In a recent article published in a "The Chiropractic Journal" by Dr. Christopher Kent, he reviews the latest literature, which supports the existence of accident-induced subluxations in children.

Orenstein, et al, did a retrospective chart review involving 73 children who presented at a children's hospital with cervical spine injuries. 67% of these injuries were traffic-related, resulting from motor vehicle crashes. The injured children were passengers in an automobile, pedestrians, or bicyclists. The mean age of the patients surveyed was 8.6 years, with bimodal peaks at 2 to 4 and 12 to 15 years. The authors noted that younger children sustained more severe injuries than older children did. Distraction and subluxation injuries were the most common injuries in children aged eight years and younger. Fractures were more common in older children. (1)

Glass, et al, evaluated 35 children with lumbar spine injuries following blunt trauma. 31 of these children were injured in motor vehicle crashes. Abnormalities noted on plain radiographs and CT scans included subluxation, distraction, and fracture alone or in combination. The authors stated, "Children involved in motor vehicle crashes are at high risk for lumbar spine injuries...lumbar spine radiographs are necessary in all cases with suspected lumbar spine injury..." (2) This paper underscores the need to evaluate the entire spine in cases of motor vehicle accidents, not just the cervical region. It may be cited when claims for lumbar radiographs are questioned in cases of children involved in car accidents.

Rachesky, et al, reported that on the cervical spine radiographs of children under 18 they examined, vehicular accidents accounted for 36% of radiographic abnormalities. It was further stated that clinical assessment of a complaint of neck pain or involvement in a vehicular accident with head trauma would have identified all cases of cervical spine injury. (3)

Other authors have described aspects of cervical spine injuries in children involved in motor vehicle accidents. Hill, et al, noted that 31% of the pediatric neck injuries reviewed were the result of motor vehicle accidents. In younger children (under 8 years of age) subluxation was seen more frequently than fracture. (4) Agran stated that non-crash vehicular events may cause injuries to children. Non-crash events discussed in this paper included sudden stops, swerves, turns, and movement of unrestrained children in the vehicle. (5) Roberts, et al, described a case where a child involved in a motor vehicle accident sustained a "whiplash" injury resulting in immediate neck and back pain. Neurobehavioral abnormalities increased in the two year period following the accident. Four years after the accident, symptoms persisted. Positron emission tomography (PET scan) demonstrated evidence of brain dysfunction. (6)

In a study of 119 children involved in road traffic accidents during 1997 Dr. Paul Stallard and colleagues from the Royal United Hospital in Bath reveal that one-third were found to be suffering from post-traumatic stress disorder. The study found that young people displayed symptoms including sleep disturbance and nightmares, separation anxiety, difficulties in concentration, intrusive thoughts, difficulties in talking to parents and friends, mood disturbance, deterioration in academic performance, specific fears and accident related play. The authors found that neither the type of accident nor the nature or severity of physical injuries were related to the presence of post-traumatic stress disorder. However, they did find that girls were far more at risk of developing the disorder than boys. Psychological services for children involved in road traffic accidents are not at present provided in a comprehensive or routine way, the researchers write, adding that the psychological needs of these children remain largely unrecognized.

The clinical manifestations of pediatric cervical spine injury may be diverse. Biedermann stated that a wide range of pediatric symptomatology may result from suboccipital strain. The disorders reported include fever of unknown origin, loss of appetite, sleeping disorders, asymmetric motor patterns, and alterations of posture. (7) Gutmann also discussed the diverse array of signs and symptoms which can occur as a result of biomechanical dysfunction in the cervical spine. (8) In the chiropractic literature, Glow published a paper addressing pediatric cervical acceleration/deceleration injuries. (9)

Minor brain injuries are much more common than was once perceived. In particular, the association of MTBI with CAD trauma has received increasing attention in the last several years (274,286,303,385-387). Attention has also been focused lately on the effect of MTBI on children (388-394). In one study (391) the authors followed children with brain injuries for 23 years and found that 31% continued to attribute physical, emotional, and intellectual problems to the original injury. In another study (392) it was discovered that children who had suffered a brain injury were 3.3 times more likely than controls to develop behavioral disorders, and that mean IQ scores were significantly lower in preschool aged children who had been injured.

MTBI as Risk for Brain Tumor?  In a recent report (1215), children who had previously been treated for brain injury were found to be more susceptible to the development of brain tumor (OR=1.4; 95% CI 1.0, 1.9). The relationship rose when LOC was added

to the calculation (OR=1.6; 95% CI 0.6, 3.9), and rose again when overnight hospital stay was used in the analysis (OR=1.7; 95% CI 0.7, 4.6). When the children had a birth injury and a subsequent brain injury the OR increased to 2.6 (95% CI 1.1, 6.9).

Lövsund et al. (69) more recently reported that children were at about 2/3 the risk of adults. The reader should also consider the unique risk for children posed by car seats and restraint systems that were designed for 50th percentile males (5'10") (148,149,162-171). A general problem in assessing risk to children is the fact that most studies have not included children.

Children are particularly prone to seat belt injury because neither the car seat nor the seat belt/shoulder harness was designed to fit them optimally. Numerous pediatric injuries have been reported and often the most serious are spinal injuries (148,149,162-171), with the most common lumbar injuries occurring at the L2-L4 segments during deceleration (frontal collisions) (170). Perhaps owing to the more elastic and pliable pediatric cervical spine, with its more horizontally oriented facet joints and undeveloped uncovertebral joints, spinal cord injuries may present without radiographic evidence of trauma, i.e. the SCIWORLA syndrome (spinal cord injury without radiographic abnormality) (175) hours or days after initial trauma. Some of these cases, although initially asymptomatic, end in paraplegia or quadriplegia. As a precaution, pediatric patients demonstrating the seat belt sign (visible bruising from the diagonal or horizontal belt webbing) or complaining of extremity pain should be evaluated carefully.

This would include peritoneal lavage or MRI. In recent reports, blunt intestinal trauma was found in 5-10% of pediatric MVC trauma; and in 64% of pediatric cases in which the seat belt sign is present (1351).

It has been reported that 80% of children are improperly restrained in vehicles (1440). This is due in part to a lack of knowledge on the part of parents as to what constitutes the optimal child seat/restraint system as well as a poor understanding of how to place and secure them properly. Following are recommendations for child seat systems (1440):

   1) Rear-facing seats, which include infant and convertible seats, are used from birth to one year and 9.07 kg (20 lb).   Forward-facing seats, which include 5-point harness, T-Shield, Tray-Shield, Toddler/Booster combinations, and Integrated   seats, are recommended for children over 1 year of age, weighing 9.07 to 18.1 kg (20 to 40 lb) and up to 101.6 cm (40 inches) or taller, as long as the child is comfortable.

  2)  Rear-facing convertible seats can be converted to forward facing seats. These include the 5-point harness, T-Shield or the Tray Shield.

  3) Toddler/Booster combinations are considered forward facing seats while the internal harness components are used. When the child reaches the weight limits for the internal harness, the harness is removed and the seat is used to boost the child high enough so the vehicle safety belt is positioned correctly. At this point this combination seat is considered a booster seat.

  4) Booster seats, belt positioning high or no back seat and shield booster seat (which is no longer recommended due to lack   of upper body protection), are designed for children 18.1 kg (40 lb) and over, up to 139.7 cm (4'7" or 55 inches) tall, and able to sit still and wear the lap/shoulder belt correctly (Safety Belt Safe, 2000). The correct seat type for a specific child cannot be determined based on age alone since children grow and develop at different rates. Weight, height and developmental stage must also be considered.

In conclusion, children involved in automobile accidents are often neglected in these types of injuries when in actuality; they suffer from the same symptoms and are at a greater risk for damages.

Most college libraries can provide copies of the papers featured in this column for a modest fee. Abstracts can be located through MEDLINEplus,  Armed with intellectual ammunition, Chiropractic Physicians providing services to Motor Vehicle Accident victims should have little difficulty supporting their position.

References

1.OrensteinJB, Klein BL, Gotschall CS, et al: "Age and outcome in pediatric cervical spine injury: 11-year experience." Pediatr Emerg Care (1994 Jun) 10(3):132.

2.Glass RE, Sivit CJ, Sturm PF, et al: Lumbar spine injury in a pediatric population: difficulties with computed tomographic diagnosis. J Trauma (1994 Nov) 37(5):815.

3.Racheskey I, Boyce WT, Duncan B, et al: "Clinical prediction of cervical spine injuries in children. Radiographic abnormalities." -Am J Dis Child (1987 Feb) 141(2):199.

4.Hill SA, Miller CA, Kosnik EJ, Hunt WE: "Pediatric neck injuries. A clinical study." J Neurosurg l984 Apd60(4):700.

5.Agran PF: "Motor vehicle occupant injuries in non-crash events." Pediatrics (1981-Jun) 67(6):838.

6.Roberts MA, Manshadi FF, Bushnell DL, Hines ME: "Neurobehavioral dysfunction following mild traumatic brain injury in childhood: a case report with positive findings on positron emission tomography (PET)." Brain Inj (1995 Jul) 9(5):427.

7.Biedermann H: "Kinematic imbalances due to suboccipital strain in newborns." Manual Medicine (1992) 6:151.

8.Gutmann G: "Blocked atlantal nerve syndrome in infants and small children." ICA Review (1990) 46(4):37.

9.Glow BJE: "Pediatric cervical acceleration/deceleration injuries." Journal of Clinical Chiropractic Pediatrics (Jan 1996) 1(1):36.

10. Drs. Christopher Kent, FCCI and Patrick Gentempo, Jr., "Children, car accidents and vertebral subluxation." The Chiropractic Journal (1996 Sept) 14.

69) Lövsund P, Nygren A, Salen B, Tingvall C: Neck injuries in rear end collisions among front and rear seat occupants. International IRCOBI Conference on the Biomechanics of Impacts, Bergisch-Gladbach, Germany, 319-325, 1988.

148) Johnson DL, Falci S: The diagnosis and treatment of pediatric lumbar spine injuries caused by rear seat lap belts.  Neurosurg 26(3):434-440, 1990.                                          

149) Reid AB, Letts RM, Black GB: Pediatric chance fractures: association with intra-abdominal injuries and seatbelt use.  J Trauma 30(4):384-391, 1990.

162) Williams N, Rose GK, Goodman AM: Lap-style seat belt associated with high cervical cord injury in a child. Injury 24(3):209-210, 1993.

163) Hoy GA, Cole WG: The pediatric cervical seat belt syndrome. Int J Care Injured 24(5):297-299, 1993.

164) Brennan FJ, Goff WB: Seat belt injury to a pelvic kidney as demonstrated by CT. J Comp Assist Tomography 17(4):664-665,  1993.

165) Taiwo B, Sloan J: Hand injury in a child--a rare adverse effect of rear seat belt use. Arch Emerg Med 8:147-149, 1991.

166) Ruta D, Beattie T, Narayan V: A prospective study of nonfatal childhood road traffic accidents: what can seat restraint achieve? J Pub Health Med 15(1):88-92, 1993.

167) Statter MB, Coran AG: Appendiceal transection in a child associated with a lap belt restraint: case report. J Trauma 33(5):765-766, 1992.

168) Glassman SD, Johnson JR, Holt RT: Seat belt injuries in children. J Trauma 33(6):882-886, 1992.

169) Osberg JS, Di Scala C: Morbidity among pediatric motor vehicle crash victims: the effectiveness of seat belts. Am J Pub Health 82(3):422-425, 1992.

170) Rumball K, Jarvis J: Seat belt injuries of the spine in young children. J Bone Joint Surg 74B(4):571-574, 1992.

171) Ebraheim NA, Savolaine ER, Southworth SR, et al.: Pediatric lumbar seat belt injuries. Orthopedics 14(9):1010-1013, 1991.

175) O'Neill MJ: Delayed-onset paraplegia from improper seat belt use. Ann Emerg Med 23(5):1123-1126, 1994.

274) Burke JP, Orton HP, West J, Strachan IM, et al.: Whiplash and its effect on the visual system. Graefe's Arch Clin Exp Opthalmol 230:335-339, 1992.

286) Goldstein J: Posttraumatic headache and the postconcussion syndrome. Med Clin N Amer 75(3):641-651 1991.

303) Hildingsson C, Wenngren B-I, Toolanen G: Eye motility after soft tissue injury of the cervical spine. Acta Orthop Scand 64(2):129-132, 1993.

385) Bohnen N, Jolles J, Vershey FRJ: Persistent neuropsychological deficits in cervical whiplash patients without direct headstrike. Acta Neurologica Belgica 93(1):23-31, 1993.

386) Radanov BP, Distefano GD, Schnidrig A, et al.: Cognitive functioning after common whiplash: a controlled follow-up study. Arch Neurol 50:87-91, 1993.

387) Packard RC: Posttraumatic headache: permanency and relationship to legal settlement. Headache 32(10):496-500, 1992.

388) Donders J: Memory functioning after traumatic brain injury in children. Brain Injury 7(5):431-437, 1993.

389) Jaffe KM, Fay GC, Polissar NL, et al.: Severity of pediatric traumatic brain injury and neurobehavioral recovery at one year—a cohort study. Arch Phys Med Rehab 74:587-595, 1993.

390) Lewis RJ, Yee L, Inkelis SH, et al.: Clinical predictors of posttraumatic seizures in children with head trauma. Ann Emerg Med 22(7):1114-1118, 1993.

391) Klonoff H, Clark C, Klonoff PS: Long-term outcome of head injuries: a 23 year follow-up study of children with head injuries. J Neurol Neurosurg Psychiat 56:410-415, 1993.

392) Michaud LJ, Rivara FP, Jaffe KM, et al.: Traumatic brain injury as a risk factor for behavioral disorders in children. Arch Phys Med Rehab 74:368-375, 1993.

393) Simpson DA, Blumbergs PC, McLean AJ, et al.: Head injuries and children: measures to reduce mortality and morbidity in road accidents. World J Surg 16:403-409, 1992.

394) Chaplin D, Deitz J, Jaffe KM: Motor performance in children after traumatic brain injury. Arch Phys Med Rehab 74:161-164, 1993.

1215) Gurney JG, Preston-Martin S, McDaniel AM, Meuller BA, Holly EA: Head injury as risk factor for brain tumors in children: results from a multicenter case-control study. Epidemiology 7:485-489, 1996.

1351) Klena JW, Kihara T, Graves C: Case study: correlation between the seat belt sign and positive abdominal computed tomography findings in pediatric trauma patients. J Crash Prevention and Injury Control 1(1):63-66, 1999.

1440) Stepanski BM, Ray LU, Nichols L: Booster seats: a community based study of installation and use by parents and caregivers. 45th Annual Proceedings of the Association for the Advancement of Automotive Medicine, San Antonio, TX,  September 24-26, 37-48, 2001.