This case illustrates a common clinical pathology in children by a not so common mechanism, especially after the institution of legislation against the use of infant walkers. Also, it is a reminder to emergency physicians to evaluate for non-accidental trauma when seeing injuries in a child who is not yet mobile.
Mark Schnellinger, MD
Manu Madhok, MD, MPH
Childrens Hospital of Minnesota
HISTORY:
A 7-month-old male presented to emergency department (ED) for altered mental status after a fall at home. As per the mom, the child was in a walker with wheels, tumbled down a flight of stairs, (approximately 12 stairs) when she was at work and grandfather was watching him. No loss of consciousness was reported. Swelling over the left side of the head and some bleeding in mouth was noted. The child was reported to be sleepy or fussy and irritable when awake. The child was initially taken to a local urgent care where child was examined and transferred to Children’s Hospital ED via ambulance. The child had one episode of non-bloody emesis en route. In the ED, child was noted to be irritable and poorly consolable by mom. The vital signs were T 37.4°C, pulse 128/min, BP 72/32 mm Hg, Respiratory rate 28/min. A large cephalhematoma was palpable over the left parietal scalp. The pupils were 3 mm, round and reactive. Oral examination showed bruising over mandibular gingiva. No bruising was seen elsewhere on the body. Rest of the examination was normal and neurologic examination was non focal. Preliminary labs were normal and CT Scan of head without contrast was performed and the child was admitted to pediatric intensive care unit.
DISCUSSION:
A Linear parietal skull fracture, extending from coronal suture to lambdoid suture, was noted on the CT scan. A single small comminution fragment and subjacent extra-axial hemorrhage was noted on the anterior aspect. No parenchymal hemorrhages, contusions or mass effect were noted. Neurosurgery observed the child in PICU. Case was also reviewed with child abuse evaluation team. Child did well overnight, repeat CT scan in the morning showed no new changes from previous study and child was cleared and discharged to home the next day.
Falls are the most frequent cause of accidental injury in the pediatric population. Children using infant walkers are at increased risk of injury, especially from falls. The majority of injuries occur as a result of falls from stairs with head injuries being common, as demonstrated in this case. Thirty-four infant walker related deaths were reported between 1973 and 1998. In 1997, new legislation was instituted, (ASTM F977-96) in order to reduce the number of injuries related to infant walkers2. Overall, there was a 76% decrease in the number of injuries from 1990 to 2001 from 20,900 injuries in 1990 to 5100 in 20013. They are still in use and caused head injury in this case. In cases of injury in an immobile child, one must evaluate for non-accidental trauma. In this case, staff and child abuse services felt that the story was consistent with the nature of the injuries.
REFERENCES:
1. Chiaviello CT, Chirsoph RA, Bond GR. Infant walker-related injuries: a prospective study of severity and incidence. Pediatrics 1994 Jun;93(6 Pt 1):974-6.
2. Bull, Marilyn, MD/ Chairperson, Committee on Injury and Poison Prevention 2000-2001. American Academy of Pediatrics: Injuries Associated With Infant Walkers. Pediatrics 2001 Sept; (3), 790-792.
3. Shields BJ, Smith GA. Success in the prevention of infant walker-related injuries: an analysis of national data, 1990-2001.Pediatrics. 2006 Mar;117(3):e452-9.
