• Fatal Falls - Article Summaries

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    Chadwick DL, et al. Deaths from falls in children: how far is fatal? J Trauma 1991;31:1353-1355.

    Methods:

    • 317 patients who presented to a trauma center with the mechanism of injury being a “fall”

    Results: Case fatality rate by fall height:

    Fall Height (feet)

    Number died

    Total

    Case fatality rate (%)

    1-4

    7

    100

    7.0

    5-9

    0

    65

    0.0

    10-45

    1

    118

    0.8

    For patients who died from a fall from 1-4 feet, histories given for the type of fall:

    Type of fall

    Number

    Associated Injuries

    Standing fall

    2

    (none)

    Fall from bed / table

    2

    (none)

    Fall down stairs

    1

    bruising on arms, labia majora, thighs

    Fall in arms of adult

    2

    (1) bruising on scalp, ear; SDH; RH and (2) RH; SDH; old tibia fracture

    Conclusions:

    • If the histories are correct, then the risk of death in children who fell from a height of 1-4 feet was eight times greater than for those who fell from 10-45 feet.
    • The findings above may be explained by assuming that the histories of short falls were false and that the children died from other, untold, trauma. In fact, three of the seven children who died from alleged short falls had physical findings on examination that suggested child abuse.
    • There may be a sample bias in this study, i.e., probably more children who fall from heights >5 feet, regardless of symptomatology, are taken to a doctor, compared to children who fall from a short height. However, given the results of other studies, looking at the injuries sustained by children who fall from low heights, these injuries are still unexpected.

    Reiber GD. Fatal falls in childhood. Am J Forensic Med Path 1993;14:201-207.

    Methods:

    • Reviewed cases of fatal head injury in children <=5 years of age where a history of “fall” was given.
    • “major fall”: >10 feet (three cases)
    • “minor fall”: <= 5-6 feet (19 cases)

    Results:

    • Skull fractures:
      • “major fall” − all had skull fractures
      • “minor fall” − 6 / 19 (31.5 percent) had skull fractures
    • Landing surface:
      • “major fall” − all landed on concrete
      • “minor fall” − 3 / 19 (16 percent) landed on concrete
    • Other findings:
      • “major fall” − none had evidence of RH or axonal injury
      • “minor fall” − 6 / 19 (31.5 percent) had RH, axonal injury or both. Also had torn frenulum ( 16 percent) and old fractures (16 percent)
    • Witnessed
      • “major fall” 2 / 3 were witnessed
      • “minor fall” none were witnessed
    • 74 percent of the “minor fall” cases were later found to represent N.A.T.

    Conclusions:

    • There are significant differences between these two groups. However, the “major fall” group includes only three patients. Abuse was found to be the cause of death in 75 percent of the “minor fall” group.
    • Death following short falls should be questioned and investigated for possible child abuse.

    Hall JR, Reyes HM, Horvat M, et al. The mortality of childhood falls. J Trauma 1989;29:1273-1275.

    Methods:

    • Records of pediatric deaths due to falls were reviewed from ME’s office.

    Results:

    • Falls accounted for 5.9 percent of pediatric trauma deaths and was the seventh most frequent cause of death in traumatic deaths of all children (but third leading cause in ages 1-4)
    • three groups of reported heights of fatal falls: eight children from >5 stories, 18 children from <=4 stories but >3 feet, and 18 children from <3 feet

    In the group who fell <3 feet:

    • All died from head injury without associated injuries
    • 6 / 18 had parental-induced delay of care >4 hours
    • 76 percent had mass lesions (subdurals, epidurals)
    • one patient was DOA (8 month old who fell off couch on to wooden floor; had a subdural hematoma)

    Conclusions:

    • Child abuse evaluations were not documented in this study that reviewed findings in pediatric deaths following short distance falls.

    Plunkett J. Fatal pediatric head injuries caused by short-distance falls . Am J Forens Med Pathol 2001;22:1-12.

    Objective:

    • To determine if there are witnessed and / or investigated fatal short distance falls that are concluded to be accidental.

    Methods:

    • Retrospective review of the  US Consumer Product Safety Commission National Injury Information Clearinghouse data from Jan. 1, 1988, through June 30, 1999, for deaths resulting from the use of playground equipment.
    • For all deaths, the author reviewed each original record from hospitals, emergency medical services, law enforcement and medical examiner offices (one autopsy was not available but it was discussed with the coroner).

    Results:

    More than 75,000 cases were reviewed:
    18 deaths from head injury secondary to a fall associated with the use of playground equipment were recorded.

    Age range of patients: 1-13 years

    • five children: 12-24 months
    • five children: 25-60 months
    • eight children: 6-13 years

    Cases:
    Fall distance = “distance of closest body part from ground at beginning of fall”

    • in 10 cases the distance reported is the actual distance
    • in eight cases the distance was estimated
    • 12 of the 18 cases were witnessed by a non-caretaker or videotaped
    • six of the 18 children had an eye examination documented in the medical record, but none of the children had a “formal retinal evaluation.”

    Case 1
    Age: 12 months
    Mechanism: Fell sideways and backwards off of a porch swing
    Fall distance: 5-6 feet
    Witnessed*: No
    Conscious: “unconscious immediately”
    CT Imaging: Subgaleal hematoma at vertex; comminuted fracture of vault; parafalcine subdural hemorrhage; right parietal subdural hemorrhage
    Eye exam: Not recorded
    Autopsy: None

    * definition of witnessed: by a non-caretaker

    Case 2
    Age: 14 months
    Mechanism: Fell backwards off of a seesaw
    Fall distance: 22.5 inches
    Witnessed: No
    Conscious: “conscious but crying … Within 10 to 15 minutes he became lethargic and limp, vomited”
    CT Imaging: Occipital subgaleal hematoma; left sided cerebral edema
    Eye exam: Normal
    Autopsy: None

    Case 3
    Age: 17 months
    Mechanism: Fell from swing on its downstroke
    Fall distance: (estimated) 5-6 feet
    Witnessed: No
    Conscious: “immediately unconscious”
    CT Imaging: Left sided subdural hematoma with extension to the  interhemispheric fissure and falx
    Eye exam: Not recorded
    Autopsy: Symmetrical contusions on buttocks and posterior thorax; left subdural hematoma; cerebral edema with anoxic encephalopathy; uncal and cerebellar tonsillar herniation

    Case 4
    Age: 20 months
    Mechanism: Fell from platform of jungle gym striking head on support post
    Fall distance: 67 inches from ground; 42 inches from support post
    Witnessed: No
    Conscious: “initially conscious and talking, but within 5 to 10 minutes became  comatose”
    CT Imaging: Right occipital depressed skull fracture; right subdural and subarachnoid hemorrhage along the tentorium and posterior falx
    Eye exam: “extensive bilateral retinal and preretinal hemorrhage”
    Autopsy: (limited) Impact subgaleal hematoma overlying the fracture

    Case 5
    Age: 23 months
    Mechanism: Fell head-first off of a plastic gym set on to plush carpet over a concrete floor
    Fall distance: 28 inches
    Witnessed: Yes (videotaped)
    Conscious: “cried after the fall but was alert and talking … approximately 5 minutes later she vomited and became stuporous”
    CT Imaging: Right-sided subdural hematoma and minimal subfalcine herniation
    Eye exam: “Bilateral retinal hemorrhages”
    Autopsy: Right subdural hematoma; cerebral edema with cerebellar tonsillar herniation

    Case 6
    Age: 26 months
    Mechanism: Fell backwards off of a playground swing
    Fall distance: 3-6 feet
    Witnessed: Yes
    Conscious: “immediately unconscious”
    CT Imaging: Subdural hematoma; acute cerebral edema
    Eye exam: “extensive bilateral retinal hemorrhage, vitreous hemorrhage in the left eye”
    Autopsy: Right parietal impact injury; small bilateral subdural hemorrhage; cerebral edema with herniation; focal hemorrhage in the right posterior midbrain and pons; retinal hemorrhage

    Case 7
    Age: 3 years, history of thrombocytopenia-absent radius syndrome
    Mechanism: Fell off of platform, striking his face
    Fall distance: 3 feet
    Witnessed: Yes
    Conscious: “initially conscious and able to walk; approximately 10 minutes later he had projectile vomiting and became  comatose”
    CT Imaging: Subdural hematoma; diffuse cerebral edema with uncal herniation
    Eye exam: Not recorded
    Autopsy: None
    Other findings: Platelet count 24,000

    Case 8
    Age: 3 years
    Mechanism: Fell forward off of a slide ladder step striking her head
    Fall distance: 22 inches
    Witnessed: Yes
    Conscious: “crying … Approximately 15 minutes later she began to vomit”
    CT Imaging: Performed but results not described
    Eye exam: Not recorded
    Autopsy: Complex fracture of left frontal bone and bilateral temporal bones; associated subgaleal hematoma; small epidural and subdural hematomas; marked cerebral edema with uncal herniation

    Case 9
    Age: 4 years
    Mechanism: Fell off slide landing on buttocks then falling on left side striking head
    Fall distance: 7 feet
    Witnessed: Yes
    Conscious: “no loss of consciousness … began vomiting and complained of left neck and head pain approximately 3 hours later”
    CT Imaging: Left parietal epidural hematoma with a midline shift
    Eye exam: Not recorded
    Autopsy: Small epidural hematoma; cerebral edema with cerebellar tonsillar and uncal herniation and hypoxic encephalopathy

    Case 10
    Age: 5 years
    Mechanism: Fell off of horizontal ladder of monkey bar
    Fall distance: 7 feet
    Witnessed: No
    Conscious: “laying face down on the ground and not moving”
    CT Imaging: Right temporal fracture with underlying subdural hematoma; subdural hematoma along right parietal and temporal lobes; right sided edema with midline shift
    Eye exam: Not recorded
    Autopsy: None

    Case 11
    Age: 6 years
    Mechanism: Fell off swing but actual fall not witnessed
    Fall distance: 2-8 feet
    Witnessed: No
    Conscious: “initially conscious and talking but within 10 minutes became  comatose”
    CT Imaging: Left frontoparietal subdural hematoma with extension into the  interhemispheric fissure and midline shift
    Eye exam: “no retinal hemorrhages”
    Autopsy: None

    Case 12
    Age: 6 years
    Mechanism: Fell from crossbar of monkey bars landing flat on his back
    Fall distance: (approximately) 10 feet
    Witnessed: No
    Conscious: “was conscious and alert” … approximately 30 minutes later, “he suddenly collapsed”
    CT Imaging: (initially) Normal
    (20 hours after the fall) Diffuse cerebral edema
    Eye exam: Not recorded
    Autopsy: None

    Case 13
    Age: 6 years
    Mechanism: Slid quickly down pole of monkey bar striking ground with feet, buttocks, back and then head
    Fall distance: 7 feet 10 inches
    Witnessed: Yes
    Conscious: “seemed fine” following incident, but six hours later “was incoherent and drooling”
    CT Imaging: Right parieto-occipital skull fracture, subdural and subarachnoid hemorrhage; right cerebral hemisphere infarct”
    Eye exam: Not recorded
    Autopsy: Right parieto-temporal subgaleal hematoma; right parietal skull fracture; subdural hematoma and cerebral edema

    Case 14
    Age: 7 years
    Mechanism: Fell off horizontal bar of monkey bars; unclear if hit forehead on bars of ladder
    Fall distance: 4-8 feet
    Witnessed: Yes
    Conscious: Unclear if initial loss of consciousness; two days after fall was stumbling and had slurred speech
    CT Imaging: (initial) Occipital subgaleal hematoma
    (two days later) Left carotid artery occlusion and left parietal and temporal lobe infarcts
    Eye exam: Not recorded
    Autopsy: Infarcts of left parietal, temporal and occipital lobes; acute cerebral edema with herniation; thrombosis of left vertebral artery

    Case 15
    Age: 8 years
    Mechanism: Fell from a retaining wall striking back and head after swinging to wall from monkey bars
    Fall distance: 34 inches
    Witnessed: Yes
    Conscious: “initially cried and complained of a headache but continued playing” … approximately 14.5 hours later “complained of a severe headache then became unresponsive and had a seizure”
    CT Imaging: Not done
    Eye exam: Not reported
    Autopsy: Right temporoparietal subdural hematoma

    Case 16
    Age: 10 years
    Mechanism: Fell off swing (seat detached from chain) striking the back of his head
    Fall distance: 3-5 feet
    Witnessed: Yes
    Conscious: “remained conscious although groggy … He suddenly lost consciousness approximately 10 minutes later”
    CT Imaging: Right frontoparietal subdural hematoma with transtentorial herniation
    Eye exam: “extensive bilateral confluent and stellate, posterior and peripheral preretinal and subhyaloid hemorrhage”
    Autopsy: Right parietal subarachnoid arteriovenous malformation; subdural hemorrhage; cerebral edema with herniation

    Case 17
    Age: 12 years
    Mechanism: Fell off swing while standing on seat as it was twisting; struck back and back of head
    Fall distance: 3-6 feet
    Witnessed: Yes
    Conscious: “immediately unconscious”
    CT Imaging: Not performed
    Eye exam: Not recorded
    Autopsy: Comminuted occipital fracture and contusions of inferior frontal and temporal lobes

    Case 18
    Age: 13 years
    Mechanism: Fell backwards while standing on the seat of a swing
    Fall distance: 2-6 feet
    Witnessed: Yes
    Conscious: “immediately unconscious”
    CT Imaging: Interhemispheric subdural hemorrhage and generalized cerebral edema
    Eye exam: Not recorded
    Autopsy: Linear occipital skull fracture; subdural hemorrhage; contusion of left cerebellar hemisphere and bifrontal lobes; cerebral edema

    • In 13 of the 18 patients, there was evidence of a subdural hemorrhage
    • In 13 of the 18 patients, there was evidence of cerebral edema
    • In 10 of the 18 patients, there was evidence of a contact injury (skull fracture, subgaleal hemorrhage and / or contusion)
    • six patients were reported to be immediately unconscious following the fall
    • eight patients were reported to develop symptoms between five-30 minutes after the fall
    • four patients were reported to develop symptoms between 3 hours and 2 days following the fall (three hours, six hours, 14.5 hours and two days)

    Conclusions:

    • In a review of more than 75,000 cases of injury resulting from falls associated with playground equipment in the United States over 11 years, 18 children aged 1-13 years suffered fatal head injuries.
    • If the two children who had thrombocytopenia-absent radius syndrome or an arteriovenous malformation are removed, six children suffered fatal falls associated with a swing and 10 children suffered fatal falls from a horizontal surface, ladder or seesaw in this series.

    Chadwick DL, Bertocci G, et al.  Annual risk of death resulting from short falls among children: less than 1 in 1 millionPediatrics 2008; 121:1213-24.

    Methods

    • The authors reviewed books, society statements, seven literature reviews and 177 articles
    • They defined short falls as less than 1.5 meters and focused on children less than 5 years of age.

    Results:

    • Based on death certificates from the California Epidemiology and Prevention for Injury Control (EPIC) branch, the true incidence of mortality in short falls is less than 6 per 2.5 million per five years, or 0.48 per million per year. 
    • The Injury Statistics Query and Reporting System of the CDC provides the total mortality rate due to falls in children under 4 years of age as three cases per 1 million per year, but does not provide further stratification based on fall height or mechanism. 
    • A review of multiply and reliably witnessed falls found four studies of falls in hospital settings, none of which resulted in death.  Of the 560 total falls in these studies, four patients sustained linear parietal fractures. 
    • No published, peer-reviewed, medical reports of death due to falls in large, licensed child care centers could be found.

    Conclusion: 

    • The quantitative estimate based on California EPIC data is less than 1 in 1 million per year, and no evidence available in the current literature supports an incidence higher than this. 
    • Difficulties in studies like this are reliability of history and low incidence in environments, such as hospitals, where events are more likely to be witnessed by one or multiple observers.