Factors to be considered with a pediatric patient involved in a motor vehicle accident:
Head Size: The size of their heads is disproportionately larger compared to their bodies.
Position in Target Vehicle:
Restraint System: Adult shoulder and lap belt? Children’s booster seat or car seat?
Pelvic Height: The reduced height of the pediatric pelvis increases the probability for the lap belt to slip over the pelvic brim resulting in abdominal and lumbar injuries.
Center of Gravity: Children up to age four have a relatively higher center of gravity and an increased tendency for the lap belt to ride upward on the abdomen allowing the child to submarine forward under the belt thereby increasing injury to the abdomen and spine.
Soft Tissue Injury: The connective tissue, and the neck and back muscles are not as well developed or as strong to resist or support the head or spinal joints in a collision. There is an increase in the probability for spinal joint and neurological injury.
Remarks and Studies:
The Center for Disease Control And Epidemiology, an Oregon Health Division, April 2001, lists the leading cause of death among children the age of one as motor vehicle crashes. One of the factors that contributed to the noted deaths was lack of appropriate restraint. The use of child safety seats with children 0-4 and booster seats with children aged 5-9 would help prevent the deaths noted.
Agran, et al, did a study that revealed 70% of restrained children involved in motor vehicle crashes suffer head and face injuries. (1)
Glassauer, et al, found that most common levels for fractures and dislocations in traumatic lesions in the spine are the lower cervical and upper thoracic vertebrae. Failure to demonstrate fractures or dislocations or other radiological evidence of trauma is no evidence against damage, since extensive spinal cord injuries in infants and young children without permanent radiological changes have been known to occur. (2)
Orenstein, et al, did a retrospective chart review involving 73 children who were presented at a children’s hospital with cervical spine injuries. 67% of these injuries were traffic related, resulting from motor vehicle crashes. Younger children sustained more severe injuries than older children. Distraction and subluxation injuries were the most common injuries in children aged eight years and younger. (3)
Glass, et al, evaluated 35 children with lumbar spine injuries following blunt trauma. 31 of those children were injured in motor vehicle crashes. Abnormalities noted on plain film radiographs and CT scans included subluxation, distraction, and fracture alone or in combination. The authors stated, “Children involved in motor vehicle crashes are at a high risk for lumbar spine injuries. Lumbar spine radiographs are necessary in all cases with suspected lumbar spine injury”. (4)
Rachesky, et al, reported that on the cervical spine radiographs of children under 18 they examined, vehicular accidents accounted for 36% of the radiographic abnormalities. It was further stated that clinical assessment of a complaint of neck pain or involvement in a vehicular accident with head trauma would have identified all cases of cervical spine injury. (5)
Hill, et al, noted that 31% of the pediatric neck injuries reviewed were the result of motor vehicle crashes. In younger children (under 8 years of age) subluxation was seen more frequently than fracture. (6)
Agran stated that non-crash vehicular events may cause injuries to children. Non-crash events discussed in this paper included sudden stops, swerves, turns, movement of unrestrained children in the vehicle. (7)
Roberts, et al, described a case where a child involved in a motor vehicle crash sustained a whiplash injury resulting in immediate neck and back pain.. Neurobehavioral abnormalities increased in the two-year period following the accident. Four years after the accident, symptoms persisted. Positron emission tomography (PET scan) demonstrated evidence of brain dysfunction. (8)
Biedermann stated that a wide range of pediatric symptomatology may result from suboccipital strain. The disorders reported include fever of unknown origin, loss of appetite, sleeping disorders, asymmetric motor patterns, and alteration of posture. (9)
Gutmann also discussed the diverse array of signs and symptoms which can occur as a result of biomechanical dysfunction in the cervical spine. (10)
Givens, et al, physicians at the Children’s Hospital of Alabama reported the incidence of cervical spine injuries in children at their hospital. They first discuss anatomy of the pediatric spine, and the differences with their adult counterparts. Large head mass and relatively underdeveloped neck musculature of the infant and young child create a bending moment at impact that is very large relative to the neck muscle strength, wedge-shaped vertebral bodies facilitating anterior articulating facets that predispose the child’s cervical spine to greater mobility than seen in adults particularly in the upper three to four cervical segments, and cartilaginous end plates in the pediatric patient. While most of the neural arches close and the dens synchondrosis fuse by approximately 3 years of age, a child’s cervical spine does not fully take on the characteristics of the adult spine until approximately 8 years of age.
These anatomical properties have important implications. With higher energy forces, as applied with rapid deceleration or hyper flexion-extension mechanisms, lethal distraction or shear forces with significant cord ischemia or infarction may occur, even in the absence of osseous fracture or subluxation.
Cervical spine injuries were found in two children, ages 5 and 6, who were restrained in lap-shoulder belts. Lap shoulder belts not only provide “no protection” for the cervical spine but may actually be the cause of certain types of injuries particularly in the 4-to-9-year age group. (12) (13) (14) Because the child’s sitting height is less than that of the average adult, the child’s center of gravity is often located on the torso above the level of the lap belt. The greater proportion of body mass above the belt may cause greater forward motion and a greater chance for head impact.
Mittenberg, et al, evaluated 65 head injury pediatric patients in six weeks post injury. Subjective complaints were compared with orthopedic patients of same age and demographics. The researchers evaluated the symptoms on the diagnostic criteria for (adult) post-concussion syndrome. 39% of the head injury group met the criteria compared to 2% of the orthopedic control. The conclusion of the researchers was that post-concussion syndrome does occur in children for both mild and moderate to severe head trauma. (15)
Di Gallo, et al, studied 57 children ages 5-18 who were in traffic accidents. Interviews were conducted with children and parents a few days after the accident, and again at 12-15 weeks afterward. 65% of the accidents were car pedestrian collisions, 18% of the injuries occurred with the child in the car.
Initially the study found 70% of the children exhibited some signs of post-traumatic stress disorder (PTSD), with 36% showing moderate to severe symptoms. At follow up the number had decreased, but 14% of the children had moderate to severe PTSD symptoms and 35% had mild symptoms. The children most likely to develop symptoms of PTSD were those who were younger (who could not understand what had happened to them) and those very distressed at the time of the accident. (16)
Keppel-Benson, et al, presents an overview of the literature. (17) In the Milgram, et al, study, 50% of child survivors of a school bus accident met the criteria for PTSD 4 weeks after the accident, and about 20% did so nine months after the accident. (18) In the Stallard, et al, study, 35% of children and adolescents who were involved in road accidents met criteria for PTSD 6 weeks after the accident. (19)
Lynch, et al, published a case report of quadriplegia in a 6-year-old girl. The girl was the front seat passenger of a four door, midsized, late model sedan, which was struck from the rear, on the right, by a truck. Impact speed was 35 MPH. The 6-year-old was restrained by a lap-shoulder seat belt. Fracture at C3-C4 was found, most likely due to severe hyper flexion over the seat belt. (20)
References
Am J Dis Child 1989, J Trauma 1973, Ped Emerg Care 1994, J Trauma 1994, Am J Dis Child 1987, J Neurosurg 1984, Pediatrics 1981, Brain Inj 1995, Manuelle Medizin 1992, ICA Review 1990, J of Trauma: Injury, Infection and Cranial Care 1996, Amer J Pub Health 1992, orthopedic Review 1994, Am J Dis Child 1989, Neuropsychology 1997, Brit J of Psychiatry 1997, J of Child Pschy and Psychiatry 2002, J of Trauma 1988, Brit Med Jour 1998, J of Trauma 1996