ABSTRACT Objective Little information exists about horse-related injury admissions to Level 1 trauma centers in the Western United States. This study describes injury patterns in this population, to reveal potential areas for injury prevention initiatives. Methods A retrospective database review of 512 non-fatal equine-related injuries over a 15-year period was conducted, using a Level 1 hospital trauma registry. To determine patterns of injury, patients injured by riding or being near a horse were classified according to age, sex, helmet use, abbreviated injury score, anatomical region injured, and length of stay. Results Equine-related injury was more frequent among females than males, the anatomical region most at risk among adults was the lower extremity (including pelvis), and among children and youth, the head. 75% of head-injured patients were not wearing a helmet at the time of injury and those with the most severe head injuries were least likely to be wearing a helmet. Conclusion Preventable equine-related injuries occur across all ages, are more frequent among females, and affect all regions of the body. Despite head-injury risks associated with horse activities, helmet use was not common among most of the injured. Decreasing the risk of these injuries requires use of appropriate protective equipment and enhanced education campaigns aimed at those in the horse industry and the general public.