Craniofacial injuries from slip, trip, and fall accidents of children

Dynamic stability during level walking and obstacle crossing in children aged 2–5 years estimated by marker-less motion capture

In the present study, dynamic stability during level walking and obstacle crossing in typically developing children aged 2–5 years (n = 13) and healthy young adults (n = 19) was investigated. The participants were asked to walk along unobstructed and obstructed walkways. The height of the obstacle was set at 10% of the leg length. Gait motion was captured by three RGB cameras. 2D body landmarks were estimated using OpenPose, a marker-less motion capture algorithm, and converted to 3D using direct linear transformation (DLT). Dynamic stability was evaluated using the margin of stability (MoS) in the forward and lateral directions. All the participants successfully crossed the obstacles. Younger children crossed the obstacle more carefully to avoid falls, as evidenced by obviously decreased gait speed just before the obstacle in 2-year-olds and the increased in maximum toe height with younger age. There was no significant difference in the MoS at the instant of heel contact between children and adults during level walking and obstacle crossing in the forward direction, although children increased the step length of the lead leg to a greater extent than the adults to ensure base of support (BoS)-center of mass (CoM) distance. In the lateral direction, children exhibited a greater MoS than adults during level walking [children: 9.5%, adults: 6.5%, median, W = 39.000, p < .001, rank-biserial correlation = −0.684]; however, some children exhibited a smaller MoS during obstacle crossing [lead leg: −5.9% to 3.6% (min–max) for 4 children, 4.7%–6.4% [95% confidence interval (CI)] for adults, p < 0.05; trail leg: 0.1%–4.4% (min–max) for 4 children, 4.7%–6.4% (95% CI) for adults, p < 0.05]]. These results indicate that in early childhood, locomotor adjustment needed to avoid contact with obstacles can be observed, whereas lateral dynamic stability is frangible.

Can TEN4 distinguish bruises from abuse, inherited bleeding disorders or accidents?

OBJECTIVE

Does TEN4 categorisation of bruises to the torso, ear or neck or any bruise in <4-month-old children differentiate between abuse, accidents or inherited bleeding disorders (IBDs)?

DESIGN

Prospective comparative longitudinal study.

SETTING

Community.

PATIENTS

Children <6 years old.

INTERVENTIONS

The number and location of bruises compared for 2568 data collections from 328 children in the community, 1301 from 106 children with IBD and 342 abuse cases.

MAIN OUTCOME MEASURES

Likelihood ratios (LRs) for the number of bruises within the TEN and non-TEN locations for pre-mobile and mobile children: abuse vs accidental injury, IBD vs accident, abuse vs IBD.

RESULTS

Any bruise in a pre-mobile child was more likely to be from abuse/IBD than accident. The more bruises a pre-mobile child had, the higher the LR for abuse/IBD vs accident. A single bruise in a TEN location in mobile children was not supportive of abuse/IBD. For mobile children with more than one bruise, including at least one in TEN locations, the LR favouring abuse/IBD increased. Applying TEN4 to collections from abused and accidental group <48 months of age with at least one bruise gave estimated sensitivity of 69% and specificity for abuse of 74%.

CONCLUSIONS

These data support further child protection investigations of a positive TEN4 screen in any pre-mobile children with a bruise and in mobile children with more than one bruise. TEN4 did not discriminate between IBD and abuse, thus IBD needs to be excluded in these children. Estimated sensitivity and specificity of TEN4 was appreciably lower than previously reported.

Oral and maxillofacial injuries in children: a retrospective study

Objectives

The purpose of this retrospective epidemiological study was to determine the etiology and pattern of maxillofacial injuries in a pediatric population.

Materials and Methods

Data for pediatric maxillofacial trauma patients aged 12 years and younger who were registered at the Department of Pediatric and Preventive Dentistry, Dr. R. Ahmed Dental College and Hospital, Kolkata, India, were reviewed and examined. Patients who were treated between October 2016 and September 2018 were analyzed according to age, sex, cause of injury, frequency and site of facial fractures, and soft tissue injuries. The chi-square tests were carried out for statistical analyses with a significance level of 5%.

Results

Of 232 patients with a mean age of 6.77±3.25 years, there were 134 males (57.8%) and 98 females (42.2%). The overall male to female ratio was 1.39:1. The most common causes of injuries were falls (56.5%) and motor vehicle accidents (16.8%). Incidence of falls decreased significantly with age (P<0.001). Dentoalveolar injuries (61.6%) and soft tissue injuries (57.3%) were more common than facial fractures (42.7%). Mandibular fractures (82.8%) were the most common facial fractures, and perioral or lip injuries were the most prevalent injuries in our patient population. There was a positive association between facial fractures and soft tissue injury (P<0.01) (odds ratio 0.26; confidence interval 0.15-0.46).

Conclusion

Falls were the leading cause of maxillofacial trauma in our sample of children, and the most common site of fractures was the mandible.

Falls Due to Loss of Consciousness are Associated With Maxillofacial Fracture Severity

PURPOSE

Falls are a common cause of the maxillofacial fractures, and falls associated with loss of consciousness might have special characteristics. The purpose of the present study was to measure the association between the types of falls and maxillofacial injury severity.

PATIENTS AND METHODS

The present retrospective cross-sectional study focused on patients with maxillofacial fractures resulting from falls who had been treated at the Hirosaki University Hospital from 1990 to 2016. The falls were divided into 2 categories according to the reason for their occurrence: 1) falls from slipping, tripping, or stumbling (STSFs); and 2) falls from loss of consciousness (LOCFs). The primary outcome measure of the present study was the severity of the maxillofacial fractures. The secondary outcomes were the pattern of maxillofacial fractures, pattern of concomitant injuries, and treatment modality. Multiple linear regression analysis was performed to evaluate the independent predictors for fracture severity.

RESULTS

A total of 148 patients had been admitted for maxillofacial fractures resulting from falls. The sample included 107 STSFs (72.3%) and 41 LOCFs (27.7%). The cause of the LOCFs was orthostatic-hypotension syncope in 13 patients, neurally mediated syncope in 10, cardiogenic syncope in 9, epilepsy in 5, and other in 4 patients. The proportion of mandibular fractures and the mean facial injury severity scale score were significantly greater in the LOCF group (2.20 ± 1.19) than in the STSF group (1.65 ± 1.15; P = .0067). The incidence of concomitant injuries was significantly greater in the STSF group than in the LOCF group (P = .023), and the distribution of sites was significantly different between the 2 groups (P = .039).

CONCLUSIONS

Our results have shown that maxillofacial fractures secondary to LOCFs tend to be more severe and to have a lower incidence of concomitant injuries compared with STSFs. We believe these features originate from the absence of protective reflexes resulting from the loss of consciousness.

The Use of a Hypoallergenic Dermal Matrix for Wrapping in Peripheral Nerve Lesions Regeneration: Functional and Quantitative Morphological Analysis in an Experimental Animal Model

INTRODUCTION

The aim of this research was to test, in an animal model, the nerve regeneration technique with a hypoallergenic acellular dermal matrix used to wrap the microsurgical neural suture.

MATERIALS AND METHODS

Two groups of rats received the cut of limb right median nerves. The regeneration technique considers for both groups an end-to-end nerve suture. In the experimental group (A) was used also a wrapping protocol by a conduit of collagen matrix currently used in oral surgery. The animals underwent functional grasping tests (at 1, 3, 5, and 7 months) and a histological and quantitative analysis of distal nerve was performed at the end of experimental time.

RESULT

After seven months, the grasping test reveals functional recovery in each tested animal; this improvement is more evident in Group A. The fibers appear well organized with restored myelin sheaths in both groups. Group A showed a great quantity of connective tissue surrounding the nerve. The quantitative morphology analysis in both groups shows a similar fibers density, fiber diameter, and myelin thickness. The differences between the groups in axon mean diameter are significant. In Group A M/d, D/d, and g-ratio is significantly higher compared to control group.

CONCLUSIONS

Histological and functional assessments show a functional recovery of the injured nerve in the test groups, stressed by the results of the grasping tests and the meaningful increasing in fiber diameter and higher g-ratio. Moreover, a connective tissue cuff distinguishes the distal portion of the injured nerve. Considering the easy availability and handling of the material used in this study we can conclude that this experimental technique can be considered as a valid alternative to protect nerves in nerve wrap surgery.

Patterns of bruising in preschool children with inherited bleeding disorders: a longitudinal study

OBJECTIVE

The extent that inherited bleeding disorders affect; number, size and location of bruises in young children <6 years.

DESIGN

Prospective, longitudinal, observational study.

SETTING

Community.

PATIENTS

105 children with bleeding disorders, were compared with 328 without a bleeding disorder and classified by mobility: premobile (non-rolling/rolling over/sitting), early mobile (crawling/cruising) and walking and by disease severity: severe bleeding disorder factor VIII/IX/XI <1 IU/dL or type 3 von Willebrand disease.

INTERVENTIONS

Number, size and location of bruises recorded in each child weekly for up to 12 weeks.

OUTCOMES

The interventions were compared between children with severe and mild/moderate bleeding disorders and those without bleeding disorders. Multiple collections for individual children were analysed by multilevel modelling.

RESULTS

Children with bleeding disorders had more and larger bruises, especially when premobile. Compared with premobile children without a bleeding disorder; the modelled ratio of means (95% CI) for number of bruises/collection was 31.82 (8.39 to 65.42) for severe bleeding disorders and 5.15 (1.23 to 11.17) for mild/moderate, and was 1.81 (1.13 to 2.23) for size of bruises. Children with bleeding disorders rarely had bruises on the ears, neck, cheeks, eyes or genitalia.

CONCLUSIONS

Children with bleeding disorder have more and larger bruises at all developmental stages. The differences were greatest in premobile children. In this age group for children with unexplained bruising, it is essential that coagulation studies are done early to avoid the erroneous diagnosis of physical abuse when the child actually has a serious bleeding disorder, however a blood test compatible with a mild/moderate bleeding disorder cannot be assumed to be the cause of bruising.

Childhood bruising distribution observed from eight mechanisms of unintentional injury

OBJECTIVE

To inform the assessment of described mechanisms of bruising in children.

DESIGN

Prospective cross-sectional study.

SETTING

The emergency department, and children in the local community.

PATIENTS

Children aged 0-13 years with bruises from unintentional injuries.

EXCLUSIONS

bleeding disorder, medication affecting coagulation or child protection concerns.

INTERVENTIONS

Injury incidents were categorised into one of eight causal mechanisms (fall from<1 m, 1-2 m, fall from standing height or less and hitting an object during fall, stairs or impact, crush, sports or motor vehicle collision).

MAIN OUTCOME MEASURES

Location, number and mechanism of bruising for each injury mechanism.

RESULTS

372 children had 559 injury incidents, resulting in 693 bruises; 85.2% of children were walking independently, with impact injuries and fall from standing height (including hitting an object) being the predominant mechanisms. A single bruise was observed in 81.7% of all incidents. Stair falls resulted in ≥3 bruises only with falls involving ≥10 steps (6/16). Bruising was rarely observed on the buttocks, upper arm, back of legs or feet. No bruises were seen in this dataset on ears, neck or genitalia. Petechial bruising was only noted in 1/293 unintentional incidents, involving a high-impact injury in a school-aged child.

CONCLUSION

These findings have the potential to aid an assessment of the plausibility of the explanation given for a child with bruising. Certain bruise distributions were rarely observed, namely multiple bruises from a single mechanism, petechiae and bruising to the ears, neck or genitalia.

Child abuse and fabricated or induced illness in the ENT setting: a systematic review

BACKGROUND

Child maltreatment is persistently under-recognised. Given that a third of maltreated children may return with serious or fatal injuries, it is imperative that otolaryngologists who are in frequent contact with children are able to detect maltreatment at first presentation.

OBJECTIVE OF REVIEW

This review aims to identify ENT injuries, signs or symptoms that are indicative of physical abuse or fabricated or induced illness (child maltreatment).

TYPE OF REVIEW

Systematic review.

SEARCH STRATEGY

An all-language search, developed in Medline Ovid and consisting of 76 key words, was conducted of published and grey literature across 10 databases from inception to July 2015, for primary observational studies involving children aged <18 years.

EVALUATION METHOD

Each relevant article underwent two independent reviews with full critical appraisal, applying strict quality standards.

RESULTS

Of the 2448 studies identified and screened, 371 underwent full review, resulting in 38 included studies that detailed 122 maltreated children. Pharyngeal perforations (n = 20) were the most frequent abusive ENT injury, predominantly affecting neonates and infants, presenting with dysphagia, drooling, haemoptysis and surgical emphysema. At least 52% of children with abusive pharyngeal injuries had additional co-existent injuries. The majority of ear injuries were inflicted to the external ear (n = 11) and included auricular deformity, abrasions, petechiae, lacerations and burns. Fabricated or induced illness cases presented most commonly with recurrent, unexplained otorrhoea or ENT lesions that failed to heal despite appropriate therapy.

CONCLUSIONS

All clinicians should be familiar with the signs of child maltreatment. Pharyngeal injuries, or injuries to the external ear, presenting in young children without an explicit history of witnessed injury should prompt a child protection referral for full evaluation. Likewise, children who present with recurrent, or apparently intractable symptoms and signs despite appropriate treatment, should raise the possibility of fabricated or induced illness, and discussion with a child protection specialist is advised. Early recognition of possible child maltreatment and instigation of appropriate safeguarding measures are essential to prevent repetition and escalation of injury. This is of paramount importance to otolaryngologists, who have the potential to identify these children in their practice.

Criteria for CT and Initial Management of Head Injured Infants: A Review

Criteria for computed tomography (CT) to head injured infants have not been established. Since the identification of neurological findings is difficult in infants, examination by CT may be necessary in some cases, but it may be difficult to perform CT because of problems with radiation exposure and body movement. Moreover, even though no intracranial abnormality was found immediately after injury, abnormal findings may appear after several hours. From this viewpoint, course observation after injury may be more important than CT in the initial treatment of head trauma in infants. The complaints and neurological manifestations of infants, particularly those aged 2 or younger, are frequently unclear; therefore, there is an opinion that CT is recommended for all pediatric patients. However, the appropriateness of its use should be determined after confirming the mechanism of injury, consciousness level, neurological findings, and presence/absence of a history of abuse. Among the currently available rules specifying criteria for CT of infants with head trauma, the Pediatric Emergency Care Applied Research Network (PECARN) study may be regarded as reliable at present. In Japan, where the majority of emergency hospitals are using CT, it may be necessary to develop criteria for CT in consideration of the actual situation. CT diagnosis for pediatric head trauma is not always necessary. When no imaging is performed, this should be fully explained at the initial treatment before selecting course observation at home. Checking on a state of the patients by telephone is useful for both patients and physicians.

Patterns of bruising in preschool children--a longitudinal study

INTRODUCTION

This study aims to identify the prevalence and pattern of bruises in preschool children over time, and explore influential variables

METHODS

Prospective longitudinal study of children (<6 years) where bruises were recorded on a body chart, weekly for up to 12 weeks. The number and location of bruises were analysed according to development. Longitudinal analysis was performed using multilevel modelling.

RESULTS

3523 bruises recorded from 2570 data collections from 328 children (mean age 19 months); 6.7% of 1010 collections from premobile children had at least one bruise (2.2% of babies who could not roll over and 9.8% in those who could), compared with 45.6% of 478 early mobile and 78.8% of 1082 walking child collections. The most common site affected in all groups was below the knees, followed by 'facial T' and head in premobile and early mobile. The ears, neck, buttocks, genitalia and hands were rarely bruised (<1% of all collections). None of gender, season or the level of social deprivation significantly influenced bruising patterns, although having a sibling increased the mean number of bruises. There was considerable variation in the number of bruises recorded between different children which increased with developmental stage and was greater than the variation between numbers of bruises in collections from the same child over time.

CONCLUSIONS

These data should help clinicians understand the patterns of 'everyday bruising' and recognise children who have an unusual numbers or distribution of bruises who may need assessment for physical abuse or bleeding disorders.

Maxillofacial Fractures due to Falls: does Fall Modality Determine the Pattern of Injury?

Objectives

In several epidemiological studies of maxillofacial trauma, falls were one of the most frequent causes of facial injury. The aim of this study is to analyse the patterns of fall-related maxillofacial injuries based on the height of the fall.

Material and Methods

Using a systematic computer-assisted database of patients hospitalised with maxillofacial fractures, only those with fall-related injuries were considered. The falls were divided into four groups: falls from slipping, tripping or stumbling (STSF), loss of consciousness (LOCF), stairs (SAF), and height (HF). Data on the age, gender, fracture site, Facial Injury Severity Scale (FISS), facial lacerations, associated lesions, type of treatment, and length of hospital stay were also analysed.

Results

This study included 557 patients (338 males, 219 females; average age 51.5 years [range 4 - 99 years]). In the over 60 age group, females were more prevalent in STSF than males. According to aetiology, STSF was the most frequent cause of maxillofacial fractures (315 patients; 56.5%) followed by LOCF (157; 28.2%), HF (55; 9.9%), and SAF (30; 5.4%). The middle third of the face was affected most frequently. After LOCF, however, the inferior third was prevalently involved. The majority of associated fractures, as well as the most severe injuries and greatest rate of facial lacerations, occurred secondary to HF.

Conclusions

This study showed that fracture severity and site are influenced not only by patient age, but also by the nature of the fall.

Epidemiology of pediatric facial trauma in Chile: a retrospective study of 7,617 cases in 3 years

OBJECTIVES

To describe the epidemiology of facial trauma injuries in a group of Chilean children aged 15 years or less.

STUDY DESIGN

Retrospective study of case series. Between 2006 and 2009, clinical records of 293,090 patients were reviewed. Data of patients with trauma injuries to the face were collected and evaluated for: age, sex, day and month of hospital admission, cause of injury, anatomical location, type of injury and presence of associated injuries.

RESULTS

A total of 7,617 patients with 8,944 injuries were found. Boy to girl ratio was 1,7:1. Preschool age children were most frequently affected. Main cause of injury were falls, soft tissue injuries the most common type of injury. Associated injuries occurred in 11% of cases.

CONCLUSIONS

Facial trauma presents a significant frequency in the group of Chilean children studied. Preeschool age boys were prone to present facial trauma of mild severity associated to falls.

Systematic reviews of bruising in relation to child abuse-what have we learnt: an overview of review updates

BACKGROUND

Dogma has long prevailed regarding the ageing of bruises, and whether certain patterns of bruising are suggestive or diagnostic of child abuse.

OBJECTIVES

We conducted the first Systematic Reviews addressing these two issues, to determine the scientific basis for current clinical practice. There have been seven updates since 2004.

METHODS

An all language literature search was performed across 13 databases, 1951-2004, using >60 key words, supplemented by 'snowballing' techniques. Quality standards included a novel confirmation of abuse scale. Updates used expanded key words, and a higher standard for confirmation of abuse.

RESULTS

Of 1495 potential studies, only three met the inclusion criteria for ageing of bruises in 2004, confirming that it is inaccurate to do so with the naked eye. This was roundly rejected when first reported, generating a wave of new studies attempting to determine a scientifically valid method to age bruises, none of which are applicable in children yet. Regarding patterns of bruising that may be suggestive or diagnostic of abuse, we included 23 of 167 studies reviewed in 2004, although only 2 were comparative studies. Included studies noted that unintentional bruises occur predominantly on the front of the body, over bony prominences and their presence is directly correlated to the child's level of independent mobility. Bruising patterns in abused children, differed in location (most common site being face, neck, ear, head, trunk, buttocks, arms), and tended to be larger. Updates have included a further 14 studies, including bruising in disabled children, defining distinguishing patterns in severely injured abused and non-abused children, and importance of petechiae.

CONCLUSIONS

Systematic Reviews of bruising challenged accepted wisdom regarding ageing of bruises, which had no scientific basis; stimulated higher quality research on patterns of bruises distinguishing abusive and non-abusive bruising patterns, and highlighted the benefits of regular updates of these reviews.

Bruising in children who are assessed for suspected physical abuse

OBJECTIVE

To describe the characteristics of bruising and mode of presentation of children referred to the paediatric child protection team with suspected physical abuse (PA), and the extent to which these differ between the children where abuse was confirmed and those where it was excluded.

DESIGN

Cross-sectional study.

SETTING AND PATIENTS

519 children, <6 years, referred to two paediatric child protection teams.

MAIN OUTCOME MEASURES

The mode of presentation, number, anatomical distribution, size and appearance of bruises according to whether PA was confirmed or excluded. ORs with 95% CI were calculated where relevant.

RESULTS

PA was confirmed in 69% of children; the rate varied from 84% when abuse was witnessed, admitted, alleged or where explanation for injury was absent or implausible, to 50% where there was a concerning history. Significantly more children with PA had bruises (89.4%) than PA-excluded (69.9%) and had significantly more sites affected (p<0.001). The odds of a PA child having bruising to: buttocks/genitalia (OR 10.9 (CI 2.6 to 46), left ear (OR 7.10 (CI 2.2 to 23.4), cheeks (Left (OR 5.20 (CI 2.5 to 10.7), Right OR 2.83 (CI 1.5 to 5.4)), neck (OR 3.77 (CI 1.3 to 10.9), trunk (back (OR 2.85 (CI 1.6 to 5.0) front (OR 4.74 (CI 2.2 to 10.2), front of thighs (OR2.48 (CI 1.4 to 4.5) or upper arms (OR 1.90 (CI 1.1 to 3.2) were significantly greater than in children with PA-excluded. Petechiae, linear or bruises with distinct pattern, bruises in clusters, additional injuries or a child known to social services for previous child abuse concerns were significantly more likely in PA.

CONCLUSIONS

Features in the presenting history, the extent and pattern of bruising differed between children with confirmed PA and those where abuse was excluded. These findings can provide a deeper understanding of bruising sustained from PA.

Facial soft tissue trauma

Traumatic facial soft tissue injuries are commonly encountered in the emergency department by plastic surgeons and other providers. Although rarely life-threatening, the treatment of these injuries can be complex and may have significant impact on the patient's facial function and aesthetics. This article provides a review of the relevant literature related to this topic and describes the authors' approach to the evaluation and management of the patient with facial soft tissue injuries.

Influence of age and fall type on head injuries in infants and toddlers

Age-based differences in fall type and neuroanatomy in infants and toddlers may affect clinical presentations and injury patterns.

OBJECTIVE

Our goal is to understand the influence of fall type and age on injuries to help guide clinical evaluation.

DESIGN/SETTING/PARTICIPANTS

Retrospectively, 285 children 0-48 months with accidental head injury from a fall and brain imaging between 2000 and 2006 were categorized by age (infant ≤1 year and toddler=1-4 years) and fall type: low (≤3 ft), intermediate (>3 and <10 ft), high height falls (≥10 ft) and stair falls.

OUTCOME MEASURES

Clinical manifestations were noted and head injuries separated into primary (bleeding) and secondary (hypoxia, edema). The influence of age and fall type on head injuries sustained was evaluated.

RESULTS

Injury patterns in children <4 years varied with age. Despite similar injury severity scores, infants sustained more skull fractures than toddlers (71% vs. 39%). Of children with skull fractures, 11% had no evidence of scalp/facial soft tissue swelling. Of the patients with primary intracranial injury, 30% had no skull fracture and 8% had neither skull fracture nor cranial soft tissue injury. Low height falls resulted in primary intracranial injury without soft tissue or skull injury in infants (6%) and toddlers (16%).

CONCLUSIONS

Within a given fall type, age-related differences in injuries exist between infants and toddlers. When interpreting a fall history, clinicians must consider the fall type and influence of age on resulting injury. For young children, intracranial injury is not always accompanied by external manifestations of their injury.

Evaluation of Japanese practice guidelines for newly diagnosed childhood idiopathic thrombocytopenic purpura

BACKGROUND

Practice guidelines for childhood idiopathic thrombocytopenic purpura (ITP) were proposed in 1998 and 2004 in Japan. It is important to evaluate the feasibility and validity of the guidelines because the guidelines are based not on evidence but on opinion.

METHODS

Records of 30 consecutive hospitalized patients aged 0-15 years (median, 3 years; 17 boys, 13 girls) were retrospectively reviewed. The feasibility and validity of the 2004 guidelines were evaluated by calculating an implementation rate, a response rate to first treatments, and a final clinical outcome.

RESULTS

Deviation from the guidelines was found in two patients. Management of the other 28 patients followed the guidelines. The implementation rate was 93.3%. Twenty-one of the 28 eligible patients (75%) responded to the first treatment, whereas seven patients (25%) required additional treatment. In 23 patients (76.7%) platelet counts returned to normal within 6 months. Seven patients (23.3%) developed chronic conditions. All patients had no complications and achieved a platelet count >150 000/µL within 6 years.

CONCLUSION

The 2004 Japanese guidelines are feasible and valid for the management of newly diagnosed childhood ITP patients.

Biomechanics of the toddler head during low-height falls: an anthropomorphic dummy analysis

OBJECT

Falls are the most common environmental setting for closed head injuries in children between 2 and 4 years of age. The authors previously found that toddlers had fewer skull fractures and scalp/facial soft-tissue injuries, and more frequent altered mental status than infants for the same low-height falls (<or=3 ft).

METHODS

To identify potential age-dependent mechanical load factors that may be responsible for these clinical findings, the authors created an instrumented dummy representing an 18-month-old child using published toddler anthropometry and mechanical properties of the skull and neck, and they measured peak angular acceleration during low-height falls (1, 2, and 3 ft) onto carpet pad and concrete. They compared these results from occiput-first impacts to previously obtained values measured in a 6-week-old infant dummy.

RESULTS

Peak angular acceleration of the toddler dummy head was largest in the sagittal and horizontal directions and increased significantly (around 2-fold) with fall height between 1 and 2 ft. Impacts onto concrete produced larger peak angular accelerations and smaller impact durations than those onto carpet pad. When compared with previously measured infant drops, toddler head accelerations were more than double those of the infant from the same height onto the same surface, likely contributing to the higher incidence of loss of consciousness reported in toddlers. Furthermore, the toddler impact forces were larger than those in the infant, but because of the thicker toddler skull, the risk of skull fracture from low-height falls is likely lower in toddlers compared with infants.

CONCLUSIONS

If similar fracture limits and brain tissue injury thresholds between infants and toddlers are assumed, it is expected that for impact events, the toddler is likely less vulnerable to skull fracture but more vulnerable to neurological impairment compared with the infant.

Fatal accidental fall from height in infants and children: a study from South Delhi

One hundred and seventy-four deaths of infants and children due to accidental fall from height received from South Delhi for autopsy were studied during the 10-year period from January 1998 to December 2007 at the All India Institute of Medical Sciences, New Delhi. Data were analysed with regard to age, sex, location of fall, height of fall, pattern of injury, cause of death and seasonal variation. These cases represented approximately 22.56% of all deaths due to a fall from height and 1.31% of all medicolegal autopsies conducted during the period. There were 106 male (60.9%) and 68 female (39.1%) victims. Age-specific rate of fall showed that the highest rate was in toddlers (39.65%), followed by 26.43% each in preschool children and school-going children and the least in infants (7.47%). The head and face was the most frequently injured body region (93.67%) and the skull was the commonest bone fractured (59.19%). The most common cause of death was head injury (84.48%). Major fall sites in decreasing order of frequency were rooftop (38.50%), balcony (24.13%), household furniture (21.26%), staircase (6.89%), window (4.59%), wall (1.72%), rickshaw/bicycle (1.15%) and tree (0.57%). Most fatalities due to a fall from height were reported in the rainy season.

Factors associated with orofacial injury and willingness to participate in interventions among adolescents treated in trauma centers

PURPOSE

Assault is the most common cause of facial injuries in adolescents treated at inner-city trauma centers, yet little is known about the behavioral and environmental antecedents of these injuries or the willingness of such at-risk adolescents to participate in behavioral interventions to minimize reinjury. The purpose of this study was to identify possible risk and protective factors among adolescents with assault-related facial injury and to assess their willingness to participate in prospective observational research and behavioral interventions.

PATIENTS AND METHODS

Interviews were conducted with 67 adolescents (range 14 to 20 yrs) who were treated in trauma centers for facial injuries. Most of these injuries were assault-related (59%), followed by motor vehicle or other accidents (29%), gunshot wounds (9%), and sports injuries (3%). The subjects were predominantly male (86%) and of ethnic minorities (91%).

RESULTS

The adolescents showed high rates of intentional injuries in the past 6 months (56%), unhealthy alcohol use, and in more than half (55%) problem levels of substance use. Compared with those with unintentional injuries, adolescents who experienced assault-related injuries were more likely to report using alcohol, tobacco, and other substances. Although a significant segment of the sample (55%) had been arrested previously, no differences in arrest rates or types of crimes for which adolescents were arrested were observed by injury type. Most subjects were unwilling to participate in interventions that involved multiple sessions; however, greater family cohesion predicted the likelihood of being willing to participate.

CONCLUSIONS

Most facial injuries in inner-city adolescents result from assault. Unhealthy alcohol use, problem levels of substance use behaviors, and family history of alcohol problems are associated markers of assault-related injuries that can be useful for risk assessment and targeted intervention. Interventions need to be brief if they are to engage these at-risk youth.

Injuries associated with bathtubs and showers among children in the United States

OBJECTIVE

The goal was to describe the epidemiological features of injuries associated with bathtubs and showers, especially those related to slips, trips, and falls, among US children.

METHODS

A retrospective study was performed by using nationally representative data from the US Consumer Product Safety Commission National Electronic Injury Surveillance System from 1990 through 2007 for children <or=18 years of age.

RESULTS

There were an estimated 791 200 bathtub- and shower-related injuries among children <or=18 years of age who were treated in US emergency departments in 1990-2007, with an average of 43 600 cases per year or approximately 5.9 injuries per 10 000 US children per year. The largest number of injuries involved children 2 years of age; children <or=4 years accounted for 54.3% of injuries. The most common diagnosis was laceration (59.5%). The most common mechanism of injury was a slip, trip, or fall, accounting for 81.0% of cases or 4.6 injuries per 10 000 US children per year. The most frequently injured body part was the face (48.0%), followed by the head/neck (15.0%). The majority (71.3%) of injuries occurred in a bathtub. Of the cases with a known place of injury, 97.1% occurred at home. An estimated 2.8% of patients were admitted, transferred to another hospital, or held for observation.

CONCLUSIONS

This is the first study on bathtub- and shower-related injuries using nationally representative data. Slips, trips, and falls in bathtubs and showers are a common cause of injury among children, especially children <or=4 years of age. The incidence of these injuries may be decreased by increasing the coefficient of friction of bathtub and shower surfaces.

Staircase falls: high-risk groups and injury characteristics in 464 patients

INTRODUCTION

Few data are available about the epidemiology and injury characteristics in staircase falls. The available literature mainly concerns children and autopsy studies.

OBJECTIVE

To describe the epidemiology and injury characteristics of staircase falls, and to identify high-risk groups for these falls.

METHODS

All patients who reported to an academic Accident & Emergency (A&E) department in 2005 after a staircase fall were selected in the Dutch Injury Surveillance System These data were linked to the hospital Trauma Registry database.

RESULTS

Four hundred and sixty-four patients (42% male, p=0.001), with a median age of 35 years were included. Children under five suffered significantly more head injuries. Male patients showed significantly more thoracic injuries than female patients. Spinal column fractures were only seen in patients over 25 years of age. Older patients tended to accumulate more rib fractures and lower extremity fractures and were admitted more frequently than the younger patients. Sixty-one patients (13%) required admission. Two patients, both with severe traumatic brain injury (TBI), died. National data on staircase falls were comparable with our hospital data. However, in comparison to the national population data, senior citizens in this study had an incidence that was markedly higher than in the younger patients.

CONCLUSION

Injuries due to staircase falls occur in all age groups, however, children under five years are relatively over-represented with higher rates of head injury. Senior citizens showed a markedly higher incidence than younger patients. Most injuries occur to the distal extremities and are relatively mild.

The prognostic value of injury severity, location of event, and age at injury in pediatric traumatic head injuries

AIMS

To estimate the prognostic value of injury severity, location of event, and demographic parameters, for symptoms of pediatric traumatic head injury (THI) 4 years later.

METHODS

Data were collected prospectively from Reykjavik City Hospital on all patients age 0-19 years, diagnosed with THI (n = 408) during one year. Information was collected on patient demographics, location of traumatic event, cause of injury, injury severity, and ICD-9 diagnosis. Injury severity was estimated according to the Head Injury Severity Scale (HISS). Four years post-injury, a questionnaire on late symptoms attributed to the THI was sent.

RESULTS

Symptoms reported were more common among patients with moderate/severe THI than among others (p < 0.001). The event location had prognostic value (p < 0.05). Overall, 72% of patients with moderate/severe motor vehicle-related THI reported symptoms. There was a curvilinear age effect (p < 0.05). Symptoms were least frequent in the youngest age group, 0-4 years, and most frequent in the age group 5-14 years. Gender and urban/rural residence were not significantly related to symptoms.

CONCLUSIONS

Motor vehicle related moderate/severe THI resulted in a high rate of late symptoms. Location had a prognostic value. Patients with motor vehicle-related THI need special consideration regardless of injury severity.