Fractures From Short Falls: Implications in Children Under Age 5

Primary care and emergency physicians frequently see young children who have fractured a bone after a fall from a low height. The child's caregiver may describe a fall from furniture, play equipment, stairs, and various other structures--or the child may have even been dropped while being carried. The clinician then has to decide whether the explanation for the fall is plausible--or whether a child abuse investigation should be pursued.

Here we review the types of fractures that are possible in an accidental fall, depict the most common mechanism of fracture, and provide recommendations about when child protective services should be alerted.

We also describe 5 cases of fractures resulting from witnessed falls from relatively low heights with corroborated histories (Box). Our goal with these cases is to describe clues that point to an accidental injury.

THE EPIDEMIOLOGY OF SHORT FALLS

When children fall from a significant height--such as from a window or a balcony--they are typically evaluated in the emergency department and treated as a trauma patient.^1,2 These patients are not our focus here. Instead, we concentrate on the child who sustains a fracture from a seemingly insignificant fall. The epidemiology of fractures sustained by children who have fallen short distances can help you determine the plausibility of the caregiver's explanation.

Accidents are the leading cause of death in preschool children (aged 1 to 4 years).³ In 2001, over 2 million children in this age group suffered accidental injuries: 3000 died as a result. While falls accounted for only 2% of all fatal injuries, they were responsible for almost half of all nonfatal injuries.⁴

The skull, the long bones of the extremities, and the clavicle are most susceptible to injury following a seemingly insignificant accidental fall.^5,6 However, these are the same bones, along with the ribs, that are fractured when a child is intentionally injured. Although serious sequelae, such as depressed skull fractures, can result from a low fall, the vast majority of children do not sustain major injury.^5-8

Table 1 cites reports that include young children who have sustained fractures from falls of heights of less than 5 feet.^5-15 Many of these studies are retrospective reviews in which child abuse could not be definitely ruled out in all instances. When reviewing these reports, it is important to note whether the caregiver's history was corroborated to obtain a true picture of the actual injuries that can result from accidental falls.

Falling or rolling out of bed is not unusual--and it is the explanation most often provided by caregivers as the cause of an infant's injury from a short fall.⁷ Being dropped by a caregiver and rolling off a sofa are the second and third most common explanations, respectively, for short falls that lead to a fracture in an infant. Toddlers are at greater risk for accidental fracture than are non-ambulating children because of their unsteady gaits; their fearless, explorative nature; and their tendency to climb and fall. Wang and colleagues¹⁵ found that the beginning of ambulation is a particularly vulnerable time and that the peak age for a child to experience an accidental injury from a fall is in the second year of life. More than half of all fractures in children are described as occurring secondary to a fall: Leventhal and coworkers¹⁶ determined that approximately one tenth of these children are classified as being abused.

Accident or Abuse?

Although the bones of a child are more elastic and porous than those in adults--and greater energy needs to be applied to young bones to cause a fracture¹⁷--falls from low heights can cause fractures in young children.¹⁷ As with falls from high heights, the following factors may affect the probability of fracture^12,18:

• The child's age.

• The height of the fall.

• The surface onto which the child falls.

• The affected body part.

• The generated impact velocity.

If the child's head is the first point of impact--which is probable in the top-heavy preschooler--a skull fracture may result. Although several cases of linear skull fractures following falls from short distances have been reported (see Table 1), it is extremely unusual for a child to sustain a complex skull fracture in this manner. The typical skull fracture caused by a short distance fall is single, narrow, linear, and located in the parietal bone.¹⁹ An accidental fall onto an object or against an edged surface from less than 5 feet can result in a depressed skull fracture in a young child.^8,11 Unfortunately, everyday falls (such as those from playground equipment or while ambulating) have led to severe head injury--some accompanied by skull fractures--that in some cases have proved fatal.^12,15,18,20

It is difficult to determine the exact risk of sustaining a life-threatening injury from a short fall because it is impossible to completely rule out intentional injury in some reports. Since life-threatening injuries are probably very rare, the clinician has to maintain a high index of suspicion for intentional trauma in any serious injury resulting from a seemingly benign fall.

The clinician has to also consider the possibility of non-accidental trauma in any child with any type of fracture--especially in infants younger than 1 year. Banaszkiewicz and associates¹⁹ found that abuse was underestimated in 28.4% of patients younger than 1 year who were brought to the clinician with a fracture. In addition, occult fractures are also most likely to be discovered on a skeletal survey in children of this age.²¹ Although leg bone fractures can occur accidentally if a child runs and falls with a twisting motion while the foot remains stationary on the floor, such fractures suggest abuse in the non-ambulatory patient.

As with skull fractures, rib fractures are of extreme concern. The distal or mid clavicle can be easily injured in an accidental fall, but a fracture of the most medial aspect of the clavicle is particularly worrisome.²² The long bones are commonly injured in an accident, but in a child older than 1 year, the long bones (femur, humerus, tibia, and forearm bones) are also the most common location of non-accidental injury.²²

EVALUATION

The caregiver's description of the event that caused the child's fracture is the most crucial part of the evaluation. Each case has to be evaluated on its own merit to determine whether the caregiver's history is consistent with the injury that resulted. Plunkett¹² describes every fall as a complex event with its own biomechanical properties that needs to be analyzed. Certain historic points are red flags that a child might have been physically abused (Table 2).

The easiest falls to evaluate are ones that were witnessed by multiple persons. Unwitnessed falls in which the caregiver cannot provide an adequate, consistent history for the circumstances surrounding the injury are the most difficult to evaluate. Suspect abuse when the child's caregiver seeks treatment in an untimely manner, lacks knowledge of the mechanism of injury, and repeated- ly offers alternative explanations for the circumstances surrounding the injury.²³

A complete head-to-toe examination--including palpation of all bony areas--is necessary to uncover local points of tenderness. Meticulous examination of the eyes (in search of retinal hemorrhages) and neurologic and dermatologic systems may reveal manifestations of shaken baby syndrome.

Imaging studies are often necessary in the assessment of an infant or young child with an obvious or suspected injury. The skeletal survey (Table 3) is recommended and is mandatory in all cases of suspected abuse in children younger than 2 years.²⁴ However, it has little value in children older than 5 years.²⁵ Patients between ages 2 and 5 years are assessed on an individual basis.

If clinical findings point to a specific injury site, that anatomic region should be evaluated with a radiograph--regardless of the child's age.²⁵ An experienced radiologist should be present while imaging is performed to ensure that high-resolution images of good quality are obtained. If the initial skeletal survey is unremarkable but abuse is still strongly suspected, a repeated skeletal survey in 2 weeks may offer greater yield in discovering occult fractures.²⁶ A bone scan is another option for searching for occult fractures: the need for this modality is determined on a case-by-case basis.

Treatment of accidental fractures is individualized, based on the location and type of fracture. In general, aggressive pain control is the priority. An orthopedic consultation may be required.

References:

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