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PEDIATRICS Vol. 106 No. 2 August 2000, pp. 301-305
, and
From the * Child and Adolescent Psychiatry Fellowship Program,
University of South Dakota, Sioux Falls, South Dakota; Department of
Medicine, Children's Hospital, and Harvard Medical School, Boston,
Massachusetts; and § Nancy Leland and Associates, St Paul,
Minnesota.
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ABSTRACT |
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Objective. Abusive parents often report that a fall on stairs resulted in their children's injuries. This review explores whether there is any evidence in the medical literature that a fall on stairs could be a plausible explanation for a small intestine perforation.
Methodology. The English-language medical literature was searched by Medline, for a 29-year period (1970-1998), for reports of the types of injuries sustained in falls on stairs and for reports of the types of blunt abdominal trauma that result in small intestine perforations. Articles that exclusively focused on infant walker injuries or the elderly were excluded. Duodenal, jejunal, and ileal perforations were included, whereas intestinal hematomas and undescribed intestinal injuries were excluded. All types of injuries to the stomach, colon, and rectum were excluded.
Results. Falls on stairs were not reported to be a cause for any of the 312 cases of small intestine perforations reviewed. There were no reports of any intraabdominal injuries, including small intestine perforations, in any of the 677 cases of falls on stairs reviewed. Falls on stairs rarely resulted in any type of truncal injury.
Conclusions. Although falls on stairs have been reported to be the most common cause of injury in childhood, no evidence was found to support the contention that an unobstructed fall on stairs could be consistent with perforation of the small intestine. Key words: abdominal trauma, child abuse, injury, small intestine perforations, stairs.
Protecting children from maltreatment is a formidable task.
In order for child protective authorities to act, convincing evidence that the child suffered abuse or neglect, rather than an illness or
unintentional injury, is required. The impetus for this article was the
case of a 4-year-old child who sustained a life-threatening small
intestine perforation. The child's caretakers reported that this
injury resulted from a fall down the stairs, which is a common explanation given by abusive parents to account for their children's injuries.1,2 Although the severity of trauma required for
abdominal visceral injury3 and the specificity of the
mechanisms of injury in small intestine perforations4-11
suggest that the history of a fall on the stairs is not consistent with
a small intestine perforation, the lack of absolute medical certainty
in rebuffing this explanation proved to be an obstacle to optimal child
protection. Because this case is not unique in the explanation of the
abusive parent or in the lack of absolute medical certainty in
disproving parental explanations, a review of the medical literature
was undertaken to examine whether there was any support for the
contention that a small intestine perforation could be a consequence of
a fall down stairs.
The English-language medical literature was searched by Medline
for a 29-year period (1970-1998), using 2 independent search strategies to examine: 1) reports of the types of blunt abdominal trauma that result in small intestine perforations; and 2) reports of
the types of injuries sustained in falls on stairs. Age limitations were not imposed in either search. Both searches were limited to
reports published since 1970 in an attempt to minimize biases that may
be introduced by earlier reports during an era when child abuse was not
as widely recognized.
Only reports of falls on stairs that confirmed the resulting injuries
through medical evaluations were included. Articles based on surveys of
patient recall of injuries were excluded. Reports that exclusively
described infant walker-related falls were excluded to minimize the
inclusion of falls that have mechanisms of injury that are inherently
different from those present in simple stairway falls. Infant walkers
change the mechanisms of injury by providing protection of certain
regions of the body, becoming an instrument of injury and generally
changing the dynamic interplay between the child and the stairs. One of
the reviews on stairway falls also excluded all infant walker-related
injuries.12 Articles that focused on general falls in the
elderly, although specific cases may have been falls on stairs, were
excluded.
Reports of duodenal, jejunal, and ileal perforations were included.
Intestinal hematomas and undescribed intestinal injuries were excluded
because the inclusion of intestinal injuries that, unlike perforations,
may not always be detected would confound the ability of this review to
fairly describe whether an intestinal injury occurred as the result of
a fall on stairs. In contrast to hematomas, perforations invariably
require operative intervention and, although there may be delays in the
diagnosis, they are ultimately detected by their precipitation of an
acute abdominal emergency. Injuries and perforations of the stomach,
colon, and rectum were excluded. In addition, intestinal perforations
resulting from trauma to inguinal hernias were excluded. Articles that
reported several types of data were included by selecting those cases
that met the inclusion criteria.
Descriptive statistics were used to assess the cases that met inclusion
criteria. The frequencies for the various causes of small intestine
perforations, the locations of injuries sustained in falls on stairs,
and the types of injuries to the truncal region were determined by a
thorough analysis of the text, tables, and figures in each article. In
particular, intraabdominal injuries were considered to be absent if the
authors specifically stated that fact,13 published a
complete list of all injuries that did not include any intraabdominal
injuries,14 or published a complete list of all
significant injuries that included injuries such as concussions but did
not include any intraabdominal injuries.12 In addition,
fractures to the truncal region were considered to be absent if the
author specifically indicated that in a graphic illustration13 or published a complete list of all
significant injuries that included fractures in the head and neck
region but did not include any fractures to the ribs, lumbosacral
spine, or pelvis.12 Results were tabulated for children by
selecting those studies that reported age-related injuries and causes.
These results were compared with the studies that included adults and
children (mixed age group) but did not specify age-related injuries and
causes.
Falls on Stairs
Only 3 reports in the medical literature met inclusion criteria
for the review of falls on stairs.12-14 The frequency and
location of the resultant injuries are described in Table
1. Head and neck injuries predominated in
the child only group, whereas extremity injuries were most common in
the mixed age group. Truncal injuries were rarely reported and this was
especially evident in the child only group. All injuries to the truncal
region in the children only group were soft tissue injuries, whereas
the mixed age group had both soft tissue and skeletal injuries in the
truncal area. No intraabdominal injuries, including small intestine
perforations, were reported in the 677 cases of falls on stairs
reviewed.
TABLE 1
METHODS
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RESULTS
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Injuries Sustained in Falls on Stairs Reported in the Medical
Literature, 1970-1998
Small Intestine Perforations
Twenty-eight articles in the medical literature included cases of small intestine perforations and described specific causes.4-7,10,11,15-36 These causes are described in Table 2. Motor vehicle injuries, child abuse, physical assaults, miscellaneous blows, nonstairway falls, and bicycle handlebar injuries predominated as causes of perforations. Tables 3 and 4 describe the details of the miscellaneous blows and nonstairway falls that were reported to result in small intestine perforations. Falls on stairs were not reported as a cause for any of the 312 cases of small intestine perforations reviewed.
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DISCUSSION |
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Limitations of Studies
Only 3 of the articles reviewed described methods to exclude false histories that were given to account for injuries actually resulting from child abuse or domestic violence.12,13,23 Although this review was limited to reports published since 1970 in an attempt to minimize the possibility of falsely including cases of child abuse, this clearly does not exclude the possibility that cases of child abuse were undetected. Prospective designs that carefully rule out the possibility of child abuse are superior in validating that a fall represents a true history. Objectively observed events, such as falls in a hospital setting or at school, are the best methods to remove cases of child abuse from samples. However, the aforementioned limitation did not confound the specific question posed by this review, because no falls on stairs were reported to cause small intestine perforations.
Falls on Stairs
Although falls down stairs have been reported to be the most common cause of childhood injury,37 the mechanism of injury in stairway falls has received little attention in the medical literature. Joffe and Ludwig13 postulated that the mechanism of injury in stairway falls consists of an initial mild to moderately severe impact followed by a series of low-energy noninjurious falls, based on their findings of a predominance of isolated injuries and no differences in either number or severity of injury between falls less than and greater than 4 steps. Our review of the articles on stairway falls demonstrated a remarkable similarity in the location of injuries and in the absence of any reports of intraabdominal injuries among the 677 cases. In addition, there was a paucity of any type of truncal injuries.
Small Intestine Perforations
In contrast to stairway falls, the hypothesized mechanisms underlying perforation of the small intestine have been widely described and include: 1) shearing or tearing forces created in sudden deceleration accidents at areas of relative fixation, such as the duodenum (eg, motor vehicle accidents and falls from heights); 2) compression or crushing of the bowel against the anterior vertebral column; and 3) bursting injuries that result from a sudden increase in intraluminal pressure over a pinched local area caused by a single point blow or a blow extending in only 1 dimension.4-11 The specificity of the mechanism of injury required to perforate the small intestine informs current standards of medical practice. The low incidence of small intestine perforation in most types of blunt abdominal trauma contributes to the popularity of nonoperative management of splenic trauma because of the rarity of associated hollow viscus perforation that would require surgical intervention.38-40 In contrast, a high index of suspicion for small intestine perforation as well as a lower threshold for surgical intervention are present in cases of motor vehicle injuries, physical assaults, child abuse, bicycle handlebar injuries, and other penetrating blows to the abdomen.4,9,17,20,21,23,24,26,33,41-47 Our comprehensive literature review of the causes of small intestine perforations was consistent with the hypothesized mechanisms of injury and demonstrated a predominance of motor vehicle injuries, physical assaults, and child abuse as causative factors. The remaining cases of perforation were reported as the result of a variety of penetrating blows to the abdomen and nonstairway falls.
Nonstairway Falls
Falls from heights accounted for 7 of the 312 cases of small intestine perforations. These 7 cases were among reports of >1000 cases of falls from heights of up to 17 stories.29,35,48-57 Although the lack of validity in comparing falls from heights with falls down stairs is recognized, the findings are significant for the rarity of small intestine perforations in some of these falls associated with much greater overall severe trauma and dynamic forces than are present in falls on stairs. Besides falls from heights, there were various other nonstairway falls that resulted in perforation of the small intestine. These falls all involved impact onto objects that extended out in 1 dimension, while allowing the patient's body to continue movement above, below, or above and below the object (eg, fence, clothesline, chair, edge of night table, and saddle of bike). In 2 cases, the fall was not described sufficiently to determine the impact surface.16,24 There were no specific reports found that described a fall onto a surface that limited the motion of the body above and below the abdomen, such as a flight of stairs.
Protection From Small Intestine Perforations in Falls on Stairs
Neither the medical literature reviewed nor the mechanisms of injury operating in falls on stairs and in small intestine perforations support the contention that a fall on stairs could be a plausible explanation for perforation of the small intestine. In fact, the juxtaposition of the close succession of protruding steps defining the impact surface and a person's skeletal structure may result in a remarkable protection of the abdomen by limiting the level of penetration to the abdomen. This may explain the rarity of any truncal injuries and the absence of any intraabdominal injuries in the studies of falls on stairs. The protection afforded to the abdomen during a fall on stairs could be negated by the presence of any obstacles on the stairs. In addition, the presence of penetrating abdominal wounds, perforations secondary to fractured bony ends, and other medical conditions that damage the integrity of the intestinal wall should be considered.58 In general, these conditions would not be expected to pose a problem in the differential diagnosis of small intestine perforations in children whose parents report a fall on the stairs as the causative factor.
Implications
Abdominal injuries in children and, in particular, small intestine perforations combined with a delay in seeking medical care are a lethal form of child abuse.20,23,42 In fact, abdominal injuries are second only to head injuries in being responsible for child abuse fatalities.3,43,59 The 1977 study of 246 children by Helfer et al60 assessed the plausibility of serious head injuries resulting from falling out of bed, which is another common explanation given by abusive parents for their children's injuries.1,2,20 The results revealed that none of the children sustained subdural hematomas, epidural hematomas, or any serious or life-threatening injury. These findings have strengthened the ability of society to provide improved child protection interventions.
Our comprehensive review of the literature demonstrated that none of the 432 children or 245 persons of mixed ages sustained any type of intraabdominal injury as the result of falls on stairs. In addition, this review demonstrated than none of the 65 children or 247 persons of mixed ages with small intestine perforations sustained this injury as the result of a fall on stairs. Any intraabdominal injury that is explained as the result of a fall on stairs should be carefully evaluated for the possibility of child abuse. Cases of small intestine perforations should be especially scrutinized and reports to child protective services should include a summation of the medical literature that demonstrates that, although falls on stairs have been reported to be the most common cause of injury in childhood, there is no evidence to suggest that an unobstructed fall on stairs could be a plausible explanation for perforation of the small intestine.
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FOOTNOTES |
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Received for publication Jan 19, 1999; accepted Aug 13, 1999.
Reprint requests to (C.M.H.) Southeastern Behavioral Healthcare, 2000 South Summit Ave, Sioux Falls, SD 57105. E-mail: chuntimer{at}aol.com
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This article has been cited by other articles:
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  M. C. Pierce, G. E. Bertocci, J. E. Janosky, F. Aguel, E. Deemer, M. Moreland, D. K. B. Boal, S. Garcia, S. Herr, N. Zuckerbraun, et al. Femur Fractures Resulting From Stair Falls Among Children: An Injury Plausibility Model Pediatrics, June 1, 2005; 115(6): 1712 - 1722. [Abstract] [Full Text] [PDF]
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 G. J. Lonergan, A. M. Baker, M. K. Morey, and S. C. Boos From the Archives of the AFIP: Child Abuse: Radiologic-Pathologic Correlation RadioGraphics, July 1, 2003; 23(4): 811 - 845. [Abstract] [Full Text] [PDF]
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