Children in side-impact motor vehicle crashes: seating positions and injury mechanisms

BACKGROUND: This study aimed to describe the injury mechanisms of children involved in side-impact car crashes, particularly as these relate to seating position, and to estimate the danger of the near-side seating position. METHODS: A prospective two-center study of children involved in severe car crashes in Canada was conducted as well as a retrospective cohort study of children involved in crashes reported in the Fatality Analysis Reporting System (FARS) and the National Automotive Sampling System: Crashworthiness Data System (NASS CDS). RESULTS: Children sitting at the side the car was struck (near-side position) sustained severe head, trunk, and limb injuries. Many of these injuries were attributable to direct intrusion, but some occurred without direct damage to the occupant compartment. Center-seat and far-side occupants had severe injuries only when unrestrained. Injury severity scores were higher for children seated on the near side, and this was statistically significant (p = 0.024) The analysis of Fatality Analysis Reporting System data showed that the risk of fatality was higher for children seated in the near-side position than for those in the center-seat position. The fatality risk ratio was 2.53 (95% confidence interval [CI], 2.08-3.07) for restrained children and 1.84 (95% CI, 1.57-2.17) for unrestrained children. Analysis of the NASS-CDS data showed that for restrained children, severe injury (ISS > or = 16) was more common among those on the near side (7 per 1,000 children) than among those in the center seat (2 per 1,000) or on the far-side seat (1 per 1,000) (p < 0.001). CONCLUSIONS: Severe injuries to near-side occupants occurred in both the presence and absence of compartment intrusion. A typical pattern of head, chest, and extremity injury similar to that seen among child pedestrians was observed among near-side child occupants in side-impact crashes. The center seat was statistically safer than the near-side seat, particularly for restrained child occupants. Scene information may be useful to trauma teams for the prediction of injury type and location. Avoiding intrusion and preventing the occupant from striking the vehicle wall are both important to side-impact protection for children. Improvement of the vehicle safety cage may protect against intrusion injuries. Seating two child occupants in inboard seating positions may provide additional protection against intrusion injuries, and also may protect against nonintrusion injuries.     

Torso injury patterns and mechanisms in car crashes: an additional diagnostic tool.

Torso injuries among car occupants involved in sever collisions are often life threatening. This study considers whether knowledge of the type of impact and associated trends of torso injuries would assist the rapid diagnosis of injuries by emergency personnel. For the purpose of this analysis the pelvis was included in the torso. The data source was the Cooperative Crash Injury Study which holds detailed injury information on over 6200 car crash occupants. Restrained front seat occupants with an ISS of 16+ who were involved in frontal or side collisions were selected. A total of 286 occupants fell into these selection criteria. The frequency of injury to each torso part was determined to give an approximate likelihood of injury in each impact configuration. The injury data were further analysed to look for patterns of injury in frontal or side impacts. The likelihood of all torso injuries, except sternal and lumbar spinal injuries, increased in side impacts, particular examples being the spleen and pelvis. There were statistically significant associations between injuries to different torso parts. In frontal impacts rib fracture indicates the distinct possibility of underlying organ injury. Vehicle damage data coupled with readily diagnosed injuries can suggest the possibility of less easily detectable injuries.     

Children after motor vehicle crashes: Restraint utilization and injury severity

BackgroundAlthough injury patterns after motor vehicle crashes (MVCs) are well documented, association between adequate restraint and injury severity is unclear. We aimed to determine if improper restraint affects injury rates and severity.MethodsA retrospective chart review of 477 children hospitalized in Pediatric Trauma Center after MVC was performed. Injuries in various age groups (0–7, 8–12, 13–16, 17–18 years) with different restraint quality measures (proper [PR] and improper/unrestrained [IUR]) as well as injury severity score (ISS: mild [1–9], moderate [10–15], severe [16–25], and profound [> 25]) were evaluated and compared. Chi-square and Wilcoxon rank-sum tests were used for statistics.ResultsIn all age groups head/neck injuries were most common (55–63%), while abdominal and pelvic injuries were least likely except group 8–12 years where abdominal injuries ranked third (17.1%). Overall, 64.5% had PR and 35.5% IUR. Interestingly, that greatest proportion of IUR was in the youngest age group (0–7). It decreased with aging and children aged 17–18 years were significantly less likely to be IUR compared to those 0–7 years (OR[odds ratio] = 0.58; 95%CI[confidence interval] 0.35–0.94). We did not find significant differences in rates of various injuries between PR and IUR. However, ISS severity in IUR was significantly greater than in PR (median with interquartile range 6(2–14) and 5(1–9), respectively; P = 0.001). As a result, IUR compared to PR were less likely to have mild ISS (OR = 0.6, 95%CI 0.39–0.90) but more likely to have profound ISS (OR = 3.3, 95%CI 1.48–7.43).ConclusionRestraint quality has significant impact on injury severity in children after MVC.Level of EvidenceLevel III.     

Optimal restraint reduces the risk of abdominal injury in children involved in motor vehicle crashes

BACKGROUND: The American Academy of Pediatrics has established guidelines for optimal, age-appropriate child occupant restraint. While optimal restraint has been shown to reduce the risk of injuries overall, its effect on specific types of injuries, in particular abdominal injuries, has not been demonstrated. METHODS: Cross-sectional study of children aged younger than 16 years in crashes of insured vehicles in 15 states, with data collected via insurance claims records and a telephone survey. A probability sample of 10927 crashes involving 17132 restrained children, representing 210926 children in 136734 crashes was collected between December 1, 1998 and May 31, 2002. Restraint use was categorized as optimal or suboptimal based on current American Academy of Pediatrics guidelines. The outcome of interest, abdominal injury, was defined as any reported injury to an intra-abdominal organ of Abbreviated Injury Scale >or=2 severity. RESULTS: Among all restrained children, optimal was noted in 59% (n = 120473) and suboptimal in 41% (n = 83555). An associated abdominal organ injury was noted in 0.05% (n = 62) of the optimal restrained group and 0.17% (n = 140) of the suboptimal group. After adjusting for age and seating position (front vs. rear), optimally restrained children were more than 3 times less likely [odds ratio 3.51 (95% confidence interval, 1.87-6.60, P < 0.001)] as suboptimally restrained children to suffer an abdominal injury. Of note, there were no abdominal injuries reported among optimally restrained 4- to 8-year-olds. CONCLUSIONS: Optimally restrained children are at a significantly lower risk of abdominal injury than children suboptimally restrained for age. This disparity emphasizes the need for aggressive education efforts aimed not only at getting children into restraint systems, but also the importance of optimal, age-appropriate restraint.     

The association between occupant restraint systems and risk of injury in frontal motor vehicle collisions

BACKGROUND: An evaluation of seat belt use and airbag deployment, either alone or in combination, on risk of injury to specific body regions has yet to be completed. METHODS: A retrospective cohort study of front seat occupants involved in police-reported, tow-away, frontal motor vehicle collisions using data from the 1995 through 2000 National Automotive Sampling System was conducted. Only vehicles with a change in velocity (delta-V) of >/= 15 km/h were included. Risk of injury (Abbreviated Injury Scale score >/= 2) to specific body regions was compared according to seat belt use and airbag deployment. RESULTS: Compared with completely unrestrained occupants, those using a seat belt alone or in combination with an airbag had a reduced overall risk of injury (relative risk, 0.42 and 0.71, respectively); no association was observed for those restrained with an airbag only (relative risk, 0.98). This pattern of results was similar for specific body regions with the exception of the lower extremity, wherein a significantly increased risk was observed for airbag deployment alone. CONCLUSION: Airbag deployment does not appear to significantly reduce the risk of injury either alone or in combination with seat belts. Airbag deployment without associated seat belt use may increase the risk of lower extremity injury.     

Causes and control of spinal cord injury in automotive crashes

This paper provides a history of automotive safety and a review of biomedical research on human tolerance and occupant protection. It discusses current understandings of body kinematics and impact biomechanics that result in neck injury. Perspective is given on the linkage between mechanical forces that are the cause and physiologic disruptions that are the consequence of spinal cord injury. The public health aspects of injury and disability are discussed as well as the need for injury prevention.

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Resumen A partir de 1930 y hasta el presente, se registra una continuada reducción en el riesgo de mortalidad por el uso de automotores. La tasa ha descendido de 15.6 muertos por 100.000.000 millas vehículares en los años 1930s a 3.5 en 1980 y a 2.2 en los comienzos de los 1990s. El presente artículo presenta una historia de seguridad automotriz y una revisión de la investigación biomédica sobre la tolerancia humana y la protección del ocupante; revisa el conocimiento actual sobre la quinemática corporal y el impacto biomecánico que resulta en lesión cervical. Se presenta la perspectiva de la relación entre las fuerzas biomecánicas que son la causa y las alteraciones fisiológicas consecuentes a lesión de la médula espinal, los aspectos de salud pública de la lesión y la incapacidad, así como la necesidad de establecer métodos de prevención del trauma.

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Résumé Cet article traíte de l'histoire de la sécurité automobile, de la recherche de la tolérance de l'homme aux accidents, et la protection des occupants des vehicules. La comphéhension de la cinétique corporelle et des forces biomécaniques qui sont responsables des lésions cervicales est actualisée. La liaison entre les forces mécaniques en cause et les perturbations physiologiques qui sont la conséquence des lésions rachidiennes est détaillée. Les aspects des lésions et des íncapacítés qui en résultent, ainsi qua leur prévention sont discutés.

     

Suboptimal restraint affects the pattern of abdominal injuries in children involved in motor vehicle crashes

Background

Both solid and hollow visceral abdominal injuries have been associated with the use of seat belts in children involved in motor vehicle crashes. The relationship between the types of restraint used and the pattern of abdominal injury is unknown.

Methods

A probability sample of restrained children involved in crashes was enrolled in an ongoing crash surveillance system (1998 through 2002) linking insurance claims data to telephone survey and crash investigation data. Significant abdominal injuries were considered when the Abbreviated Injury Scale (AIS) score was ≥2 and were defined as hollow visceral (HV; intestine, bladder), or solid visceral (liver, spleen, pancreas, kidney). Restraint type was categorized as optimal restraint (OR) or suboptimal restraint (S-OR) based on the child’s age and size.

Results

For the 33 months of review, interviews were obtained for 13,558 restrained children aged 0 to 15 years, of which, 56% were OR (n = 7,591) and 44% were S-OR (n = 5,967). A significant abdominal injury was recorded in 78 children. A hollow visceral injury was recorded in 38 (9 OR and 29 S-OR), and a solid visceral injury in 32 (18 OR and 14 S-OR). Both hollow and solid visceral injuries were present in 8 children (2 OR and 6 S-OR). Suboptimally restrained children had a higher risk for hollow visceral injury when compared with optimally restrained children (Odds Ratio, 4.14 [95% Confidence Interval 1.33 to 13.22, P < .01]).

Conclusions

Among restrained children with intraabdominal injuries, those who were suboptimally restrained were 4 times more likely to have a hollow visceral than a solid visceral injury when compared with those who were optimally restrained. This suggests that the mechanism of injury for hollow viscus may be directly related to the improper positioning of the restraint.     

All-terrain vehicle and bicycle crashes in children: epidemiology and comparison of injury severity

Background/Purpose: Despite statements by the American Academy of Pediatrics (AAP) and the US Consumer Product Safety Commission (CPSC) against the use of all-terrain vehicles (ATVs) by children under the age of 16 years, nearly half of ATV-related injuries and over 35% of all ATV-related deaths continue to occur in this age group. Because ATV and bicycle crashes have been associated with serious injury in children, the authors compared the demographics, mechanism of injury, injury severity, and outcome of children with ATV- and bicycle-related injuries. Further, the authors sought to identify whether ATV-related injuries elicited changes in risk-taking behavior. Methods: A retrospective, comparative analysis of 109 children admitted for ATV-related injuries and 994 children admitted for bicycle-related injuries to a level 1 pediatric trauma center between January 1991 and June 2000 was performed. A phone survey was conducted to determine self-reported changes in safety behaviors or use patterns after ATV injury. Results: Mean age was 11.1 [plusmn] 3.5 years (range, 2 to 18 years) for ATV crashes versus 9.4 [plusmn] 3.3 years (range, 1 to 17 years) for bicycle crashes (P [lt ] .05). Ninety-three percent of ATV crashes occurred in children less than 16 years of age; 31% in children [le ]10 years of age; and 7% in children [le ]5 years of age. Male-to-female ratio was about 3:1 for both groups. White race accounted for 97% of ATV injuries compared with 79% of bicycle injuries (P [lt ] .05). Falls from ATVs or bicycles were the most common mechanism of injury (41% v 59%, respectively). Collisions with motor vehicles were more common for bicyclists (32% v 10%), whereas collisions with stationary objects were more common among ATV riders (27% v 9%). Sixteen percent of ATV crashes were caused by a roll-over mechanism. Mean injury severity score (ISS) were significantly higher for victims of ATV crashes (8.3 ATV v 6.7 bicycle; P [lt ] .05). ATV-related trauma was associated with multiple injuries, more operative interventions, and longer hospital stays. Location and distribution of injuries were similar for both groups. Helmet use was low in both groups but higher for ATV riders (23% v 8%; P [lt ] .5). Mortality rate was similar for both groups (0.9% for ATV riders v 0.7% for bicyclists). There was a 39% response for the phone survey post-ATV injury. Twenty-three of 43 (53%) respondents owned the ATV, and 70% of these received safety information at the time of purchase. However, only 14% of injured riders received any formal training before riding ATVs. Postinjury, 60% of children continued to ride, although 42% reported decreased riding time. Fifty-four percent of children reportedly wore helmets preinjury, and there were no changes in helmet usage postinjury. There were no differences in pre- and postinjury parental supervision (61% v 65%). Conclusions: Both ATV and bicycle-related injuries occur predominantly in boys, but ATV victims are older and almost all are white. Almost all ATV injuries occurred in children under the age of 16 years. Although both ATV and bicycle crashes cause severe injuries in children, injury severity is higher for ATV crashes in terms of multiple injuries, need for operative intervention, and longer length of stay. Despite severe injuries, the majority of children injured by ATVs continue to ride, albeit fewer hours per day, and safety behaviors are unaltered. These data reinforce the current AAP stance that legislation prohibiting the use of ATVs in children under the age of 16 years without a valid driver's license should be pursued and enforced aggressively.     

Shoulder restraint injury of the female breast

Female breast trauma occasionally occurs while using a three-point lap-diagonal seat belt while involved in a motor vehicle collision. Breast trauma is either a crush injury or an avulsion injury. Breast traumatic injury is infrequently reported. The records and complete follow-up results from all patients who were treated for breast trauma caused by lap-diagonal seat belt injury over a 25-year period were reviewed and reported. A series of 19 female patients were treated for breast trauma that occurred during a motor vehicle collision in which the patient was using a three-point lap-diagonal seat belt restraint. Patient age range at the time of injury was 18-75 years. The patients' breast injuries were classified according to the type and severity of breast trauma. Fourteen patients had a class I mild crush injury. All recovered completely with conservative breast care. Four patients had a class II moderate crush injury. All four patients had an area of painful chronic fat necrosis removed. Two of four patients with a class II injury continue to have mild to moderate chronic breast pain. A single patient with a class III severe crush injury was successfully treated nonsurgically. The breast healed with a diagonal furrow. No chronic breast pain has been associated with this class III breast crush injury. No class IV avulsion breast injuries were treated in this clinical series. A classification of breast trauma from a motor vehicle collision in which the female was wearing a three-point lap-diagonal seat belt restraint has been developed. Results of treatment of 19 patients are reported with breast trauma, with a clinical guide for immediate and long-term care. Chronic breast pain persists in two patients in this series with a class II breast injury who had an area of traumatic fat necrosis. No breast cancer occurred in long-term complete follow-up in this series of 19 patients with breast trauma.     

Head injury mechanisms in helmet-protected motorcyclists: prospective multicenter study.

BACKGROUND: In a prospective study, three research groups at Hannover (H) and Munich (M) in Germany and Glasgow (G) in the United Kingdom collected data from motorcycle crashes between July 1996 and July 1998 to investigate head injury mechanisms in helmet-protected motorcyclists. METHODS: The head lesions of motorcyclists with Abbreviated Injury Score-Head (AISHead) 2+ injuries and/or helmet impact were classified into direct force effect (DFE) and indirect force effect (IFE) lesions. The effecting forces and the force consequences were analyzed in detail. RESULTS: Two-hundred twenty-six motorcyclists (H, n = 115; M, n = 56; and G, n = 55) were included. Collision opponents were cars (57.8%), trucks (8.0%), pedestrians (2.3%), bicycles (1.4%), two-wheel motor vehicles (0.8%), and others (4.2%). In 25.4% no other moving object was involved. The mean impact speed was 55 km/h (range, 0-120 km/h) and correlated with AISHead. Seventy-six (33%) motorcyclists had no head injury, 21% (n = 48) AISHead 1, and 46% (n = 103) AISHead 2+. Four hundred nine head lesions were further classified: 36.9% DFE and 63.1% IFE. Lesions included 20.5% bone, 51.3% brain, and 28.1% skin. The most frequent brain lesions were subdural hematomas (22.4%, n = 47) and subarachnoid hematomas (25.2%, n = 53). Lesions of skin or bone were mainly DFE lesions, whereas brain lesions were mostly IFE lesions. CONCLUSION: A modification of the design of the helmet shell may have a preventative effect on DFE lesions, which are caused by a high amount of direct force transfer. Acceleration or deceleration forces induce IFE lesions, particularly rotation, which is an important and underestimated factor. The reduction of the effecting forces and the kinetic consequences should be a goal for future motorcycle helmet generations.     

Brachial plexus injury associated with chest restraint seatbelt: case report

Rapid deceleration while wearing a lap-shoulder strap seatbelt may result in a traction injury to the brachial plexus on the side of the shoulder strap. Occult vascular injury should be considered in patients with this injury pattern. The deficit will recover after a neuropraxic type injury.     

Life-altering outcomes after lower extremity injury sustained in motor vehicle crashes

BACKGROUND: Lower extremity injuries (LEIs) sustained in vehicular crashes result in physical problems and unexpected psychosocial consequences. Their significance is diminished by low Abbreviated Injury Scale scores. METHODS: Drivers who sustained LEIs were identified as part of the Crash Injury Research and Engineering Network (CIREN) and interviewed during hospitalization, at 6 months, and at 1 year. All were occupants of newer vehicles with seatbelts and airbags. RESULTS: Sixty-five patients were followed for 1 year. Injuries included mild brain injury (43%), ankle/foot fractures (55%), and bilateral injuries (37%). One year post-injury, 46% reported limitations in walking and 22% with ankle/foot fractures were unable to return to work. Depression (39%), cognitive problems (32%), and post-traumatic stress disorder (18%) were significant in the mild brain injury group. CONCLUSIONS: Long-lasting physical and psychological burdens may impede recovery and alter the lifestyle of patients with LEI. These issues need to be addressed by trauma center personnel.     

Neurological injury and death in all-terrain vehicle crashes in West Virginia: a 10-year retrospective review

OBJECTIVE: The purpose of this study was to profile all-terrain vehicle crash victims with neurological injuries who were treated at a Level I trauma center. METHODS: We retrospectively reviewed trauma registry data for 238 patients who were admitted to the Jon Michael Moore Trauma Center at the West Virginia University School of Medicine after all-terrain vehicle crashes, between January 1991 and December 2000. Age, helmet status, alcohol and drug use, head injuries, length of stay, disposition, and hospital costs were studied. Death rates, head injuries, age, helmet use, and safety legislation in all 50 states were compared. RESULTS: Eighty percent of victims were male, with an average age of 27.3 years. Only 22% of all patients were wearing helmets. Alcohol and/or drugs were involved in almost one-half of all incidents. Fifty-five of 238 patients sustained spinal axis injuries; only 5 were wearing helmets. One-third of victims (75 of 238 victims) were in the pediatric population, and only 21% were wearing helmets. Only 15% of victims less than 16 years of age were wearing helmets. There were a total of eight deaths; only one patient was wearing a helmet. CONCLUSION: In the United States, all-terrain vehicles caused an estimated 240 deaths/yr between 1990 and 1994, which increased to 357 deaths/yr between 1995 and 2000. Brain and spine injuries occurred in 80% of fatal crashes. West Virginia has a fatality rate approximately eight times the national rate. Helmets reduce the risk of head injury by 64%, but only 21 states have helmet laws. Juvenile passengers on adult-driven vehicles are infrequently helmeted (<20%) and frequently injured (>65%). We conclude that safety legislation would save lives.