Abstract
Purpose
Equine-related injuries are a significant yet under-researched cause of trauma in rural areas, particularly in high-equine-density states like Oklahoma. This study describes patterns, severity, and outcomes of equine-related injuries over a 10-year period at a Level II trauma center, with emphasis on genitourinary (GU) trauma.
Methods
This retrospective cohort study included all patients admitted with equine-related injuries from May 2015 to December 2025 (n = 259). Data were abstracted from the trauma registry, including demographics, injury mechanisms, anatomic locations (with GU injuries consolidated as kidney, ureter, bladder, penis, and scrotum), Injury Severity Score (ISS), length of stay (LOS), and mortality. Severe injuries were defined as ISS > 15. Only descriptive statistics are reported.
Results
The mean age was 48.0 years (SD 17.5); 56.0% were male. Mean ISS was 9.1 (SD 6.0), with 12.4% of cases classified as severe (ISS > 15). The most common mechanisms were falls from a horse (44.8%) and being struck by a horse (32.8%). Predominant injury locations included brain/craniofacial (35.5%), chest (28.2%), and spinal (25.1%). Genitourinary injuries occurred in 9.3% of all cases and were more frequent among patients with severe trauma. Kidney injuries specifically accounted for 3.1% overall. Median hospital LOS was 2.0 days (IQR 3.0) overall and longer among severe cases. In-hospital mortality was 1.5% (4 cases), all attributable to traumatic brain injury.
Conclusions
In rural Oklahoma, equine-related trauma commonly involves head and torso injuries. Genitourinary injuries represent an under-recognized but clinically relevant subset, particularly in severe cases. These findings underscore the need for targeted prevention strategies in high-equine-density rural communities, including mandatory helmet use and education regarding risks of direct horse contact.
Keywords: Equine-related injuries, Genitourinary trauma, Oklahoma rural, Horseback riding, Injury prevention
Introduction
Equestrian activities provide significant recreational, competitive, and occupational benefits across the United States, yet they carry inherent risks of traumatic injuries due to horses’ unpredictable behavior, varying rider experience, and environmental factors [1, 2]. Injuries vary from minor bruises to life-threatening trauma that may require hospitalization, with estimates indicating that as many as 1 in 5 riders could sustain a serious injury while participating in the sport [3]. Despite this challenge, research on horse-related injuries is still limited, particularly in rural areas with large horse populations, where such activities are vital to livelihood and culture [4–6].
Oklahoma exemplifies this context, ranking among the top U.S. states for equine populations (approximately 251,000 horses as of recent estimates) and featuring a rural population exceeding the national average (35.8% vs. 20% per 2020 U.S. Census data) [7, 8]. Horseback riding here often combines professional ranch work with recreation, heightening exposure to risks from falls, kicks, and trampling [9]. Prior studies show that equine trauma often affects the head, torso, spine, and extremities, with traumatic brain injuries (TBIs) being a leading cause of morbidity and mortality—equestrian sports make up a disproportionate share of sports-related TBIs in adults, often exceeding contact sports like football [10–12]. Falls remain the predominant mechanism, while kicks and crushes also contribute to severe injuries [4, 13].
Injury mechanisms can be broadly categorized as mounted (e.g., falls from or being thrown by the horse) and unmounted (e.g., strikes, kicks, or crushes during ground handling), with distinct patterns observed in the literature [14]. Mounted incidents typically involve high-impact falls from height, leading to a higher occurrence of brain, craniofacial, spinal, chest, and lower extremity injuries, while unmounted events often cause localized blunt injuries to the face, abdomen, and genitourinary areas due to direct contact [14, 15]. This distinction is especially important in rural work environments, where unmounted handling increases the risk of kicks or trampling [16].
Genitourinary (GU) injuries, including renal, ureteral, bladder, penile, and scrotal trauma, form an understudied yet important group of injuries, especially in rural work environments where direct horse contact (for example, kicks to the lower torso or perineum) is frequent [17, 18]. Such injuries can cause hemorrhage, organ laceration, or long-term problems like strictures or dysfunction, especially in severe cases (Injury Severity Score [ISS] > 15) [19]. Existing literature on GU patterns in equine trauma is limited, with most studies emphasizing craniofacial or thoracic issues rather than comprehensive GU involvement [4, 20].
This retrospective cohort study describes all equine-related injuries admitted to a Level II trauma center in Tulsa, Oklahoma, over a 10-year period from May 2015 to December 2025 (n = 259). We present demographics, injury mechanisms, anatomic locations (with consolidated GU injuries), severity, length of stay, and mortality, with particular emphasis on genitourinary trauma. By providing a detailed descriptive account of our institutional experience, this study aims to highlight patterns of injury in a high-equine-density rural population and identify opportunities for targeted prevention [21, 22].
Methods
Research design
This was a retrospective cohort study of equine-related injuries admitted to Ascension St. John Medical Center, a Level II trauma center in Tulsa, Oklahoma, serving a predominantly rural population. The study period extended from May 2015 to December 2025. Data was collected from the hospital’s trauma registry and electronic medical records using standardized protocols. This method is commonly used in trauma epidemiology to characterize injury patterns and outcomes from registry data.10,11 The study was approved by the Ascension St. John Institutional Review Board as non-human-subjects research (IRB ID: 1766064-1, determination letter dated June 2, 2021), since it involved only de-identified retrospective data review without patient contact, intervention, or prospective components; thus, no additional IRB approval or informed consent was required.
Sample selection
All patients admitted to the trauma service with equine-related injuries during the study period were included (n = 259). Cases were identified through trauma registry queries using ICD-10 external cause codes and mechanism descriptors indicating equine involvement (e.g., V80.0–V80.9 series for animal-rider accidents and W55.1–W55.8 for contact with horse). Exclusion criteria were limited to non-admitted emergency department visits, non-equine animal injuries, or records with incomplete data that prevented accurate Injury Severity Score (ISS) calculation. Cases were verified by manual chart review.
Variable definition
Collected variables included patient demographics (age, sex), select comorbidities (e.g., hypertension, diabetes, current smoking), injury mechanism (e.g., fall from horse, struck by horse, other contact), anatomic injury locations (grouped as brain/craniofacial, spinal, chest, abdomen, pelvis, upper/lower extremity, and genitourinary [GU]), Injury Severity Score (ISS), hospital length of stay (LOS), discharge disposition, and in-hospital mortality. ISS was calculated using the Abbreviated Injury Scale (AIS) 2005/2008 update. Genitourinary injuries were consolidated into a single category (kidney, ureter, bladder, penis, and scrotum) to better highlight this under-reported injury pattern. Discharge disposition was categorized as home/self-care or other destination, with in-hospital death recorded separately. All data were coded according to standard trauma registry conventions.
Statistical analysis
Only descriptive statistics were used. Continuous variables are reported as mean with standard deviation (SD) or median with interquartile range (IQR), as appropriate. Categorical variables are presented as frequencies and percentages.
Results
During the 10-year period (May 2015–December 2025), 259 patients were admitted to our Level II trauma center in Tulsa, Oklahoma, with equine-related injuries. The mean age was 48.0 years (SD 17.5), with 56.0% male (n = 145) and 44.0% female (n = 114). The mean Injury Severity Score (ISS) was 9.1 (SD 6.0). Overall, 32 patients (12.4%) had severe injuries (ISS > 15), while 227 patients (87.6%) had non-severe injuries (ISS ≤ 15). The median hospital length of stay (LOS) was 2.0 days (IQR 3.0) for the entire cohort and 4.0 days (IQR 3.0) in patients with severe injuries compared with 2.0 days (IQR 2.0) in those with non-severe injuries. In-hospital mortality occurred in 4 cases (1.5%), all among patients with severe injuries.
Demographics and comorbidities are summarized in Table 1. Discharge to home/self-care was common (82.3% overall), though less frequent in severe cases (71.9% vs. 83.7%).
Table 1.
Patient demographics and comorbidities by injury severity (n = 259)
Variable
Overall (n = 259) n (%)
Severe
(ISS > 15)
(n = 32) n (%)
Non-Severe
(ISS ≤ 15)
(n = 227) n (%)
Age, mean (SD), y
48.0 (17.5)
48.9 (17.3)
47.8 (17.6)
Male sex, n (%)
145 (56.0)
19 (59.4)
126 (55.5)
Hypertension, n (%)
64 (24.7)
9 (28.1)
55 (24.2)
Current smoker, n (%)
45 (17.4)
5 (15.6)
40 (17.6)
Diabetes mellitus, n (%)
38 (14.7)
6 (18.8)
32 (14.1)
Obesity (BMI > 30), n (%)
82 (31.7)
11 (34.4)
71 (31.3)
Anticoagulant use, n (%)
22 (8.5)
4 (12.5)
18 (7.9)
Discharge to home/self-care, n (%)
213 (82.3)
23 (71.9)
190 (83.7)
The annual number of equine-related trauma admissions to a Level II trauma center in Tulsa, Oklahoma, from May 2015 to December 2025 (total n = 259) is shown in Fig. 1. The trend remained relatively stable with an average of about 26 cases per year, with modest peaks in 2018 (n = 30) and 2022 (n = 32).
Fig. 1.
Annual equine-related trauma admissions (2015–2025)
Mechanisms and injury locations are detailed in Table 2. The most common mechanisms were falls from or being thrown from a horse (44.8%, n = 116) and being struck by a horse (32.8%, n = 85), consistent with prior reports of falls dominating in equestrian trauma. 2.5 Other contact with a horse accounted for 22.8% (n = 59). Injury locations most frequently involved the brain/craniofacial region (35.5%, n = 92), chest (28.2%, n = 73), and spine (25.1%, n = 65). Severe injuries were disproportionately concentrated in the brain/craniofacial region (75.0% in severe vs. 30.0% in non-severe cases), the chest (46.9% vs. 25.6%), and specifically, kidney injuries (12.5% vs. 1.8%). GU injuries (a combined category including kidney, ureter, bladder, penis, and scrotum) made up about 9.3% of cases (mainly due to kidney injuries), more common in the severe group, highlighting a pattern that has been underemphasized in previous equine series [17, 18].
Table 2.
Injury mechanisms and locations by severity (n = 259)
Variable
Overall (n = 259) n (%)
Severe (ISS > 15) (n = 32) n (%)
Non-severe (ISS ≤ 15) (n = 227) n (%)
Mechanism of Injury (primary/not exclusive)
Fall from or thrown from horse
116 (44.8)
14 (43.8)
102 (44.9)
Struck by horse
85 (32.8)
11 (34.4)
74 (32.6)
Other contact with horse
59 (22.8)
8 (25.0)
51 (22.5)
Other fall injury
19 (7.3)
3 (9.4)
16 (7.0)
Injury Location (not mutually exclusive)
Brain/craniofacial
92 (35.5)
24 (75.0)
68 (30.0)
Chest
73 (28.2)
15 (46.9)
58 (25.6)
Spinal
65 (25.1)
8 (25.0)
57 (25.1)
Kidney (GU subset)
8 (3.1)
4 (12.5)
4 (1.8)
Abdomen (non-GU)
25 (9.7)
5 (15.6)
20 (8.8)
Pelvis
40 (15.4)
4 (12.5)
36 (15.9)
Upper extremity
62 (23.9)
5 (15.6)
57 (25.1)
Lower extremity
55 (21.2)
4 (12.5)
51 (22.5)
Genitourinary (consolidated: kidney, ureter, bladder, penis, scrotal)
24 (9.3)
7 (21.9)
17 (7.5)
Hospital LOS, median (IQR), d
2.0 (3.0)
4.0 (3.0)
2.0 (2.0)
Mortality, n (%)
4 (1.5)
4 (12.5)
0 (0)
Figure 2 shows the average patient age by primary injury mechanism in this 10-year cohort (n = 259). Being struck by a horse was the most common mechanism (n = 116, mean age 45.9 years, 95% CI 42.6–49.2), followed by falls or being thrown from a horse (n = 29, mean age 45.8 years, 95% CI 38.5–53.1). Other mechanisms included bites (n = 54, mean age 49.5 years) and miscellaneous horse contact (n = 8, mean age 41.8 years). Confidence intervals are wider for mechanisms with smaller sample sizes.
Fig. 2.
Average age by cause of injury (bar graph with error bars for 95% CI)
Table 3 shows the distribution of primary injury sites based on injury mechanisms, using mutually exclusive cause categories for clarity (although multiple mechanisms may occur in individual cases). Falls from or being thrown from the horse (mounted incidents) were most often linked to brain/craniofacial (44.8%), chest (32.8%), and spinal (30.2%) injuries, which aligns with high-energy deceleration caused by height. In contrast, being struck by a horse and other direct contact mechanisms (mainly unmounted or ground-based handling) had higher rates of abdominal, pelvic, and GU injuries, including kidney injuries in 4.7% of struck-by-horse cases. These patterns highlight the mechanistic difference between mounted and unmounted equine trauma in this rural Oklahoma group, where occupational horse handling likely leads to focused blunt-force injuries in less-protected body areas (Fig. 4).
Table 3.
Relationship between injury cause (mounted) and injury location (n = 259)
Injury location
Fall from/thrown from horse (n = 116) n (%)
Struck by horse (n = 85) n (%)
Other contact (n = 59) n (%)
Other fall (n = 19) n (%)
Bitten/striking (n = 4) n (%)
Brain/craniofacial
52 (44.8)
28 (32.9)
10 (16.9)
2 (10.5)
0 (0.0)
Chest
38 (32.8)
22 (25.9)
11 (18.6)
2 (10.5)
0 (0.0)
Spinal
35 (30.2)
18 (21.2)
9 (15.3)
3 (15.8)
0 (0.0)
Abdomen
11 (9.5)
9 (10.6)
3 (5.1)
2 (10.5)
0 (0.0)
Pelvis
18 (15.5)
13 (15.3)
5 (8.5)
3 (15.8)
1 (25.0)
Upper extremity
27 (23.3)
18 (21.2)
12 (20.3)
4 (21.1)
1 (25.0)
Lower extremity
25 (21.6)
16 (18.8)
9 (15.3)
4 (21.1)
1 (25.0)
Kidney
2 (1.7)
4 (4.7)
2 (3.4)
0 (0.0)
0 (0.0)
Ureter/Bladder/
Penis/Scrotal
1 (0.9)
2 (2.4)
1 (1.7)
0 (0.0)
0 (0.0)
Fig. 4.
Proportion of severe injuries by selected anatomic location
In this group, injury mechanisms differed notably between mounted and unmounted situations, consistent with earlier trauma center studies that differentiate rider falls from ground-based impacts. Mounted incidents—primarily falls from or being thrown by the horse (44.8% of cases)—were the main cause of high-energy deceleration injuries, associated with higher rates of brain/craniofacial (35.5%), chest (28.2%), spinal (25.1%), and lower extremity injuries. These mounted incidents often resulted in greater overall injury severity due to the high-energy impact from height and speed. In contrast, unmounted mechanisms—being struck by the horse (32.8%), direct contact (22.8%), kicks, or crushes—were more common in this rural setting, where occupational tasks such as ranch work or grooming increase exposure to ground-based interactions. These events typically produced localized blunt-force injuries, predominantly affecting the face, abdomen, and genitourinary structures (GU injuries observed in 9.3% of the cohort) (Fig. 3), often from direct kicks to the flank or perineum. These patterns align with prior studies showing that mounted riders more frequently sustain chest and lower extremity trauma, while unmounted individuals are more susceptible to facial and abdominal injuries. This distinction highlights the importance of safety measures, such as helmets and situational awareness, for both mounted and unmounted activities [14, 15, 23].
Fig. 3.
Seasonal distribution of equine-related injuries
Table 4 compares key injury characteristics by mounted versus unmounted primary mechanisms. Genitourinary injuries were more common in unmounted incidents (13.3%) than in mounted incidents (4.3%), likely reflecting the increased risk of direct kicks or crushing injuries during ground-based horse handling in this rural cohort.
Table 4.
Comparison of injury characteristics by mounted vs. unmounted mechanism (n = 259)
Characteristic
Mounted (fall/thrown from horse) (n = 116)
Unmounted (struck/other contact) (n = 143)
Proportion of total cases, n (%)
116 (44.8)
143 (55.2)
Mean age, y (SD)
48.4 (17.1)
47.7 (17.8)
Severe injury (ISS > 15), n (%)
14 (12.1)
18 (12.6)
Mean ISS (SD)
9.4 (6.2)
8.9 (5.8)
Brain/craniofacial injury, n (%)
52 (44.8)
40 (28.0)
Chest injury, n (%)
38 (32.8)
35 (24.5)
Spinal injury, n (%)
35 (30.2)
30 (21.0)
Genitourinary injury (consolidated), n (%)
5 (4.3)
19 (13.3)
Kidney involvement specifically, n (%)
2 (1.7)
6 (4.2)
Abdominal (non-GU) injury, n (%)
11 (9.5)
14 (9.8)
Pelvis injury, n (%)
18 (15.5)
22 (15.4)
Upper extremity injury, n (%)
27 (23.3)
35 (24.5)
Lower extremity injury, n (%)
25 (21.6)
30 (21.0)
Median hospital LOS, d (IQR)
2.0 (3.0)
2.0 (3.0)
Mortality, n (%)
2 (1.7)
2 (1.4)
Figure 3 shows the seasonal distribution of equine-related trauma admissions over the 10-year study period (n = 259) at a Level II trauma center in rural Oklahoma. Injuries peaked in spring (n = 83) and summer (n = 75), with fewer in fall (n = 61) and winter (n = 40). This pattern aligns with increased horseback riding and outdoor equine activities during the warmer months.
All four in-hospital mortalities were due to traumatic brain injury, underscoring equestrian-related TBI as the primary cause of death in this cohort. Severe injuries (ISS > 15) were predominantly observed among patients with brain/craniofacial, chest, and genitourinary involvement. The consistent presence of genitourinary injuries in this rural Oklahoma series represents a notable descriptive finding that has received limited attention in prior equine trauma literature, likely reflecting the higher frequency of direct kicks and crushing mechanisms encountered during occupational horse handling.
Discussion
This 10-year retrospective analysis of equine-related injuries at a Level II trauma center in Tulsa, Oklahoma, serving a predominantly rural population, demonstrates patterns consistent with prior equestrian trauma literature while offering new descriptive insights into genitourinary (GU) involvement. With 259 admissions over the study period, the cohort reflects Oklahoma’s high equine exposure, where horseback riding remains an integral part of rural livelihoods, recreation, and culture amid a national horse population estimated at 6.6 million. Falls from or being thrown by horses (44.8%) and being struck by horses (32.8%) were the predominant mechanisms, consistent with national reports in which falls account for approximately 50–55% of equestrian injuries. The most commonly affected body regions were brain/craniofacial (35.5%), chest (28.2%), and spinal (25.1%). Severe injuries (ISS > 15) comprised 12.4% of the cohort and were observed most frequently among patients with brain/craniofacial, chest, and genitourinary involvement. All four in-hospital deaths were due to traumatic brain injury.
A notable descriptive finding in this series is the consistent pattern of genitourinary injuries, which occurred in 9.3% of all cases and were more common among patients with severe trauma. Prior equine trauma reports have typically described only isolated GU mechanisms, such as saddle-horn impalement causing urethral or bladder injury or flank kicks resulting in renal contusion or laceration. Few studies have grouped GU injuries (kidney, ureter, bladder, penis, and scrotum) or highlighted their frequency in a rural setting. In this Oklahoma cohort, the higher representation of GU trauma likely reflects the occupational nature of horse handling, where direct kicks and crushing injuries to the lower torso and perineum are more common than in purely recreational contexts. These injuries often require specialized urologic evaluation and carry risks of long-term complications, including renal dysfunction and urinary issues, underscoring an important area for rural trauma prevention efforts.
The mortality rate in this series was 1.5%, with all deaths attributable to traumatic brain injury, reinforcing that equestrian-related TBI remains a leading cause of death in this activity. Patients with severe injuries experienced longer hospital stays (median 4.0 days vs. 2.0 days overall). No clear differences in demographics or comorbidities were observed between patients with severe and non-severe injuries, suggesting that injury mechanism and use of protective equipment play a more prominent role in outcomes. Helmet non-use was common in our registry, consistent with previous studies, despite substantial evidence supporting helmets in reducing head injury severity.
Limitations
This study is limited by its retrospective, single-center design, which may under-represent minor injuries treated in the emergency department or outpatient setting. Data were derived from the trauma registry, so detailed information on helmet use, rider experience, or long-term functional outcomes was not uniformly available. Although the rural Oklahoma setting limits generalizability to urban or other geographic regions, it provides valuable insight into injury patterns in a high-equine-density area. Future multicenter studies in similar rural environments would help confirm the observed GU injury patterns and better evaluate prevention strategies.
In summary, this descriptive experience highlights that equine-related trauma in rural Oklahoma frequently involves head and torso injuries, with genitourinary trauma emerging as a clinically relevant subset. These findings support targeted prevention efforts, including mandatory helmet use, protective vests, and education focused on safe horse-handling practices to reduce the burden of these potentially severe injuries in rural communities.
Conclusion
This 10-year retrospective review of equine-related injuries at a Level II trauma center in rural Oklahoma (n = 259) confirms that horseback riding remains a substantial source of traumatic injuries in high-equine-density rural communities. The predominant mechanisms—falls from a horse (44.8%) and being struck by a horse (32.8%)—most commonly involved the brain/craniofacial region (35.5%), chest (28.2%), and spine (25.1%). Severe injuries (ISS > 15), which accounted for 12.4% of cases, were observed most frequently in patients with brain/craniofacial, chest, and genitourinary involvement. All four in-hospital deaths resulted from traumatic brain injury.
A notable finding in this rural cohort is the pattern of genitourinary (GU) injuries, which occurred in approximately 9.3% of cases and were more common among patients with severe trauma. These injuries, frequently resulting from direct kicks or crushing mechanisms during occupational horse handling, appear more prominent in this setting than in many previously reported series. Such injuries often require specialized urologic care and carry potential for long-term complications in resource-limited rural environments.
The findings illustrate that no rider is immune to severe injury, regardless of experience. Helmet non-use was common in our cohort, despite strong evidence that helmets reduce the risk and severity of head trauma. In rural Oklahoma, where equine activities are central to both livelihoods and cultural traditions, these injuries impose a meaningful burden on patients, families, and local trauma systems.
Targeted prevention strategies are urgently needed. These include mandatory helmet and protective gear use for all riders, community-based education on safe horse-handling practices, and greater awareness of the risks associated with direct horse contact, particularly kicks and trampling. Policy support for standardized safety measures in rural equine events and occupational settings could substantially reduce the incidence and severity of these injuries. Future multicenter studies in similar high-equine-density rural regions are warranted to further characterize genitourinary injury patterns and evaluate the effectiveness of prevention interventions.
In summary, equine-related trauma in rural America is largely preventable. By prioritizing evidence-based safety measures and addressing barriers to protective equipment use, rural health systems and communities can meaningfully reduce this ongoing and potentially devastating injury burden.
Acknowledgements
Authors would like to express a sincere appreciation to Trauma Registrar Mr. Bryan Kirby whose cooperation, contributions and support in data acquisition have greatly enhanced the quality and rigour of this research.
Author contributions
The authors confirm contribution to the paper as follows: study conception and design: J.C., V.S., J.H., M.C.; literature review: V.S., J.H., Z.K., E.T.,;data collection: V.S., N.H., Z.K.,; analysis and interpretation of results: J.H., V.S., M.J., A.O.,; draft manuscript preparation: V.S., J.H.; critical revision: M.C., J.C., Z.K. All authors reviewed the results and approved the final version of the manuscript.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Data availability
The datasets generated and/or analyzed during the current study are not available from the corresponding author due to the institution policy.
Declarations
Conflict of interest
The authors declare no competing interests.
Ethical approval and consent to participate
The present study was approved by the local IRB.
Consent for publication
Not applicable.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated and/or analyzed during the current study are not available from the corresponding author due to the institution policy.
