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When evaluating a child with head trauma, a clinician must know when inflicted trauma should be included in the differential diagnosis. It may be difficult to differentiate abusive head trauma from accidental injury since accidental falls are common occurrences in infants and children. In addition, falls or accidental injuries are frequently offered as explanations when abuse has occurred. It is therefore important to become familiar with the published literature regarding the severity and type of injuries sustained from children who have fallen from various objects and heights.
The Mayerson Center for Safe and Healthy Children at Cincinnati Children’s Hospital Medical Center provides the following clinical update of literature, organized by types of falls and by mechanism of fall, specifically falls from beds, falls down stairs, falls in walkers, falls from heights and fatal falls.
Helfer (1977), Nimityungskul (1987) and Lyons (1993) each performed similar studies of children falling from beds / cribs, etc., while in the hospital. Combining these series produces 368 children who fell about 2-4 feet and had no or minor injuries (total of three skull fractures; one clavicle fracture). The children in these series are older, which limits the applicability to infants.
Mayr’s (2000) retrospective examined 218 children who fell from a bunk bed; 3.2 percent had cranial vault fractures, and follow-up of children with head injury showed that they had lasting impairments.
Ruddick (2008) studied 11 infants who fell accidentally to the floor in the maternity ward; most of the infants had no findings or simple linear skull fractures.
Read the article summaries about falls from beds.
Joffe (1988) and Chiaviello (1994) examined injuries that result when children fall down stairs. Both studies noted that single injuries to the head or extremities predominate. Both also noted a greater occurrence of injury in infants who fell while being carried (Joffe reported that 4 / 10 infants who fell while being carried sustained a skull fracture). Chiaviello’s series had a higher frequency of significantly injured children (7 percent had skull fractures vs. 2 percent in the Joffe series, and one child had a subdural hematoma). Joffe also noted that there was no correlation between severity of injury and number of steps fallen down. They postulate that stairway injuries are less severe than free falls of the same total distance and consist of a mild-moderately severe impact followed by a series of low-energy falls. Docherty (2010) also evaluated children who fell down stairs. There were no significant injuries in this group.
Read the article summaries about stairway falls.
Studies in younger children were performed in the evaluation of falls sustained while in a walker. Chiaviello (1994) studied 65 patients in walkers who tipped over or fell down steps, and Smith (1997) performed a similar study on 271 children. The mean age of patients was about 9 months. In these series, 10 percent (Smith) and 15 percent (Chiaviello) of patients suffered skull fractures and 1 percent and 8 percent, respectively, had intracranial bleeds. There was also one clavicular fracture, one radius / ulna fracture and one cervical spine fracture. In addition, Smith found that the number of steps fallen down was significantly associated with skull fractures. Those patients who struck concrete were also more likely to have a skull fracture (not significant). One limitation of both of these studies is that there is not adequate documentation that intentional trauma was investigated (for example, none of the patients had retinal exams recorded).
Read the article summaries about falls from walkers and shopping carts.
Barlow (1983) and Roshkow (1990) both studied falls from heights, again in older patients. Barlow found that the shortest falls that resulted in death were from approximately 30 feet. Roshkow had slightly different findings: that the pattern of injury, including the presence of a head injury, did not relate to the height of the fall and that significant head injury was not uncommon after falls from heights >10 feet.
Tarantino (1999) studied 167 patients 10 months of age or younger who sustained vertical falls 4 feet or lower. Fifteen percent of patients suffered significant injuries including seven long bone fractures and 12 linear skull fractures. The patients had evaluation for inflicted injury (but some information was lacking or omitted, i.e., skeletal surveys). The authors also found that a child with significant injury was more likely to have been dropped from the arms of a caretaker (p=.003). In this study, no child sustained a significant intracranial injury from a short vertical fall.
Williams (1991) reports on 106 children who fell from a height of less than 10 feet and were witnessed by a non-caretaker. Three children in this series suffered a depressed skull fracture from falling against surfaces. All of the children in this series are older, which limits the applicability to infants.
Leventhal (1993) found that it is common for children to suffer fractures from falls (60 percent of children in their study sustained a fracture from falls). The greater the height of the fall, the more common it was to incur a skull fracture.
Rivara (1993), Kim (2000), Warrington (2001), Johnson (2005), Pitone (2006), Thompson (2010) all reviewed children who suffered falls. They all found that young children do not typically sustain severe or life-threatening injuries from falls. Falls from greater heights can result in more injury.
Read the article summaries about free / vertical falls.
Chadwick (1991) looked at 317 children admitted to a trauma center with the mechanism of injury being a “fall.” They found that 7 / 100 children died from a fall of 1-4 feet, 0 / 65 children died from a fall of 5-9 feet and 1 / 118 children died from a fall of 10-45 feet. Three of the children who died from a fall of 1-4 feet also had associated injuries such as bruising to the head and trunk, old fractures and retinal hemorrhages. They conclude that the best explanation of these findings is that the history was incorrect for the seven children who died following a fall of 1-4 feet.
Reiber (1993) reports on a smaller series of patients who suffered a fatal head injury with the history of a “fall.” The series is divided into two groups: those with a history of a minor fall (<5-6 feet) and those with a history of a major fall (>10 feet). Seventy four percent of patients in the “minor fall” category were later found to be victims of non-accidental trauma. Thirty-two percent in the “minor fall” group were also found to have retinal hemorrhages, axonal injury or both. Sixteen percent in the “minor fall” group also had evidence of a torn frenulum, and another 16 percent had old fractures. Reiber comes to the same conclusion as Chadwick above, that cases with extensive injury and a history of a short fall may not have an accurate history.
Hall (1989) reviewed records of pediatric deaths from a history of a fall. He found that 18 children died from a fall <3 feet; 18 children died from a fall >3 feet but <4 stories and eight children died from a fall >5 stories. Falls accounted for 5.9 percent of pediatric trauma deaths. He did not report if non-accidental trauma was considered and excluded.
Plunkett (2001) examined more than 75,000 cases from the US Consumer Product Safety Commission and revealed 18 fall-related head injury deaths over an 11-year period. The age range of the 18 children is 1-13 years. Seven of the children fell from a swing, and 11 of the children fell from a horizontal surface, ladder or seesaw.
Chadwick (2008) reviewed the literature and databases to approximate the incidence of deaths from short falls in children. He found an incidence (based on California EPIC data) of 0.48 per million per year.
Read the article summaries about fatal falls.
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