Ten Years of Experience With Falls From a Height in Children

By Barbara Barlow, Maria Niemirska, Rajinder P. Gandhi, and Wiener Leblanc New York, New York

�9 Falls f rom a height are a major cause of acciden- tal death in urban children. The medical and social data on 61 children admit ted over the last decade for falls of one or more stories w e r e rev iewed. Seventy- seven percent of the children survived. Of the chil- dren who fell th ree stories or less, all survived (100%) . Fifty percent morta l i ty occurred be tween the f i f th and sixth floors. Seventy-seven percent of the falls w e r e accidental and 2 3 % of the children jumped or w e r e pushed. The 9 6 % decrease in acci- dental falls f rom w indows since 1979 demonstra tes that the "Chi ldren Can' t Fly" program in N e w York City has almost el iminated accidental falls f rom win- dows in our hospital population.

INDEX W O R D S : Falls f rom heights.

F ALLS F R O M A H E I G H T are a major cause of accidental death in urban chil-

dren. 1-4 The available medical and social data for 61 children under 16 years of age who were admitted to the Pediatric Surgical Service of Harlem Hospital over the last decade after fall- ing from a height were reviewed. Social data on the group were evaluated by comparison to a control group of children admitted during the same period for simple fractures.

PATIENT GROUP

The age and sex distribution of the 61 children are depicted in Fig. 1: 70% were boys and 52% were 4 years old or younger. Eighty percent of the falls occurred between noon and 9 pro; 46% were during the summer months.

INJURIES

Major injuries are listed in Table 1. Of these patients, 39 had multiple major injuries, 16 had a single major injury, and 6 sustained only abrasions. Most children landed on the concrete sidewalk or on piles of garbage between buildings.

Fractures were the most common injury, followed in frequency by head trauma. There were no intraabdominal or pulmonary injuries in children who fell three or fewer floors.

MANAGEMENT

Most children reached the hospital within 40 minutes of their fall. Rapid resuscitation and evaluation in the emer- gency room allowed triage of children with major injuries requiring surgery directly to the operating room. Radiologic evaluation was undertaken only in stable patients. The aver- age time from arrival to surgery was 68 minutes, ranging from 34 minutes to 3 hours, 15 minutes.

Evaluation

Abdominal tap was performed only in unconscious patients or unstable patients when clinical evaluation was unreliable. Five patients had simple tap without lavage: three were positive and had laparotomy; two were negative and were observed. Tap with lavage was performed in only three patients: one was positive and the patient was explored; two were equivocal and the patients were observed. There were no negative laparotomies and no late laparotomies for injuries not diagnosed during initial evaluation.

Children with gross or microscopic hematuria were evalu- ated by IVP. Seven IVPs were grossly abnormal: six had fractured kidneys and one a duplicated collecting system.

Angiography was performed in only two patients: one carotid angiogram which was normal and one celiac angio- gram which was used to evaluate a massive subcapsular hematoma of the liver. Liver spleen scan was used to evaluate stable patients with upper-abdominal trauma who were being observed.

Emergency laparotomy was performed in seven of the patients for the following injuries: 1 evisceration, 2 ruptured spleens with shock, 1 pancreatic injury with peritonitis, 2 fractured kidneys with shock, and 1 fractured liver with shock. There were no perforations of the gastrointestinal tract. One child who was observed for a subcapsular hema- toma of the liver required drainage after 3 weeks because of failure to improve and onset of pleural effusion and fever.

DEATHS, COMPLICATIONS, AND SEQUELAE

Falls from a height produce the highest mortality of any category of injury seen in our pediatric population. In our experience, 23% of the children died: 9 were dead on arrival; 2 died in the emergency room; and 3 died within 24 hours of admission.

Major injuries in the 14 children who died are listed in Table 2. Severe brain injury caused the deaths of 11 children, 1 died of exsanguination from liver and spleen rupture; 1 of crushed chest with liver and spleen rupture; and 1 from cardiac contusion. Only the two children with liver-spleen rupture without head injury might have been saved had they reached the hospital before arrest.

The two children who died in the emergency room were a child with multiple open skull fractures and a ruptured spleen

From the Departments of Surgery and Pediatrics, Harlem Hospital Center, College of Physicians and Surgeons of Columbia University, New York, New York.

Presented before the 3lst Annual Meeting of the Surgical Section of the American Academy of Pediatrics, New York, New York, October 23-24, 1982.

Address reprint requests to Barbara Barlow, MD, Chief of Pediatric Surgery, Harlem Hospital Center, 506 Lenox Avenue, KP-17103, New York, NY 10037.

�9 1983 by Grune & Stratton, Inc.

Journal of Pediatric Surgery, Vol. 18, No. 4 (August), 1983 509

510 BARLOWET AL

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Fig. 1. Age and sex distr ibut ion of 61 chi ldren who fell from a height.

which did not produce significant blood loss; and a child with spinal cord transection, multiple fractures including the sternum, with cardiac contusion and a contained aortic laceration, who developed arrhythmia and arrested.

The three children dying within 24 hours of admission were comatose from severe head injury; in addition, one had a major burn and the other two had aspiration with pulmonary insufficiency. One aspirated vomitus and the other had diffuse blood aspiration prior to admission.

There was no correlation between age and survival in children. One hundred percent who fell three or fewer floors survived. Fifty-percent mortality occurred between the 5th and 6th floors (Fig. 2). The 50% mortality for adults in our hospital occurs between the 3rd and 4th floors, s

Table 1. Major Injuries in 61 Children Who Fell From a Height

Type of No, of Specific No, of Injury Patients Injury Patients

Head 56 Concussion 25

Skull fracture 17 Brain contusion 13

Subdural I Chest 17 Hemopneumothorax 6

Rib fracture 6

Lung contusion 3 Cardiac contusion 1

Sternum fracture 1 tOO Abdomen 44 Liver laceration 11

Splenic rupture 8 Evisceration 1 75 Pancreatic contusion 1 =~ Retroperitoneal ~:

o hematoma 4 5 50

Renal injury 19 =

Fractures 70 Facial bones 3

Spine 2

Clavicle 2 Humerus 4

Radius-ulna 21 Pelvis 8

Femur 20 Tibia-fibulla 8 Metacarpals 2

Table 2. Major Injuries in 14 Fatal Falls

Based on Autopsy Reports

Type of No. of Specific No. of Injury Patients Injury Patients

Head 22 Skull fractures 10

Brain contusion 11

Subdural 1 Chest 12 Hemopneumothorax 4

Rib fractures 2

Crushed chest 1 Lung contusion 3 Cardiac aortic injury 1

Sternal fracture 1 Abdomen 13 Liver laceration 5

Splenic rupture 6

Renal fracture 2 Fractures 23 Spine 1

Clavicle 1 Humerus 2 Radius-ulna 4

Pelvis 1

Femur 12 Tibia-fibulla 2

The complications encountered were: pulmonary edema from fluid overload in a child transferred from another hospital; one child with pneumonia; one sympathetic pleural effusion in a child with subcapsular hematoma of the liver; transient hypertension in a child with a large retroperitoneal hematoma from pelvic fracture; and tendon entrapment in callus of a fractured radius.

There were few permanent physical sequelae: a blind eye secondary to second cranial nerve injury; hand paresis follow- ing ulnar and median nerve injury secondary to fracture; and a short leg after tibial epiphyseal injury resulted in epiphyseal growth arrest.

The long-term psychologic sequelae in the surviving chil- dren include six children requiring outpatient psychiatric care and four requiring psychiatric hospitalization. There were 14 children with one or more of the following symptoms after their fall: speech problems, wetting, soiling, behavior disorders, school problems, and night terrors.

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Height of Fall in Floors

Fig. 2. Height of fall and morta l i ty in 61 children who fell f rom a height.

FALLS FROM A HEIGHT IN CHILDREN 511

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Years

Fig. 3. Yearly distribution of falls and site of falls for 61 children who fell from a height.

Circumstances of Injury

Of all the falls, 50 were through windows, 4 off of roofs, 3 off of fire escapes, 2 off of bridges, and 2 down elevator shafts. Seventy-seven percent of the falls were accidental. The 11 children who fell off roofs, fire escapes, bridges, or down elevator shafts were engaged in dangerous play. Thirty- six chilren fell accidentally out of windows; all were 10 years older or younger. Twenty-three percent of the falls were not accidents. Ten children jumped: 3 attempting suicide, 5 to escape parental beating, 1 to escape beating by a brother, and 1 to escape a fire. Four children were pushed: three by a sibling and one by a parent. All known suicide attempts were in adolescents.

Social Background

There was no significant difference in family structure, financial background, or number of siblings between children admitted for falls and children admitted for simple fracture. The majority of children from both groups were from single- parent families on welfare with an average of three children per family. This appears to reflect the composition of our hospital population.

DISCUSSION

Prevention

The New York City Depar tment of Heal th developed a health educat ion program "Chi ldren C a n ' t Fly" in 1972, after a 4-year study of child mortal i ty demonst ra ted that falls from heights represented 12% of all accidental deaths in chil- dren under 15 in New York City. In 1976 the New York City Board of Heal th passed a law requir ing owners of mult iple dwellings to provide window guards in apar tments where chi ldren 10 years old or younger resided, s t ipulat ing that all landlords be in compliance by 1979. This pro- gram includes reporting of falls by Emergency Rooms and police, media campaigns, cont inuing educat ion programs, and, initially, provision of free window guards?

The yearly incidence of falls admit ted to our service since 1970 is depicted in Fig. 3; the site of the fall is noted. Since the law took effect in 1979, only one child was admit ted for an acci- dental fall through a window. Based on the previous 9 years of experience we would have expected 16 children to have been admit ted for acc iden ta l falls f rom windows. This 96% decrease in accidental falls through windows demonstrates that the "Chi ldren C a n ' t Fly" pro- gram has been effective in our communi ty and suggests that other u rban areas should establish similar programs.

ACKNOWLEDGMENT

The authors wish to thank Dr Elliot Gross, Chief Medical Examiner of the City of New York, for supplying the autopsy data, and D. Campbell for her assistance in preparing this manuscript.

REFERENCES 1. Spiegel CN, Lindaman FC: Children can't fly: A

program to prevent childhood morbidity and mortality from window fails. Am J Public Health 67:1143-1147, 1977

2. Bergner L, Mayer S, Harris D: Falls from heights: A childhood epidemic in an urban area. AJPH 61:90-96, 1971

3. Sieben RL, Leavitt JD, French JH: Falls as childhood accidents: An increasing urban risk. Pediatrics 47:886-892, 1971

4. Smith MD, Burrington JD, Woolf AD: Injuries in children sustained in free falls: An analysis of 66 cases. J Trauma 15:987-991, 1975

5. Lewis WS, Lee AB, Grantham SA: Jumpers syndrome: The trauma of high free fall as seen at Harlem Hospital. J Trauma 5:812-818, 1965