Introduction
Short falls causing minor injury occur very frequently in infants and children. Long falls causing more serious injury are not rare. Serious inflicted injuries are often falsely attributed to short falls by the persons who inflicted them.
Bipedality is the quintessential characteristic of humans, and the bumps and bruises from the falls of infants and young children are part of the evolutionary price paid for this advantage. Falling is universal among children who are learning to walk. In addition, young children often climb to and fall from elevated surfaces. However, if such falls were often fatal, the human race would not have survived.
In the 1960s Kravitz studied infant falls by asking mothers about their children’s falls. In one study, he asked the parents of infants attending a clinic to recall the falls of their children aged 10 months to 2 years some months after the falls occurred. The other focused on 336 infants under 1 year of age, asking parents to describe falls soon after they happened. Both studies were of falls from elevated surfaces rather than ground level falls. Both groups demonstrated “peaks” of fall incidence around 6 to 8 months, but both found falls at all ages including at 1 month of age. During this study, 536 infants experienced 328 falls, and about half of all infants fell at least once. Eighteen infants were hospitalized and none died. Three infants had skull fractures, two had concussion, and one had a subdural hematoma. There were no extremity fractures. Kravitz stated that child abuse was not found in any of these cases, but he did not explain how it was excluded. The most frequent circumstance leading to a fall was climbing out of a crib, and Kravitz concluded that crib design was the most important correctible factor.
Warrington and Wright used the ongoing Avon Longitudinal Study of Parents and Children (ALSPAC) that had enrolled 14,000 newborn babies and their parents for prospective determination of their illnesses and injuries and associated risk factors. A questionnaire administered to all parents when the infants were 6 months of age inquired about falls and resultant injuries. Data were available for 11,466 infants; 2554 of them generated 3357 falls from “elevated places.” Falls from beds or settees comprised 53% of the falls, and 10% of the infants fell from someone’s arms. The rest fell from chairs, changing tables, prams, bouncers, and tables, and 5.6% “fell over” (a term not defined). An injury was sustained in 437 cases. Serious injury, defined as concussion or fracture, occurred in 21 cases (<1% of falls). Eighteen were admitted to hospital. No deaths or life-threatening injuries were reported, and the authors concluded that although falls in infants less than 6 months of age are “surprisingly common,” injuries were “… infrequent, generally trivial, and almost entirely confined to the head.”
Figure 59-1 captures sequential snapshots of a toddler’s fall recorded in a childcare center and demonstrates why the vast majority of ground level falls in this age group are benign. Short falls have been shown to result in minor trauma such as bruising, linear parietal skull fractures, and clavicle or extremity fractures, but fatal injuries from short falls are extremely rare.
A rational discussion of injury mechanisms requires the use of standard definitions. Definitions have been provided by the work of Christoffel, the ICD-9, ICD-10, and other sources. The definitions used are found in Table 59-1 .
| Elevated surface | A surface above ground or floor level |
| Fall | To come down by force of gravity suddenly (noun or verb). |
| Fall height | The change in height of the center of gravity of the falling object from the starting point to the ending point of the fall (In practice, usually the height of an elevated surface from the floor or the ground) |
| Ground level fall | A fall beginning and ending at ground level usually from standing to prone, supine, or sitting position |
| Infants | Persons at ages between birth and the first birthday |
| Injury | 1. An event resulting in damage to a body part; 2. The damage or pathology resulting from an event |
| Intentional injury | Injuries that were intended to injure a person (i.e., assaults, homicides, self-inflicted injuries, and suicides) |
| Long fall | A fall of >1.5 meters |
| Nonaccidental injury | An injury inflicted by other than accidental means often without clear intent to cause injury |
| Outcome | The status of a case at an advanced or ultimate point |
| Point of recognition | The point in a case at which a health professional has a “reasonable suspicion” that the child with an injury and a fall history might be injured by “other than accidental means” |
| Short fall | A fall of <1.5 meters (includes falls from all household furniture items except bunk beds) |
| Young children | Persons between birth and the fifth birthday |
Types of Fall Injuries
Head Injuries with Fall Histories
Most children with life-threatening head injuries present with impaired consciousness and sometimes altered breathing or full arrest. In some cases, the child is dead at the scene or on arrival at the hospital. This chapter applies to those children who survive long enough to reach a setting in which a thorough medical evaluation is possible. Many children with head injury from falls have obvious head bruising, but many do not. Certain patterns of bruising, however, would be unlikely to have been caused by a fall and should alert the clinician to the possibility of abuse. Figure 59-2 (found in Chapter 59 Supplemental Resources online at www.expertconsult.com ) shows such an injury.
Complex and diastatic skull fractures (see Figure 59-3 online) have not been reported in association with short falls in observed settings such as hospitals. Their presence indicates that a major force was involved in the injury event. Initial presentation with obvious severe injury and a minimal event history is typical of inflicted head injury.
One type of serious cranial injury that is well known to be caused by short falls is the epidural hematoma (see Figure 59-4 online). A laceration of an artery can cause bleeding between the dura and the skull, leading to the rapid accumulation of a large, space-occupying hematoma. This can cause life-threatening increased intracranial pressure and deep coma or death. Epidural hematomas are easily recognized on CT scans and can be successfully treated if surgery is performed quickly after diagnosis. In some cases, the epidural hematoma will communicate through a skull fracture with a subgaleal hematoma.
Abdominal Injuries with Fall Histories
Life-threatening abdominal injuries, usually present in one of two ways: (1) hypovolemic shock, which can occur shortly after injury, or (2) sepsis and peritonitis, which occur hours or days after an injury perforating a hollow viscus. There may or may not be bruising present on the abdominal skin. Sometimes bruising on the back over spinous processes provides a clue that the child was injured by deep indenting blunt trauma to the abdomen while lying on the back on a firm surface (see Figure 59-5 online).
Recognition of abdominal injury as a cause of otherwise unexplained hypovolemic shock requires experience and a high index of suspicion on the part of the physician. In these cases, shock results from blood loss into the peritoneal cavity from damaged viscera or blood vessels. Clinicians might be misled by short fall histories that do not predict life-threatening injury, and the abdomen can be soft. Children with serious intraabdominal bleeding can look fairly normal for a time and then deteriorate very quickly. Several useful articles discuss evaluating possibly inflicted abdominal injuries. Short falls of previously healthy infants and young children are extremely unlikely to cause life-threatening abdominal injuries.
Chest Injuries with Fall Histories
Unexplained healing rib fractures are sometimes found on skeletal surveys obtained in infants and toddlers who are being evaluated for possible child abuse (see Figure 59-6 online). Posterior and lateral rib fractures, pulmonary contusions, and hemothoraces are more likely to be caused by child abuse rather than falls, although complex falls and falls from heights can also cause these conditions. Rarely, infants and children present with cardiac injuries such as hemopericardium, again a finding not likely to occur in a household fall and more often found in inflicted injuries. There is a single case report of ventricular fibrillation (commotio cordis) following a fall. The condition is difficult to diagnose in living children and almost impossible after death in the absence of an accurate history.
Less Serious Injuries
Fractures of the extremities and linear parietal skull fractures occur infrequently (in about 1%) in the short falls that have been witnessed by multiple people in hospitals. Other minor and moderate injuries, including concussion, , are often associated with less reliable short fall histories. Pierce et al has provided an algorithm for the analysis of femur fractures occurring in association with short fall histories. It focuses the criteria suggested by Leventhal et al. The algorithm points out that “… differences exist in 4 key categories: (1) history quality and detail; (2) biomechanical compatibility of the fracture morphologic features; (3) time line for seeking medical care; and, (4) presence of other injuries.”
The widespread use of definitions of abusive injury, which require that the injuries be severe in relationship to their explanations, has created an epidemiological anomaly. It has resulted in an apparent high case fatality rate for abusive as compared with unintentional injury. It is important to improve the recognition of minor and moderate inflicted physical injuries, because the affected children are likely to be at risk for future, more serious, injury.
Recognition and Reporting
The “point of recognition” is that point in the case at which a health professional has a reasonable suspicion that the child with an injury and a fall history might be injured by “other than accidental means.” At this point a report is usually made to a child protection agency. From that point forward the process of medical assessment requires confirming or excluding that diagnosis. The point can occur as early as the first health care contact or as late as at autopsy or during an even later review by a child fatality review team. In most cases, the parents or guardians of the child should be informed that a report has been made and that an investigation will probably follow. Reporting suspected abuse is mandatory in all states, although details may vary. There can be criminal sanctions and civil liability for failure to report suspected abuse.
“Points of recognition” are not unique to inflicted or abusive injuries. They occur in any medical condition, when the physician becomes aware that the facts in the case require one or more serious conditions to be diagnosed or excluded as soon as possible. However, in cases of suspected abuse when a report is made to an agency, the caretakers who are providing histories of the events leading up to the child’s change of condition may adopt attitudes aimed at protecting themselves and alter the histories that they provide.
Is It a Fall or Is It Abuse? Assessing the Child
The initial clinical assessment of the child presenting to the emergency department with the history of a fall begins by rapidly assessing the injury and medically stabilizing the child before further evaluation is undertaken. Once the child is stabilized and assessed, the process of differentiating among nonintentional trauma, abuse, or neglect begins. A complete description of the appropriate medical workup for a child presenting with the history of a fall when possible child physical abuse or neglect is being considered can be found in Chapter 59 Supplemental Resources online at www.expertconsult.com .
Radiological Imaging
Radiological imaging, including CT, is helpful in determining the types and severity of injury and is warranted in cases in which the physical examination is unreliable because of patient age, presence of other injuries that may obfuscate the physical examination, or the presence of nonspecific signs or symptoms that could be indicative of head injury. , (See Chapter 46, “Biochemical Markers of Head Trauma in Children” ; Chapter 33, “Imaging of Skeletal Trauma in Abused Children” ; Chapter 34, “The Role of Cross-Sectional Imaging in Evaluating Pediatric Skeletal Trauma” ; and Chapter 35, “Long Bone Fracture Biomechanics.” )
Consultations
Consultations and involvement of pediatric subspecialists in the diagnostic workup, medical management, and appropriate documentation of these cases vary significantly depending on several factors including the severity of the injury, the type of injury, the age of the child, and the examination findings. Many institutions now have multidisciplinary medical/surgical teams to efficiently manage these potentially complex cases with the associated medical, psychological, social, and legal implications.
Differential Diagnosis
When considering whether an injury is caused by a fall or by abuse, several characteristics of the injury and the event will give the clinician important information. Table 59-2 outlines these characteristics of injuries.
| Body Region/Injury Type | Relationship to Abuse | Differential Diagnosis |
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| Genitals/Anus |
| Straddle injuries can mimic abuse. |
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