JBJS | Article

The Journal of Bone & Joint Surgery, Volume 82, Issue 6

The Orthopaedic Forum | June 01, 2000

Orthopaedic Injuries in Children Secondary to Airbag Deployment*

Charles T. Mehlman, D.O., M.P.H.; Kenneth A. Scott, D.O., M.B.A.; Bernadette L. Koch, M.D.; Victor F. Garcia, M.D.

Investigation performed at the Departments of Pediatric Orthopaedic Surgery, Pediatric Radiology, and Pediatric Trauma/General Surgery, Children's Hospital Medical Center, Cincinnati, University of Cincinnati College of Medicine, Cincinnati, Ohio
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
Children's Hospital Medical Center, Cincinnati, 3333 Burnet Avenue, Cincinnati, Ohio 45229-3039.

The Journal of Bone & Joint Surgery. 2000; 82:895-895

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Introduction

Introduction | Case Report | Conclusions | References

In recent years, airbag deployment has become recognized as a substantial contributor to vehicular-related trauma in children^1,32,37. Particular attention has been focused on the mortality associated with these devices, with children younger than the age of ten years having a 34 percent higher risk of dying if they are passengers in a frontal motor-vehicle accident when dual airbags are present². However, there have been very few reports concerning orthopaedic injuries in children secondary to airbag deployment and, to the best of our knowledge, none concerning extremity injuries in nonfatally injured children.

Airbag patents were first issued in the 1950s, but the technology lay dormant for virtually thirty years²³. In 1987, Federal Motor Vehicle Standard 208, Occupant Crash Protection, stating that airbags should be fitted in combination with three-point seat belts in all passenger automobiles, trucks, and vans, was released in the United States²⁴. A second federal mandate, in 1991, required airbag installation in all new automobiles by the beginning of model year 1998 and in all new light trucks by model year 1999²³. Currently, more than fifty-six million vehicles have driver-side airbags and nearly twenty-seven million have additional front-passenger-side airbags.

Frontal impact in the range of about eight to fourteen miles (12.9 to 22.5 kilometers) per hour or greater will trigger airbag deployment^23,27. Any of up to five sensors located in the front-bumper region send electrical signals that ignite a sodium azide propellant. The combustion of the propellant liberates nitrogen gas, carbon dioxide, and an alkaline aerosol. The airbag inflates within fifty milliseconds of impact to cushion the passenger. This rapid series of events requires an inflation rate of about 150 to 200 miles (241.4 to 321.9 kilometers) per hour^23,24.

Airbag-generated gas and debris have been shown to cause chemical irritation and burns in both adults and children who are crash victims. The impact of the rapidly inflating nylon fabric bag and the airbag module cover is thought to be the cause of the remainder of airbag injuries^21,33. Most reports of nonfatal airbag injury have focused on soft-tissue trauma, ocular injury, facial burns, and orbital fracture^11,15,33,38. On review of published reports of fatally injured children, the only orthopaedic injuries that we could identify were cervical spine injury and decapitation^5,9,11,21,39. Cervical spine injury also has been reported in several nonfatally injured children^9,25. To the best of our knowledge, the current report is the first to describe airbag-related extremity injuries in a child who survived a collision.

Although adults are becoming increasingly more accustomed to wearing seat belts, it is alarming that 40 percent of children traveling in motor vehicles are unrestrained³⁵. Even when a child safety seat is used, it is used improperly up to 80 percent of the time^10,35. Review of the 1996 statistics revealed that 1701 children younger than fifteen years of age died as passengers in motor-vehicle collisions²⁸. The National Highway Traffic Safety Administration (NHTSA) reported that 55 percent of children who were involved in these fatal collisions were completely unrestrained²⁸. NHTSA also reported that only two of thirty-two fatal injuries caused by airbag deployment from January 1993 to November 1996 were sustained by children who were properly restrained in the front seat by lap and shoulder belts^26-28. The recent guidelines released by NHTSA (see Table) were prompted by reports of airbag injuries to children and emphasize that all children of any age should be properly secured in the back seat^26-28.

Airbags have substantially reduced the adult mortality risk for both drivers and right-front-seat passengers^13,17,22,36. Driver fatalities have been reduced 28 percent since the introduction of airbags³¹. It has been estimated that passenger fatalities were 18 percent lower in automobiles equipped with airbags². High-speed adult fatalities are reduced, but children are at increased risk in low-speed collisions that result in airbag deployment. Airbag injuries have been reported in 43 percent of all deployments⁷. While most of these injuries are minor in adults, the injuries sustained by children are more severe and have a higher potential to be fatal^7,10,19. Numerous studies have shown that children traveling in the rear seat who are properly restrained have the best chance for survival^2,6. Despite legislation and public-service announcements regarding child-passenger safety, it is estimated that more than 30 percent of children involved in fatal crashes were riding in the front seat of the vehicle².

The first adult airbag-related fatalities were reported in the early 1990s¹⁶. Since that time, deaths of children due to airbag deployment have been frequently reported^{4,5,11,19,21,25,33,39}. The occurrence of airbag-associated deaths of children has paralleled the number of vehicles with passenger-side airbags^26-28. This statistic could rise as more vehicles are equipped with passenger-side airbags. Nonfatal injuries (including orthopaedic injuries) also have begun to receive greater attention.

Orthopaedic injuries due to airbag deployment have been reported widely in adults^{3,8,12,14,18,20,29,30}, but these reports have focused almost exclusively on upper-extremity fractures. Several nonfatal cervical spine injuries have been reported in children, but we were unable to identify any previous reports of airbag-related extremity injuries in children^9,25.

We studied the case history of a child who sustained serious orthopaedic injuries of the upper extremity in association with a nonfatal airbag deployment. The child was reported to have been a restrained front-seat passenger.

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Fig. 1-A:: Figs. 1-A and 1-B: Plain radiographs showing the lateral condyle fracture of the distal aspect of the left humerus.
Fig. 1-A: Anteroposterior radiograph showing the classic metaphyseal fragment (Thurston-Holland fragment [arrow]) accompanying the injury.

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Fig. 1-B:: Lateral radiograph demonstrating the fracture (long arrows) as well as joint effusion (short arrows).

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Fig. 2-A:: Figs. 2-A and 2-B: Magnetic resonance images showing the injury of the left brachial plexus.
Fig. 2-A: Coronal T2-weighted image demonstrating deviation of the lower cervical cord to the right as well as a pseudomeningocele (arrow) at the left seventh cervical level, consistent with nerve-root avulsion.

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Fig. 2-B:: Axial T2-weighted image showing edema in the left supraclavicular soft tissues (long arrows), fluid collection adjacent to the left cervical neural foramina (arrowhead), cord deviation to the right, and a pseudomeningocele (open arrow) at the left seventh cervical level.

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Table I: National Highway Traffic Safety Administration Guidelines Regarding Airbags and Children26

l Highway Traffic Safety Administration Guidelines Regarding Airbags and Children26

1. The back seat is the safest place for children of any age to ride.

2. Never put an infant (less than one year old) in the front of a car with a passenger-side airbag.

3. Infants must always ride in the back seat, facing the rear of the car.

4. Make sure everyone is buckled up. Unbuckled occupants can be hurt or killed by an airbag.

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Table I: National Highway Traffic Safety Administration Guidelines Regarding Airbags and Children26

l Highway Traffic Safety Administration Guidelines Regarding Airbags and Children26

1. The back seat is the safest place for children of any age to ride.

2. Never put an infant (less than one year old) in the front of a car with a passenger-side airbag.

3. Infants must always ride in the back seat, facing the rear of the car.

4. Make sure everyone is buckled up. Unbuckled occupants can be hurt or killed by an airbag.

Case Report

Introduction | Case Report | Conclusions | References

A three-year and eleven-month-old girl weighing nineteen kilograms was a restrained front-seat passenger in a 1995 Ford Taurus that was involved in a head-on collision with another vehicle. The estimated speed of impact was thirty miles (48.3 kilometers) per hour. The passenger-side airbag of the automobile deployed on impact, resulting in a minimally displaced lateral condyle fracture of the distal aspect of the left humerus as well as a severe injury of the left brachial plexus. Additional injuries included a right infraorbital blow-out fracture, a right retinal hemorrhage, a small tentorial subarachnoid hemorrhage, and superficial abrasions and burns about the head and neck.

The fracture of the lateral condyle (Fig. 1-A and Fig. 1-B) healed uneventfully with closed, nonoperative care. Physical examination of the left brachial plexus was remarkable for evidence of Horner syndrome, a complete absence of left upper-extremity motor function, and left upper-extremity sensory function that was detectable only within the fourth cervical and first thoracic dermatomes. Magnetic resonance images (Fig. 2-A and Fig. 2-B), made with a repetition time of 5000 milliseconds, an echo time of 126 milliseconds, and two excitations, revealed pseudomeningocele formation from the fourth cervical to the first thoracic nerve root, with evidence of avulsions of the fifth through eighth cervical nerve roots. An electromyogram confirmed these preganglionic lesions of the left brachial plexus.

A pediatric neurosurgical consultation was obtained for the purpose of primary operative repair of the avulsed nerve roots. The left brachial plexus was surgically explored and declared irreparable.

At the two-year follow-up evaluation, the child had not recovered any function of the left upper extremity. The injuries about the head and neck all healed without clinically important sequelae.

Conclusions

Introduction | Case Report | Conclusions | References

The front seat of an automobile is a dangerous place for children who are younger than the age of twelve years^10,19,21. In fact, it has been found that "the rear seat is intrinsically safer than the front seat for an occupant of any age."¹⁰ The main concern is for front-seat child passengers involved in low-velocity accidents that, in the absence of an airbag, would cause little or no harm. Automobile protection systems that monitor seat-belt use, as well as restraint systems that automatically deactivate on the basis of the weight of the seat's occupant, are just starting to become available on a limited basis. The future development of so-called smart airbags that will not deploy if a child is present, as well as shutoff switches, may help to negate the front-seat airbag hazard for children³⁴. Such devices may be advantageous in certain settings, such as vehicles without back seats. Until that time, universal observance of existing airbag precautions for children is necessary. Otherwise, as the number of airbag-equipped automobiles in this country increases, we will undoubtedly see both more numerous and more serious orthopaedic injuries in children.

Note: The authors would like to acknowledge the assistance of Chana White, Pediatric Orthopaedic Society, in the preparation of this manuscript.

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