5.5%.
Detailed anatomic injury classification (AIS by body region) was available for a subset of ATV-related injuries (26/32 cases) with sufficiently complete anatomic injury coding in the trauma registry. Within this subgroup, head injuries were most common (16/26, 61.5%), followed by facial (12/26, 46.2%) and upper extremity injuries (10/26, 38.5%). Thoracic (9/26, 34.6%) and abdominal (8/26, 30.8%) injuries were also frequently observed, with additional involvement of the lower extremities (8/26, 30.8%) and spine (5/26, 19.2%). External injuries were uncommon (1/26, 3.8%), and no isolated neck injuries were identified. All patients in this subgroup sustained at least one serious injury (AIS ≥ 3), with 13/26 (50.0%) sustaining severe injuries (AIS ≥ 4) and 4/26 (15.4%) demonstrating critical injuries (AIS ≥ 5). Detailed anatomic injury distribution and maximum AIS severity for the ATV subset with available AIS data are summarized in Table 2.
Table 2.
Anatomic injury distribution and maximum AIS severity among ATV-related cases with available AIS data (n = 26).
4. Discussion
In this contemporary cohort, RMVs accounted for a substantial proportion of severe pediatric trauma, with patterns mirroring those described in Canadian pediatric studies and international data [3,4,5,6,7]. Children were predominantly male adolescents, frequently unhelmeted, and commonly operating the vehicle themselves, patterns well described in prior literature [3,4,5,6,7]. These findings reinforce the ongoing vulnerability of youth engaged in recreational off-road vehicle use. Because our cohort was restricted to major trauma presenting to a tertiary pediatric center, these findings reflect patterns of severe injury rather than population-level incidence and should be interpreted accordingly.
4.1. Injury Severity and Mechanisms
The mechanisms observed—rollovers, ejections, and high-energy blunt trauma—align with established pediatric RMV injury patterns [3,4,5,6]. Prior Canadian studies have demonstrated that adolescents often lack the physical strength, cognitive capacity, and perceptual judgment required to safely operate adult-sized recreational vehicles [3,4,5,6]. Vehicle design characteristics, including instability, high centers of gravity, and rapid acceleration relative to rider size, further contribute to risk of severe multisystem trauma [5,8]. Inexperience, inadequate protective equipment, and excessive speed likely further contribute to injury severity in this population.
In our cohort, injury severity was substantial, with a mean ISS of 21 and more than half of patients requiring operative intervention including emergency neurosurgical procedures. These findings are consistent with prior pediatric RMV literature describing substantial operative burden and multisystem injury [7]. In the subset of ATV-related cases with available AIS data, head injuries were most common, followed by facial and extremity injuries, with additional thoracic, abdominal, and spinal involvement. All patients in this subgroup experienced at least one serious injury, and half had severe injuries, supporting the high clinical severity of these events. Because detailed anatomic injury classifications were only available for a subset of ATV-related cases, broader interpretation across the full RMV cohort remains limited.
Helmet use was documented in only 40% of RMV-injured children when considering the full cohort, mirroring rates reported in other Canadian and international pediatric studies [4,5,6,7]. Helmet non-use remains one of the most important modifiable predictors of severe head injury and highlights ongoing gaps in enforcement and safety education.
4.2. Comparison with Adult Provincial Trauma
The parallels between pediatric and adult RMV injury patterns in Alberta are striking. Krauss et al. reported high mortality, severe injury patterns, low helmet use, and frequent alcohol involvement among adults injured in ATV-related incidents in Alberta [8]. While alcohol involvement was less frequent in the pediatric cohort, its presence remains concerning given the preventability of this risk factor. Motorcycle trauma data from Alberta further emphasizes the predictable health system burden associated with high-energy recreational vehicles [9], while comparative trauma literature has similarly described substantial morbidity associated with four-wheel all-terrain vehicles relative to motorcycles [10].
Together, these findings suggest that pediatric RMV injuries occur within a broader provincial landscape characterized by significant morbidity, mortality, and healthcare utilization related to recreational motorized vehicles.
4.3. Timing, Rurality, and Environmental Context
Injuries occurred most frequently during afternoon and evening hours, corresponding to peak recreational activity. Although seasonal variation was not specifically examined, prior literature suggests strong seasonal clustering during warmer months [8]. We did not observe a clear increase in e-bike or e-scooter injuries during the study period; however, growing international reports highlight pediatric e-bike and e-scooter trauma as an important emerging area for surveillance. The overrepresentation of rural postal codes reflects known patterns of RMV availability, private land use, and reduced regulatory oversight in rural settings [3,4,5,6]. Forward sortation area (T0) is commonly used in Canadian epidemiologic research as a proxy for rural residence, although some misclassification is possible.
Industry data support increasing exposure among youth. Moto Canada reports ongoing growth in off-road vehicle sales, including youth-orientated models and expanded access to recreational trail networks [1]. Together, these trends likely contribute to sustained pediatric injury burden.
4.4. Health System Burden and Acute Morbidity
More than half of the RMV-injured children required operative intervention and nearly one-third required PICU admission, reflecting substantial acute morbidity and resource utilization. While registry data allowed characterization of operative and critical care needs, additional measures such as transfusion requirements, ventilation duration, and multidisciplinary involvement were not consistently captured and warrant further study.
These in-hospital indicators represent substantial acute morbidity, even in the absence of long-term functional outcome data. Similar patterns of multisystem injury, operative burden, and extended hospitalization have been reported in pediatric cohorts from Ontario and Newfoundland, as well as in multinational analyses [3,6,7]. Strohecker et al. aptly characterized pediatric ATV injuries as an “epidemic of cost and grief,” reflecting both direct healthcare expenditures and broader familial and societal impact [5].
4.5. Prevention Implications
Despite the severity and preventability of RMV-related injuries, Alberta’s regulatory environment remains permissive. The Canadian Paediatric Society recommends prohibiting ATV use for children under 16, mandating helmet use, and enforcing standardized safety training; however, Alberta continues to lack minimum age requirements on private land and consistent helmet enforcement [2]. These regulatory gaps likely contribute to the severe injury patterns observed.
Case–control data have demonstrated that targeted injury-prevention policies may substantially mitigate risk [11]. Evidence synthesized by the Eastern Association for the Surgery of Trauma further supports legislative interventions, including helmet mandates, age restrictions, and graduated licensing, as effective strategies for reducing severe ATV injuries [12]. Although youth-designed, lower-powered recreational vehicles are increasingly promoted as a primary prevention strategy, our analysis could not assess the impact of vehicle size or engine power on injury risk, as these characteristics are not captured in trauma registry data.
We agree with the reviewer that key behavioral and environmental exposures, including rider training, supervision, riding purpose, terrain familiarity, and protective equipment beyond helmets, are important determinants of injury risk. However, these variables were not consistently captured in trauma registry documentation. Our findings should therefore be interpreted as hypothesis-generating and supportive of further prospective research examining modifiable behavioral risk factors. Emerging vehicle types such as e-bikes were not captured in this cohort and represent an important area for future research.
4.6. Implications for Public Health and Policy
The convergence of pediatric trauma data, adult provincial injury patterns, and increasing recreational vehicle exposure highlights an urgent need for coordinated provincial action. Alberta’s high RMV ownership, extensive rural geography, and permissive regulatory framework create conditions conducive to preventable pediatric harm. These findings support consideration of policy and prevention strategies aimed at reducing RMV-related pediatric trauma.
Given the substantial operative and critical care resources required to manage these injuries, prevention represents a meaningful opportunity to reduce morbidity, mortality, and healthcare utilization. Strengthening legislation and implementing evidence-informed safety measures may substantially improve outcomes for children and adolescents exposed to recreational motorized vehicles.
5. Limitations
This study is limited by its retrospective design and single-center setting. Findings reflect only pediatric patients with major trauma (ISS > 12) treated at a tertiary center and likely underestimate the broader provincial burden. Children with minor or moderate injuries, those managed at community hospitals, and cases not captured by trauma registry coding were excluded. Prehospital deaths were not captured in this dataset. As a result, injury incidence, helmet use rates, and alcohol involvement may differ from the broader pediatric population.
Event-level factors, such as speed, supervision, riding experience, terrain familiarity, and detailed crash mechanisms, were inconsistently documented. Helmet use and alcohol involvement relied on EMS or clinical documentation and may be subject to reporting bias. Crash location was undocumented in a substantial proportion of cases, limiting environmental interpretation. Additional resource utilization measures, including ventilation duration and transfusion requirements, were not consistently available in registry data.
Vehicle-specific characteristics, including engine size, power output, and whether machines were youth-designed or adult-sized, were not captured in the trauma registry. As a result, we were unable to evaluate the relationship between vehicle size or power and injury severity relative to rider age and body size. This represents an important limitation, as prior injury prevention frameworks emphasize youth-appropriate vehicles and power limitations as key primary prevention strategies for reducing severe pediatric RMV-related injuries.
Granular anatomic injury classifications were available only for a subset of ATV-related cases with sufficiently complete anatomic injury coding and were not consistently available across the full RMV cohort. Accordingly, more detailed injury-pattern characterization was limited to this subgroup and may not fully reflect other RMV mechanisms. Future analyses incorporating more complete standardized injury classification data may further refine understanding of RMV-related pediatric trauma.
The COVID-19 pandemic may also have influenced recreational patterns and healthcare-seeking behaviors during the study period. Finally, generalizability may be limited to regions with similar RMV use patterns and legislation; however, parallels with other Canadian studies support broader relevance.
6. Conclusions
Recreational motorized vehicles remain an important cause of severe, preventable trauma among children and adolescents in Alberta. In this cohort, injuries were characterized by high-energy mechanisms, low helmet use, multisystem trauma, and substantial operative and critical care needs. These findings are consistent with other Canadian pediatric cohorts and align closely with adult provincial data, underscoring the significant burden of RMV-related injury among children with major trauma.
Despite the recognized risks, Alberta continues to have permissive regulations regarding age restrictions, inconsistent helmet enforcement, and a lack of standardized safety training. These conditions likely contribute to preventable harm. Strengthening legislation and implementing evidence-informed safety measures, including mandatory helmet use and age-appropriate vehicle restrictions, may help reduce pediatric morbidity and mortality.
By integrating contemporary pediatric data with adult injury patterns and current industry trends, this study highlights the need for coordinated prevention strategies and policy consideration. Continued surveillance and targeted injury prevention initiatives will be important as RMV use continues to evolve across Alberta.
Author Contributions
Conceptualization, J.Z., D.G. and R.B.; methodology, J.Z., F.H. and R.B.; formal analysis, J.Z., F.H. and R.B.; investigation, J.Z.; resources, K.B. and R.B.; data curation, K.B.; writing—original draft preparation, J.Z.; writing—review and editing, J.Z., D.O., K.B., D.G., F.H. and R.B.; visualization, J.Z.; supervision, R.B.; project administration, J.Z. and R.B. All authors have read and agreed to the published version of the manuscript.
Funding
This research received no external funding.
Institutional Review Board Statement
The study was conducted in accordance with the Declaration of Helsinki and approved by the University of Alberta Research Ethics Board (REB# Pro00154881; 7 July 2025).
Informed Consent Statement
Patient consent was waived due to the retrospective nature of the study and the use of de-identified data.
Data Availability Statement
The data presented in this study are available upon reasonable request from the corresponding author, subject to institutional data governance and privacy regulations.
Acknowledgments
The authors thank Kyla Hoogers for her assistance with trauma registry data extraction and study data support.
Conflicts of Interest
The authors declare no conflicts of interest.
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