The role of restraint and seat position in pediatric facial fractures

Pediatric motor vehicle crashes injuries: A systematic review for forensic evaluation

Children involved in car crashes can experience either direct trauma or inertial injuries resulting from interactions with external objects, such as other vehicles, or with the restraint system. Furthermore, improper use of restraint systems can lead to additional severe injuries. Recent reports from international institutions underscored the persistent prevalence of inadequate restraint systems utilization and this widespread issue increases children's vulnerability and risk of injuries.The aim of this study is to provide a systematic review of the literature on injuries sustained in children involved in road accidents describing and analyzing elements useful for forensic assessment.The literature search was performed using PubMed, Scopus and Web of Science from January 1970 to March 2023. Eligible studies have investigated issues of interest to forensic medicine about traffic accidents involving pediatric passengers. A total of 69 studies satisfied the inclusion criteria and were categorized and analyzed according to the anatomical regions of the body affected (head, neck, thoraco-abdominal, and limb injuries), and the assessment of lesions in reconstruction of the accident was examined and discussed.The review highlights that in motor vehicle accidents involving children, the forensic evaluation of both the cause of death and accident dynamics needs to consider several factors, such as the child's age, the type of restraint system employed, and the specific passenger seat occupied. Considering the complexity of the factors that can be involved in this road accident, it is crucial that there is a comprehensive exchange of information between the judge and the medical expert.

Using Crash Outcome Data Evaluation System (CODES) to examine injury in front vs. rear-seated infants and children involved in a motor vehicle crash in New York State

Background

In New York State (NYS), motor vehicle (MV) injury to child passengers is a leading cause of hospitalization and emergency department (ED) visits in children aged 0–12 years. NYS laws require appropriate child restraints for ages 0–7 years and safety belts for ages 8 and up while traveling in a private passenger vehicle, but do not specify a seating position.

Methods

Factors associated with injury in front-seated (n = 11,212) compared to rear-seated (n = 93,092) passengers aged 0–12 years were examined by age groups 0–3, 4–7 and 8–12 years using the 2012–2014 NYS Crash Outcome Data Evaluation System (CODES). CODES consists of Department of Motor Vehicle (DMV) crash reports linked to ED visits and hospitalizations. The front seat was row 1 and the rear rows 2–3. Vehicle towed from scene and air bag deployed were proxies for crash severity. Injury was dichotomized based on Maximum Abbreviated Injury Severity (MAIS) scores greater than zero. Multivariable logistic regression (odds ratios (OR) with 95% CI) was used to examine factors predictive of injury for the total population and for each age group.

Results

Front-seated children had more frequent injury than those rear-seated (8.46% vs. 4.92%, p < 0.0001). Children in child restraints experienced fewer medically-treated injuries compared to seat belted or unrestrained children (3.80, 6.50 and 13.62%, p < 0.0001 respectively). A higher proportion of children traveling with an unrestrained vs. restrained driver experienced injury (14.50% vs 5.26%, p < 0.0001). After controlling for crash severity, multivariable adjusted predictors of injury for children aged 0–12 years included riding in the front seat (1.20, 1.10–1.31), being unrestrained vs. child restraint (2.13, 1.73–2.62), being restrained in a seat belt vs. child restraint (1.20, 1.11–1.31), and traveling in a car vs. other vehicle type (1.21, 1.14–1.28). Similarly, protective factors included traveling with a restrained driver (0.61, 0.50–0.75), a driver aged < 25 years (0.91, 0.82–0.99), being an occupant of a later vehicle model year 2005–2008 (0.68, 0.53–0.89) or 2009–2015 (0.55, 0.42–0.71) compared to older model years (1970–1993).

Conclusions

Compared to front-seated children, rear-seated children and children in age-appropriate restraints had lower adjusted odds of medically-treated injury.

The prevalence of head and facial injuries among children in Saudi Arabia following road traffic crashes

BACKGROUND

Motor vehicle crashes (MVCs) are the leading cause of death among children in Saudi Arabia. Childhood injuries can be prevented or minimized if safety measures, such as car seats, are implemented. The literature on the epidemiology of head and facial injury among children is limited, which affects the ability to understand the extent of the burden and hinders investment in public health prevention.

OBJECTIVE

Describe the epidemiology of head and facial injuries among children admitted to the hospital following MVCs.

DESIGN

Retrospective chart review.

SETTING

Five hospitals in several regions.

PATIENTS AND METHODS

We collected data on all patients ≤16 years old, who were admitted to the hospital following MVCs between 2016-2019. Differences in various characteristics like head injury status and age groups were compared.

MAIN OUTCOME MEASURES

Head and facial injuries.

SAMPLE SIZE

253 patients.

RESULTS

Of the injured population, 97 (38.3%) sustained a head injury, and 88 (34.8%) had a facial injury. Thirteen (9.1%) children were driving the car at the time of the crash. About half of the children were seated in the back (53.8%) without a seatbelt or safety seat.

CONCLUSION

The prevalence of head and facial injuries is striking. In addition, the study revealed that driving among children is not uncommon, which warrants monitoring and implementing interventions. Improved documentation of restraint use and police enforcement of safety laws can play a significant role in reducing associated injuries. The study findings highlight the importance of combination or rear seating as well as age-appropriate restraint in order to reduce the likelihood of head or facial injuries among children.

LIMITATIONS

Retrospective study using the electronic search system to identify patients, but may have missed cases that were not coded correctly. Large amount of missing data for some variables. Additionally, the analysis was limited to those admitted to the hospital.

CONFLICT OF INTEREST

None.

Restraint use and injury in forward and rear-facing infants and toddlers involved in a fatal motor vehicle crash on a U. S. Roadway

BACKGROUND

Use of appropriate child passenger safety restraints reduces injury in infants, with rear facing restraints favored over forward facing. In 2011, the American Academy of Pediatrics (AAP) began recommending that infants and children under the age of 2 years be restrained in a rear-facing seat installed in the vehicle's rear seat. This study examines the practice of rear-facing restraints pre- and post-AAP recommendations for children under 2 years.

METHODS

Data from the Fatality Analysis Reporting System (FARS) from 2008 to 2015 were used to examine restraint status and injuries in rear-seated infants and toddlers aged 0 to less than 2 years involved in fatal collisions (n = 4966). Subpopulation analyses were conducted on 1557 children with seat facing direction recorded. Multivariable logistic regression was used to generate odds ratios (OR) with 95% confidence intervals (CI). Covariates considered for inclusion in the multivariable model included passenger characteristics (age, gender, seating position), driver characteristics (age, gender, seat belt status, alcohol status, drug status, previous traffic violations), vehicle characteristics (vehicle type), and crash-level characteristics (day/night, weekday/weekend, rush hour, expressway/surface street, urban/rural).

RESULTS

Approximately 6.7% (330 of 4996) of infants and toddlers were unrestrained with mortality that was approximately triple that of restrained infants (40.0% vs 13.7%, P < 0.0001). In multivariable adjusted models, predictors of an infant being unrestrained included unrestrained driver (OR: 3.17, 95% CI: 2.38-4.21), driver aged less than 20 years (OR: 2.18, 95% CI: 1.42-3.34), driver alcohol use (OR: 2.21, 95% CI: 1.42-3.44), center-seated infant (OR: 1.55, 95% CI: 1.19-2.03) and weekday crash (OR: 1.52, 95% CI: 1.12-2.01). Of all rear-seated children whose restraint status were reported (4966), rear-facing restraint use increased from 5.0% to 23.2% between 2008 and 2015 (P < 0.0001). The odds of rear-facing restraint use increased after introduction of the AAP guideline among infants aged 0 to < 1 year old (OR: 2.12, 95% CI: 1.46-3.10) and among toddlers aged 1 to < 2 years old (OR: 1.97, 95% CI: 1.03-3.79).

CONCLUSION

Trends in the use of rear-facing child restraints improved over the timeframe of this study, but remain low despite the introduction of AAP guidelines and the strengthening of child restraint laws.

Analysis of 809 facial bone fractures in a pediatric and adolescent population

Background

Facial fractures are infrequent in children and adolescents and have different clinical features from those in adults. The low incidence in children and adolescents reflects the flexibility and underdevelopment of their facial skeletons, as well as their more protected environments. Only a few reports have reviewed such patients in Korea. The authors performed a retrospective study to analyze the characteristics of facial fractures in the Korean pediatric population.

Methods

We conducted a retrospective review on a series of 741 patients, aged <18 years, with facial fractures who had been treated at our hospital between 2006 and 2010. The following parameters were evaluated: age, sex, cause, location and type of fractures, associated injuries, treatment and complications.

Results

A total of 741 consecutive patients met the inclusion criteria. The ratio of boys to girls was 5.7:1. Facial fractures most commonly occurred in patients between 13 and 15 years of age (36.3%). The most common causes of injury was violence. The nasal fracture was the most common type of fracture (69%) and the blowout fracture was the second most common (20%). Associated injuries occurred in 156 patients (21%).

Conclusions

The incidence of pediatric facial fractures caused by violence is high in Korea. Our results show that as age increases, etiological factors and fracture patterns gradually shift towards those found in adults. This study provides an overview of facial fractures in these age groups that helps illustrate the trends and characteristics of the fractures and may be helpful in further evaluation and management.

The role of seating position in determining the injury pattern among unrestrained children involved in motor vehicle collisions presenting to a level I trauma center

BACKGROUND AND OBJECTIVES

Seating position in motor vehicle collisions (MVC) plays a major role in determining the injury pattern in mainly restrained children. However, compliance with child seating and restraint laws is still suboptimal. The role of seating position in predicting injury patterns among unrestrained children has not been previously studied.

DESIGN AND SETTING

Retrospective review based on the trauma registry of a level I trauma center in Riyadh, Saudi Arabia. Data collection was restricted to unrestrained children involved in MVC.

PATIENTS AND METHODS

Between July 2001 and March 2010, 274 records were identified. Detailed information about the collision, child seating position and the use of restraints was cross-verified using parental phone interviews.

RESULTS

Of the 274 identified records, cross-verification was possible for 89 (32.4%) unrestrained children, 64 boys and 25 girls, with a mean (SD) age of 83 (40) months. Of these children, 41 (46.1%) were front seated (FS), and 48 (53.9%) were back seated (BS). There were higher rates of rollover (52.1% vs 24.4%, P=.02), ejection (41.7% vs 22%, P=.05), and occupant death ratio (14.8 vs 4, P=.04) among BS children. However, the two groups did not differ in pediatric trauma scores, Glascow coma scale score, or age distribution. FS children were more likely to present with isolated head, neck or facial injuries (HNFI) (51.2% vs 25%, P=.01), whereas BS children were more likely to suffer long bone or pelvic fractures (LPF) (60.4% vs 36.6%, P=.025).

CONCLUSION

Injury pattern can vary according to seating position among unrestrained children presenting at trauma centers after MVC. While FS children are more likely to present with HNFI, BS children more often sustain LPF. BS children had similar trauma severity compared with FS children despite the higher-impact nature of their MVCs. While highlighting the value of proper restraints use and seating position, these results can be valuable in the initial assessment of traumatized children involved in MVC.

Traumatic displacement of maxillary permanent incisor into the nasal cavity

PURPOSE

The purpose of this paper was to describe a case of unviable alveolar repositioning of an intruded tooth into the nasal cavity and to bring the subject of intrusive tooth injury among patients with dentoalveolar fractures to the attention of trauma surgeons.

PATIENT

A 26-year-old male was involved in a car accident and crashed his mouth against the dashboard due to sudden deceleration. Intraoral examination revealed an anterior maxillary dentoalveolar fracture and absence of the central maxillary incisors, right lateral maxillary incisor, and left maxillary canine. Computed tomography showed a dislocated tooth in the nasal cavity. The "missing" left maxillary canine was easily recovered from the floor of the left nostril.

CONCLUSIONS

Because complete dislocation of a tooth can cause a frontal sinus abscess, an airway complication, a respiratory tract obstruction, and a complicated lung abscess or sinusitis, anytime a tooth is not accounted for after a dentoalveolar trauma, the possibility that it has been fully intruded should be considered. Computed tomographic scan should be a routine diagnostic study in all cases with associated missing anatomical structures in the oral and maxillofacial region. The need to involve the dental professional in the initial assessment of dental trauma in emergency rooms in hospitals is important in order to identify how many teeth might be missing after dental trauma and to correctly reposition the avulsed teeth when possible.

Injuries to belted older children in motor vehicle crashes

CONTEXT

The American Academy of Pediatrics and the National Highway Traffic Safety Administration currently recommend that, unless they are under 57in. in height, 8-12-year-old children use seat belts and all should ride in the rear seats of vehicles. These recommendations assume that the vehicle seat belt should provide adequate protection for these older children in the event of a crash.

OBJECTIVES

To describe characteristics of older children in the rear seat using seat belts in crashes, to estimate their risk and body region distribution of injury, and to identify risk factors for injury.

METHODS

A representative sample of 6680 seat belt-restrained occupants, 8-12 years of age, seated in the rear seat during crashes involving insured vehicles in 16 US states between December 1998 and December 2007. A telephone interview was conducted with the driver of each vehicle. The main outcome was the parent-reported injury defined as Abbreviated Injury Scale (AIS) 2 or greater injuries.

RESULTS

The risk of injury for belted 8-12 year olds in the rear seat was 1.3%. Head injury was the most common injury (60%), followed by injuries to the face (9%), upper extremity (9%) and abdomen (9%). One out of five (21%) 8-12 year olds either did not use the shoulder portion of the vehicle seat belt or placed it incorrectly behind their back or under their arm. Bivariate analyses indicated a higher risk of injury for these children (1.8%) as compared to children using both the lap and shoulder portions of the seat belt (1.1%). However, this difference was not statistically significant when other risk factors such as crash severity and characteristics of the driver were considered.

CONCLUSIONS

Injuries to the head, face, abdomen and upper extremity are the most common injuries to target for improved protection among 8-12 year olds in seat belts. Driver and crash characteristics are important risk factors for injury. A recent federal motor vehicle safety standard requiring lap and shoulder belts in all rear seat positions has the potential to further decrease the risk of injury to older children using seat belts.

Odds of critical injuries in unrestrained pediatric victims of motor vehicle collision

OBJECTIVES

To compare morbidity and mortality between pediatric victims of motor vehicle collisions (MVC) who were unrestrained to those restrained and to describe compliance with child restraint usage in our population.

MATERIALS AND METHODS

A retrospective consecutive chart review study was performed on MVC victims 14 years old and younger who presented to our academic, level 1 trauma emergency department in 2003. Each patient's emergency department and hospital course was reviewed and data were collected. Odds ratios (ORs) were calculated for unrestrained children with respect to restrained children for fractures; intraabdominal injuries, intrathoracic injuries, intracranial injuries, admission, surgery, blood transfusion, intubation; and deaths. Hospital charges and length of hospital stay were compared between those unrestrained and restrained. Percentage of children unrestrained was determined.

RESULTS

Of 336 patients, 81 (24%) were unrestrained. Mean hospital stay for unrestrained children was longer, 1.94 days (95% confidence interval [CI] 0.75-3.12) versus 0.098 days (95% CI 0.02-0.21). Unrestrained victims had higher mean charges, 14,754 dollars (95% CI 7676 dollars-21,831 dollars) versus 1996 dollars (95% CI 1207 dollars-2786 dollars). Admissions (OR = 14.48, 95% CI 5.91-38.63), fractures (OR = 5.85, 95% CI 2.13-16.89), intraabdominal injuries (OR = 20.16, 95% CI 2.36-930.68), and intrathoracic injuries (OR = 13.09, 95% CI 1.26-647.05) were all more likely in unrestrained patients. No restrained child had intracranial injury, whereas 9/81 (11.11%) of unrestrained did. Odds were higher in unrestrained for surgery [OR = 13.09, 95% CI 3.30-74.33] and transfusion [OR = 27.61, 95% CI 3.56-229.85]. Ten out of 81 (12.35%) of unrestrained children required intubation versus none for restrained. The only 2 mortalities were unrestrained patients.

CONCLUSION

Critical injuries and cost of care are higher in unrestrained than restrained children. Improved compliance with child safety restraint in southern Arizona should decrease childhood morbidity and mortality from MVCs.

Critical gaps in child passenger safety practices, surveillance, and legislation: Georgia, 2001

OBJECTIVE

Motor vehicle crashes remain the leading cause of death among US children 1 year of age and older. Although age-appropriate child passenger restraint use and back seating position are effective injury prevention strategies, many children 12 years of age and younger ride inappropriately restrained and seated in the front seat. In Georgia and in most states, surveillance of child passenger restraint use is less than optimal. Although child safety seat legislation is 1 of the most effective mechanisms for increasing correct restraint use and back seating position, Georgia's child occupant restraint law, like the laws in most states, falls short of practices recommended by government and child advocacy safety groups. The objective of this study was to document child passenger restraint use and seating position among children aged 0 to 12 years in Georgia and to use these study results to evaluate the efficacy of Georgia's child restraint surveillance and legislation.

METHODS

In May and June 2001, police roadblocks were used to collect information about child passenger age, restraint use, and seating position.

RESULTS

Data were collected on 1858 children who were riding in 1221 vehicles in 24 different Georgia counties. Results showed that 56% of children were inappropriately restrained and/or in the front seat. The most problematic age groups included infants who were in forward-facing child safety seats (28%) and/or in the front seat (22%); children who were 5 to 8 years of age in car seat belts alone (88%), rather than age- and size-appropriate child safety seats (6%); and children who were 9 to 12 years of age and riding in the front seat (39%). We compared our results with the existing Georgia passenger restraint surveillance system and found that it would have missed 77% of the children in our study who were inappropriately restrained and/or riding in the front seat. In a similar comparison, Georgia's restraint law did not cover over 74% of the children in our study who were riding at risk.

CONCLUSION

The results of this study highlight 3 important areas for improving child passenger safety: targeted interventions to promote booster seat use and riding in the back seat, expanded child passenger restraint and seating position surveillance, and expanded legislation to mandate booster seat use and back seating position.

Etiology and Patterns of Pediatric Mandibular Fractures in Portugal: A Retrospective Study of 10 Years

OBJECTIVE

To determine the pattern of occurrence of mandibular fractures in the pediatric population in Portugal.

MATERIALS AND METHODS

This retrospective study reviews the records of patients 18 years of age or younger from the 10-year period 1993 to 2002. Age, gender, anatomic site, cause of the accident, weekly and monthly variation, location and type of fractures, presence and location of associated injuries, treatment methods, and complications were reviewed.

RESULTS

During this 10-year period, 521 patients with 681 mandibular fractures were treated. Motor-vehicle accident (MVA) was the most common (53.9% patients) cause of fracture. Almost half of the patients (48.8%) were in the oldest age group (16 to 18 years old). The condyle of the mandible was involved in 31.0% of the fractures. Maxillomandibular (MMF) fixation was used in 534 (78.4%) fractures. Overall mortality in this series was 0.6% (3 patients); mortality was caused by multiple traumas, mainly head trauma.

CONCLUSION

There is a need to reinforce legislation aimed to prevent MVA and the total enforcement of existing laws to reduce maxillofacial injuries among children and adolescents.

Craniomaxillofacial trauma in children: a review of 3,385 cases with 6,060 injuries in 10 years

PURPOSE

Trauma is the leading cause of diseases and death in children. The goal of this study was to assess the impact of the main causes of accidents among children resulting in pediatric craniomaxillofacial trauma.

PATIENTS AND METHODS

Between 1991 and 2000, data for 3,385 patients younger than 15 years of age who sustained a total of 6,060 craniomaxillofacial injuries were recorded for cause of injury, age and gender distribution, frequency and type of injury, injury mechanisms, localization and frequency of soft tissue injuries, dentoalveolar trauma, facial bone fractures, and concomitant injuries. Univariate statistical analyses were followed by logistic regression analyses for the 3 injury types to determine the impact of the main injury causes on the type of injury at different ages in pediatric facial trauma patients.

RESULTS

Play (58.2%), sport (31.8%), and traffic accidents (5%), acts of violence (3.9%), and other causes (1.1%) were noted. A total of 389 patients (11.5%) had 615 fractures, 2,582 patients (76.3%) had 3,384 dentoalveolar injuries, and 1,697 patients (50.1%) had 2,061 soft tissue injuries. The girl-to-boy ratio was 3:5, and the mean age was 7 +/- 4.4 years. For children sustaining facial trauma, logistic regression analyses revealed increased risks for fractures (+238%) and soft tissue lesions (+89%) in children involved in traffic accidents. Dental trauma was more frequent (>+38%) in both sport and play accidents (all P <.001).

CONCLUSIONS

This study dissected the distinct impact of injury mechanisms in pediatric craniomaxillofacial trauma. Logistic regression analyses revealed statistically highly significant outcome differences in pediatric facial trauma depending on the injury mechanism.