Mayerson Center for Safe and Healthy Children

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    + Injuries in infants and small children resulting from witnessed and corroborated free falls

    Williams RA. Injuries in infants and small children resulting from witnessed and corroborated free falls. J Trauma 1991;31:1350-1352.

    Methods:

    • Witnessed group: 106 patients <3 years who had a free fall from a stationary object and witnessed by two or more people or by non-caretaker
    • Unwitnessed group: 53 patients <3 years who had a free fall that was not witnessed or witnessed only by a single caretaker

    Results:

    • Witnessed group:
      • For falls <10 feet :
      • No patients suffered LOC
      • three serious injuries: (depressed skull fractures following falls against edged surfaces)
      • Only mild injuries occurred in patients falling between 10-22 feet (bruises, abrasions, lacerations, simple fractures)
      • One death occurred in an infant who fell 70 feet
    • Unwitnessed group:
      • For falls <5 feet:
      • 18 severe injuries: (intracranial bleed, cerebral edema, cerebral contusion, depressed skull fracture, ruptured organ, compound or comminuted fracture)
      • two deaths

    Conclusions:

    • The children who were observed to fall by non-caretakers sustained much less severe injury compared to the group who fell from a shorter height and who were not observed by a non-caretaker.
    • The substantial injuries sustained by the children who fell from low heights were not expected, based on studies by Selbst, Lyons and Smith.
    • Therefore, many of the severe injuries sustained by infants who were said to have fallen <5 feet may have been injured by other mechanisms.

    + Ten years of experience with falls from a height in children

    Barlow B, et al. Ten years of experience with falls from a height in children. J Ped Surg 1983;18:509-511.

    Methods:

    • Sixty-one patients between 1-16 years of age who fell from a height were evaluated

    Results:

    • Head injuries were second to fractures in frequency of injuries
    • 56 patients had head injury: 25 concussions, 17 skull fractures, 13 brain contusions, and one subdural hematoma
    • Survival: 100 percent survival if fell <= 3 floors and 50 percent survival between fifth and sixth floors

    Conclusions:

    • No mortality if fall <3 floors.
    • No correlation between age and survival.

    + Imaging evaluation of children after falls from a height: review of 45 cases

    Roshkow JE, et al. Imaging evaluation of children after falls from a height: review of 45 cases. Radiology 1990;175:359-363.

    Methods:

    • Forty-five patients aged 1-12 years who fell from a height of 10 feet or greater were evaluated (patients who were not admitted or dead on arrival to hospital were not included).

    Results:

    • Head injuries occurred in 42 percent of patients
    • 31 patients had skull films and 11 revealed fractures: four linear and seven depressed
    • 25 patients had head CT scans: seven linear skull fractures, nine depressed skull fractures, one epidural hemorrhage, four subdural hemorrhages, seven  subarachnoid hemorrhages, two intraventricular hemorrhages and one shearing injury
    • The occurrence of head injury was not related to the height of the fall
    • Intracranial injury was not necessarily associated with a skull fracture

    Conclusions:

    • Injury pattern did not correlate with height of fall.
    • Significant intracranial injury occurred with falls > 10 feet.

    + Short vertical falls in infants

    Tarantino CA, et al. Short vertical falls in infants. Ped Emerg Care 1999;115:5-8.

    Methods:

    • 167 patients <10 months of age (mean 5.2 months) who suffered a vertical fall <=4 feet
    • Falls were off bed / couch / surface or dropped by caretaker
    • Excluded trajectory falls, striking surfaces or walker-related falls

    Results:

    • 15 percent of patients had significant injury:
      • seven long bone fractures (three femur fractures; one humerus fracture, two tibia fractures; one clavicle fracture)
      • 18 patients sustained head injuries:
        • two had intracranial hemorrhages (both found to be victims of child abuse)
        • 12 had linear skull fractures
        • four had symptoms of closed head injury but no skull fractures
    • 4 / 7 of patients with long bone fractures had a referral to Department of Family Services (DFS); all four were discharged to parents.
    • 2 / 2 of the patients with intracranial hemorrhages were found to be victims of child abuse (both confessions).
    • 3 / 12 patients with linear skull fractures had a referral to DFS; one was placed in foster care.
    • A child with a significant injury was statistically more likely to have been dropped from the arms of a  caretaker (p=.003)

    Conclusion:

    • Significant although not life-threatening injuries were not uncommon in short falls.
    • In this series, no child sustained intracranial, visceral or multiple significant injury from a fall from a surface.
    • Being dropped from a caretaker’s arms resulted in a more significant injury than falling from a surface.

    + Fractures in young children Distinguishing child abuse from unintentional injuries

    Leventhal JM, Thomas SA, Rosenfield NS, Markowitz RI. Fractures in young children Distinguishing child abuse from unintentional injuries. AJDC 1993;147:87-92.

    Objective:

    • To determine what features would be helpful in distinguishing unintentional from intentional (i.e., abusive) fractures in children.

    Methods:

    • Retrospective study of the medical charts and roentgenograms of children < 3 years of age with fractures.
    • Assessments were made using a seven-point scale to rate the likelihood that the fracture was due to abuse.
    • The location of fractures resulting from falls as well as the height of the fall as it relates to the presence of a complicated skull fracture were specifically examined.

    Results:

    • 215 patients had confirmed fractures; mean age 15.7 months
    • 130 children suffered fractures from falls (60 percent)
      • In 14 (11 percent) children the cause was classified as abuse
      • In 12 (9 percent) children the cause was classified as unknown
      • In 104 (80 percent) children the cause was classified as unintentional

    Number of complicated skull fractures from falls in 104 children
    in which the cause was classified as unintentional:

    Height of fall (cm)

    Number of children (total)

    Number with skull fractures (%)

    Running

    6

    0 (0%)

    < 60

    24

    8 (33%)

    60-119

    33

    23 (70%)

    120-210

    26

    17 (65%)

    >210

    7

    5 (71%)

    Unknown

    8

    1 (12.5%)

    Conclusions:

    • It is common for children to suffer fractures from falls.
    • The greater the height of the fall, the more common it is to suffer a skull fracture.

    + Population-based study of fall injuries in children and adolescents resulting in hospitalization or death

    Rivara FP, Alexander B, Johnston B, Soderberg R.  Population-based study of fall injuries in children and adolescents resulting in hospitalization or deathPediatrics 1993; 92:61-3.

    Methods:

    • Population-based study from the Washington State Comprehensive Hospital Abstract Reporting System Data
    • Children less than 19 years old who sustained injury from falls from 1989 to 1990 and who were admitted to the hospital

    Results:

    • Children less than 10 years of age tended to fall from some height and older children tended to fall from their own height level. 
    • 42.1 percent of pre-school aged children had head trauma of some kind.
    • There were 11 fall-related deaths, with only one occurring in a child under 10 years old.
    • Falls from objects such as couches or beds were noted to have very few injuries. 
    • Injuries were typically seen in falls from heights over 10 feet.

    Conclusion: 

    • Short falls did not produce many injuries.
    • Deaths from falls are rare.

    + Analysis of pediatric head injury from falls

    Kim KA, Wang MY, et al.  Analysis of pediatric head injury from fallsNeurosurg 2000; 8:Article 3.

    Methods:

    • Retrospective study of 729 cases of children younger than 15 years old with complains of fall causing trauma
    • Cases were divided into “high falls” (15 feet or more) and “low falls” (less than 15 feet)

    Results:

    • Overall mortality for both groups was 1.7 percent.  (2.4percent in the high fall group and 1 percent for the low fall group)
    • Intracranial hemorrhage was found in 8.6 percent of patients in the high fall group.

    Conclusion: 

    • Intracranial hemorrhage is not uncommon in children who suffer high falls.
    • Deaths from falls less than 15 feet are uncommon.

    + Accidents and resulting injuries in premobile infants: data from the ALSPAC study

    Warrington SA, Wright CM, ALSPAC Study Team.  Accidents and resulting injuries in premobile infants:  data from the ALSPAC studyArch Dis Child 2001; 85:104-7

    Methods:

    • This study utilized information from the Avon Longitudinal Study of Parents and Children (ALSPAC)
      • Postal questionnaires were mailed out at 4 weeks, 6 months, 15 months, and 18 months
    • At 6 months, moms were asked to describe any accident, and their responses were categorized as “falls” or “burns”

    Results:

    • Data were available for 11,466 children
    • In this group, 3,357 falls were found in 2,554 children
    • In 437 cases, there was some form of injury 
      • More than half of these were bruises
      • Serious injury, including concussion or fracture, occurred in 21 cases (less than 1 percent)
      • There were four skull fractures, three of which were not admitted to the hospital
      • The most common injuries were to the head (97percent) and the most common mechanism was due to fall from a couch or similar piece of furniture

    Conclusion: 

    • Accidents are common in infants, notably falls from furniture.
    • Injuries to the head were common, but were typically trivial.  Serious injury was present in <1 percent of falls.

    + Accidental head injuries in children under 5 years of age

    Johnson K, Fischer T, et al.  Accidental head injuries in children under 5 years of age. Clin Radiology 2005; 60:464-8.

    Methods:

    • Prospective study of 72 children aged 4 months to 4.75 years of age with head injuries after a fall
    • To be considered for the study, event must have been witnessed by more than one observer, occurred within hours of arrival in the emergency department and determined to be a domestic accident
    • Follow-up was maintained for six to nine months.

    Results:

    • Fall height ranged from less than 50 cm to greater than 3 meters.  (Most were less than 1 meter)
    • Skull radiography was done in 32 children and four were identified as sustaining fractures.
    • No children developed neurologic symptoms at any point in the study.

    Conclusion: 

    • The majority of accidental domestic falls do not cause skull fracture without significant height or fall onto a small, focused point or area.

    + Patterns of injury associated with routine childhood falls

    Pitone ML, Attia MW.  Patterns of injury associated with routine childhood fallsPediatric Emergency Care 2006; 22:470-4.

    Methods:

    • Retrospective review of charts of falls down stairs, falls from own height, falls from an object, and other

    Results:

    • A total of 787 cases were reviewed 
    • 13 percent of falls were down steps, 32 percent were from patients’ own height, 48 percent were from an object, and 6 percent were classified as “other” 
    • Head injury was the most frequent diagnosis
      • Most head injuries required no interventions or studies
      • In one infant, there was a non-displaced skull fracture, but this was not associated with intracranial hemorrhage

    Conclusion: 

    • Routine household falls cause little or insignificant injury. 

    + Pediatric short-distance household falls: biomechanics and associated injury severity

    Thompson AK, Bertocci G, Rice W, Pierce M.  Pediatric short-distance household falls:  biomechanics and associated injury severityAccid Anal Prev  2010; 10:1016

    Methods:

    • Prospective study of children 4 years of age or younger with a fall from furniture 
    • Only definite accidents and likely accidents were included in the study

    Results:

    • 79 cases were reviewed with ages ranging from 1 to 47 months 
    • No subjects suffered an injury of 4 or higher on the AIS 
      • There were two patients who sustained an AIS score of 3 (serious injury), both of which were small subdural hematomas
    • More severe injuries occurred with greater heights

    Conclusion: 

    • Young children do not typically sustain severe or life-threatening injuries in falls from furniture in homes.