PEDIATRICS Vol. 104 No. 1
July 1999,
p. e7
ELECTRONIC ARTICLE:
Rollover Injuries in Residential Driveways: Age-related Patterns
of Injury
Mark L. Silen, MD, MBA*,
Evan R. Kokoska, MD*,
Diana G. Fendya, MSN*,
Arlet G. Kurkchubasche, MD
,
Thomas R. Weber, MD*,
Thomas F. Tracy, and
Jr, MD
From the * Division of Pediatric Surgery, Departments of Surgery
and Pediatrics, Saint Louis University Health Sciences Center and
Cardinal Glennon Children's Hospital, St Louis, Missouri; and
Division of Pediatric Surgery, Departments of Surgery and
Pediatrics, Brown University School of Medicine, Providence, Rhode
Island.
 |
ABSTRACT |
Background. The major objective of the
present study was to determine the severity of nonfatal
injuries sustained by children (<16 years old) when a motor vehicle
rolls over them. We also sought to determine whether younger children
(<24 months old) demonstrated different patterns of injury and/or a
worse outcome, compared with older children (>24 months old).
Methods. We reviewed the medical records of 3971 consecutive admissions to a single trauma service at an urban
children's hospital between March 1990 and October 1994. During this
time period, 26 (0.7%) children presented with rollover injuries
incurred by motor vehicles in residential driveways. Outcome was
measured by length of both intensive care unit admission and
hospitalization.
Results. Two children died shortly after admission
and were excluded from the remainder of the study. Younger
children (<24 months old) had significantly higher injury severity
scores and lower pediatric trauma scale scores. Both the duration in
the intensive care unit and the length of hospitalization were
significantly longer in younger children, compared with children >24
months old. One explanation for these observations was that younger
children had a significantly higher incidence of both head and neck and extremity injury but a similar incidence and severity of chest and
abdominal trauma, compared with older children. Injuries requiring operative intervention were rare.
Conclusion. Younger patients sustaining rollover injuries
in the residential driveway have a worse outcome, in part, because of
the head and neck or extremity injures that they incur. The majority of rollover injuries can be managed conservatively.
pediatric trauma, driveway, pedestrian events, rollover injuries,
injury severity score, pediatric trauma scale.
Injury resulting from vehicular trauma remains a major
problem in the pediatric population. Traffic-related injuries account for nearly half of all injury deaths among children and adolescents in
the United States.1 Although less common, pedestrian injuries are an important cause of morbidity and mortality in children
younger than 4 years and account for one third of all deaths in this
age group. The residential driveway is a common location for pedestrian
injuries, especially in children younger than two years
(toddlers).2,3 The major objective of the present study
was to determine the severity of nonfatal rollover (wheels of the
vehicle roll over the child) injuries sustained by children on
residential driveways. We also investigated whether younger children
(<24 months old) demonstrated different patterns of injury and/or
worse outcome.
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METHODS |
We initially reviewed the medical records of 3971 consecutive
admissions to a single trauma service at an urban children's hospital
between March 1990 and October 1994 and identified pedestrian versus
motor vehicle injuries that occurred only in driveways. The catchment
region of Cardinal Glennon Children's Hospital is a 250 km radius that
includes both urban (the city of St Louis, MO) and rural areas. This
catchment region is shared equally with another urban, level 1 pediatric trauma facility. Only children sustaining injuries associated
with a motor vehicle rolling over the child (opposed to a motor vehicle
colliding with the child) were included. The objective of the study was
to investigate the characteristics of children with nonfatal injuries;
thus, children who died soon after admission were excluded from the
study. Collected data included patient age, gender, length of admission
to the intensive care unit (ICU), length of hospitalization, injury
severity score (ISS)4 (<10, minor; >15, serious; >25,
severe; range of 1-75), pediatric trauma scale (PTS)
score5 (>9, minor; 5-8, serious; <4, severe; range of
6-12). ANOVA using a Scheffe post hoc test was performed on all
groups with continuous data (such as age or length of hospitalization),
whereas 
2 or Fisher's exact test was used for analysis
of nominal data. For nonparametric data (such as ISS and PTS score),
the Mann-Whitney U test was used for statistical comparison.
A P value <.05 defined statistical significance. StatView
4.5 (Abacus Concepts, Inc, Berkeley, CA) was used for all statistical
analysis.
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RESULTS |
During the 41/2-year period that was previously mentioned,
26 (0.7%) children were injured by motor vehicles in residential driveways located in the County of St Louis or in the surrounding rural
areas. In all cases, the vehicle rolled over the child; no injury was
the result of vehicular impact alone. Eighteen (69%) injuries resulted
from a child being struck by a vehicle that was being backed up by an
adult. In two instances, the child was rolled over twice. The remaining
8 (31%) injuries were caused by either an older child and/or sibling
(<16 years of age) rolling over the child (n = 4) or
the child engaging the vehicle into gear and then attempting to leave
the vehicle (n = 4).
Two children (24 and 36 months old) died soon after admission as a
result of massive head injuries and were excluded from the remainder of
the study. Among the 24 survivors, there were 12 males and 12 females.
Mean patient age was 44 (11-132) months, and 19 children were <60
months old (Fig 1).
The mean ISS and PTS scores were 23 (1-50) and 6.3 (0-12),
respectively. Injuries sustained by younger (<24 months old) children, defined by both trauma indices, were more severe. Younger children had
a higher mean ISS (mean rank 17.2 vs 9.2; P = .006) and
lower mean PTS score (mean rank 7.8 vs 15.9; P = .006)
(Figs 2 and 3).
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Fig. 2.
ISS of younger (<24 months) or older (>24 months) children with
rollover injuries. The number (n) of children in each
group is depicted beside the respective figure legend.
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Fig. 3.
PTS scores of younger (<24 months) or older (>24 months) children
with rollover injuries. The number (n) of children in
each group is depicted beside the respective figure legend.
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Overall, length of ICU admission and hospitalization was 3.2 (0-22)
and 8.0 (1-40) days, respectively. Younger (<24 months old) children
had significantly longer lengths of ICU admission and hospitalization
(Fig 4). With regard to injury patterns, younger children had a significantly higher incidence of both head and
neck and extremity injury, but a similar incidence of chest and
abdominal trauma, compared with older children (Fig
5). Tire marks were associated commonly with
major underlying injuries in the thorax (4/6; 66.7%) and abdomen (4/5;
40%).
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Fig. 4.
The effect of patient age upon either the duration of ICU admission or
length of hospitalization. The number (n) of children in
each group is depicted beside the respective figure legend.
*P < .05 versus children >24 months of age.
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Fig. 5.
The distribution of rollover injuries of all (total), younger, or older
children. The number (n) of children in each group is
depicted beside the respective figure legend. *P < .05 versus children >24 months of age.
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The 16 children sustaining injuries as a result of a vehicle driven by
an adult were younger (32 ± 6 months vs 68 ± 12 months; P < .01), had higher ISSs (mean rank 15.5 vs 6.5;
P < .01), and lower PTS scores (mean rank 9.7 vs 18.1;
P < .01). Children sustaining injuries as a result of
a vehicle driven by an adult, compared with children sustaining
injuries associated with either a vehicle driven by an older child or
caused by the patient engaging the vehicle into gear and jumping out,
also had a longer course in the ICU (4.6 ± 1.3 days vs 0.4 ± 0.3 days; P = .03) and had an increased length of
hospitalization (10.3 ± 2.3 vs 3.5 ± 0.7; P = .05). The previously mentioned observations may be the result of a
higher incidence of head and neck trauma (P < .05)
among the children who sustained injuried from a rollover by an
adult-driven vehicle.
Specific injuries, sorted by anatomic region, are shown in Table
1. Of note, only one injury (frontal
lobe laceration) required immediate operative intervention. Three
children with hemo/pneumothorax were treated with tube thoracostomy and
5 children with pulmonary contusion were managed with a brief period of
ventilatory support. All intraabdominal injuries were treated
nonoperatively.
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DISCUSSION |
The residential driveway is an important site of pediatric trauma
involving motor vehicles. Injuries sustained by children in this
location are different from the typical high velocity motor
vehicle-pedestrian event. The mechanism of injury is a crushing force
by the vehicle rather than a sudden blunt impact or deceleration force.6 The potential lethal nature of these injuries has
been appreciated recently.2 The patients in the current series emphasize the severity and typical pattern of nonlethal injuries
sustained in the residential driveway.
Our data suggest that younger children (toddlers) sustaining rollover
injuries have more severe injuries and worse outcomes. One explanation
for this observation is that younger children have a higher incidence
of both head and neck and extremity injury but a similar incidence of
significant chest and abdominal trauma. Perhaps younger children are
less mobile and therefore are less able to pull or crawl away from a
moving tire. In addition, the impact of a given size tire will be
distributed across more organ systems in a small child, compared with a
larger child.
Previous reports have identified unlocked motor vehicles set in motion
by children themselves as a potentially preventable cause of such
injuries.7,8 Unlocked vehicles account for one third of
all injuries in the present series. Clearly, if the vehicles had been
locked by the driver or if they had been equipped with
automatic locking systems, these events could have been avoided.
Education of drivers through education programs and public service
announcements may be beneficial.
The ISS scores in the current study are higher than those reported by
Agran et al.9 However, a major difference between the two
groups is that 51% of the patients reported by Agran et al were
treated and released from the emergency department. This difference may
be explained by the fact that their data represented the experience of
several hospitals, whereas our patients were evaluated and treated at a
single level 1 trauma center. Presumably, those patients in our
catchment area who were treated and discharged from an emergency
department were never referred to our institution. In a report by Winn
et al,3 61% of all pedestrian events involving toddlers
(<24 months old) occurred on residential driveways. The 9% mortality,
51% hospitalization rate, and mean ISS of 10 are similar to findings
from the previous report by the same group.9 Between
October 10, 1988 and August 18, 1994, 67 trauma centers that provide
care for children submitted data to the Pediatric Trauma Registry
staffed by Tufts University. During this period, which is
similar to the current study, 255 patients of a total of 42 029
children in the registry sustained a pedestrian injury at home. Of
these 255 children, 6 were dead at the scene and another 5 died shortly
after admission to the hospital for an overall fatality rate of 4%.
The mortality rate of the current study was 2/26 = 7.6%.
Two thirds of the injuries in the present series were the result of the
adult-initiated motion of a vehicle, usually while backing up, striking
a pediatric pedestrian. Prevention of this type of injury in the
residential driveway is imperative. Physical separation of a
residential driveway from the play area of children by fencing has been
reported recently to result in a 50% reduction in the risk of driveway
events.10 Public education and organized injury prevention
programs (eg, the national Safe Kids campaign) must make parents,
teachers, and other responsible adults aware of the hazards and risks
of residential driveway events. Parents should be encouraged to walk
around the car before leaving an area in which children may have been.
Making motor vehicle manufacturers aware of not only of the hazards but
also of the injury patterns described in the present report may result
in constructive automobile or truck design changes. In cases in which
the child was the driver, perhaps the ignition was left on or the key
was left in the ignition. Safety designs to prevent a driver from
leaving the key in the ignition or leaving the ignition on may decrease
the opportunity for another child to become the driver. The use of
audible signals when any vehicle is driven in reverse and the
alteration of the design of rear bumpers may also be valuable. Finally,
on-board front and back radar may become an important adjunct as
research continues and costs become more reasonable.
Physicians evaluating children injured in driveway vehicle events
should be aware of the pattern of injuries among survivors and the
differences in injuries in relation to the patients' ages. Although in
our study the majority of the injuries were nonlethal, rapid evaluation
and management remain critical to improve survival rates and quality of
life after driveway events. Additional evaluation of the epidemiology
of driveway events involving children may result in additional
important advances in the prevention of these, often devastating,
injuries.
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FOOTNOTES |
Portions of this work were presented at the First European
Congress of Pediatric Surgery; May 4-6, 1995; Graz, Austria.
Received for publication Sep 25, 1998; accepted Feb 24, 1999.
Reprint requests to (M.L.S.) Division of Pediatric Surgery,
Cardinal Glennon Children's Hospital, 1465 S Grand Blvd, St Louis, MO
63104. E-mail: silenml{at}wpogate.slu.edu
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ABBREVIATIONS |
ICU, intensive care unit;
ISS, injury severity
score;
PTS, pediatric trauma scale.
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Pediatrics (ISSN 0031 4005). Copyright ©1999 by the American Academy of Pediatrics
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