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It is widely accepted that all-terrain vehicles (ATVs) can be dangerous to operators. Understanding the mechanisms of ATV crashes, especially rollovers, can provide important insight to consumers, legislators, and manufacturers on ATV safety and protection of the users.From March 1, 2003 to July 31, 2005, all patients with ATV-related injuries presenting to a regional trauma center were enrolled in an ATV crash data bank. Data were collected on the patients and the circumstances surrounding each crash.A total of 193 persons were treated during the study period for ATV-related injuries. Among the 190 nonfatally injured patients, almost half (47%) were diagnosed with a head injury. In 63% of crashes the ATV rolled over. The direction of the rollover was strongly associated with the type of riding terrain or slope. ATVs traveling on flat or uneven surfaces were strongly associated with right-side rollovers (odds ratio [OR] = 32.9, 95% confidence interval [CI] = 6.6–221.5). ATVs traveling uphill were strongly associated with backward rollovers (OR = 173.6, 95% CI = 27.2–1,497.0). Children had a significantly greater risk compared with adults of right-side rollovers on flat and uneven surfaces (OR = 4.7, 95% CI = 1.2–17.5) Adults were more likely to be injured in rollover crashes where the ATV was traveling uphill; in all of these cases the vehicle rolled backwards.These findings suggest that nonrandom, modifiable factors are likely involved. Our data provide unique insight into specific mechanisms of ATV crashes, particularly rollovers, and those involving children. Findings may be applicable to changes in ATV design and education of users.