Biomechanics of the toddler head during low-height falls: an anthropomorphic dummy analysis

Laboratory investigation

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  • Department of Bioengineering, The University of Pennsylvania, Philadelphia, Pennsylvania
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Object

Falls are the most common environmental setting for closed head injuries in children between 2 and 4 years of age. The authors previously found that toddlers had fewer skull fractures and scalp/facial soft-tissue injuries, and more frequent altered mental status than infants for the same low-height falls (≤3 ft).

Methods

To identify potential age-dependent mechanical load factors that may be responsible for these clinical findings, the authors created an instrumented dummy representing an 18-month-old child using published toddler anthropometry and mechanical properties of the skull and neck, and they measured peak angular acceleration during low-height falls (1, 2, and 3 ft) onto carpet pad and concrete. They compared these results from occiput-first impacts to previously obtained values measured in a 6-week-old infant dummy.

Results

Peak angular acceleration of the toddler dummy head was largest in the sagittal and horizontal directions and increased significantly (around 2-fold) with fall height between 1 and 2 ft. Impacts onto concrete produced larger peak angular accelerations and smaller impact durations than those onto carpet pad. When compared with previously measured infant drops, toddler head accelerations were more than double those of the infant from the same height onto the same surface, likely contributing to the higher incidence of loss of consciousness reported in toddlers. Furthermore, the toddler impact forces were larger than those in the infant, but because of the thicker toddler skull, the risk of skull fracture from low-height falls is likely lower in toddlers compared with infants.

Conclusions

If similar fracture limits and brain tissue injury thresholds between infants and toddlers are assumed, it is expected that for impact events, the toddler is likely less vulnerable to skull fracture but more vulnerable to neurological impairment compared with the infant.

Abbreviations used in this paper: CRABI = child restraint air bag interaction; HIC = head injury criterion; HIC15 = HIC with a maximum time interval of 15 msec; HIC36 = HIC with a maximum time interval of 36 msec.

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Contributor Notes

Address correspondence to: Susan S. Margulies, Ph.D., Department of Bioengineering, The University of Pennsylvania, 240 Skirkanich Hall, 210 South 33rd Street, Philadelphia, Pennsylvania 19104-6321. email: margulie@seas.upenn.edu.
  • 1

    Adeloye A, , Kattan KR, & Silverman FN: Thickness of the normal skull in the American Blacks and Whites. Am J Phys Anthropol 43:2330, 1975

    • Search Google Scholar
    • Export Citation
  • 2

    Agran PF, , Anderson C, , Winn D, , Trent R, , Walton-Haynes L, & Thayer S: Rates of pediatric injuries by 3-month intervals for children 0 to 3 years of age. Pediatrics 111:e683e692, 2003

    • Search Google Scholar
    • Export Citation
  • 3

    Aisenson MR: Closing of the anterior fontanelle. Pediatrics 6:223226, 1950

  • 4

    Anderson RN, , Minino AM, , Fingerhut LA, , Warner M, & Heinen MA: Deaths: Injuries, 2001. National Vital Statistics Report Hyattsville, MD, National Center for Health Statistics, 52:21 2004. (http://www.cdc.gov/nchs/data/nvsr/nvsr52/nvsr52_21acc.pdf) [Accessed April 1, 2010]

    • Search Google Scholar
    • Export Citation
  • 5

    Bagnall KM, , Harris PF, & Jones PR: A radiographic study of the human fetal spine. 1. The development of the secondary cervical curvature. J Anat 123:777782, 1977

    • Search Google Scholar
    • Export Citation
  • 6

    Bagnall KM, , Harris PF, & Jones PR: A radiographic study of the human fetal spine. 2. The sequence of development of ossification centres in the vertebral column. J Anat 124:791802, 1977

    • Search Google Scholar
    • Export Citation
  • 7

    Bertocci GE, , Pierce MC, , Deemer E, , Aguel F, , Janosky JE, & Vogeley E: Influence of fall height and impact surface on biomechanics of feet-first free falls in children. Injury 35:417424, 2004

    • Search Google Scholar
    • Export Citation
  • 8

    Bertocci GE, , Pierce MC, , Deemer E, , Aguel F, , Janosky JE, & Vogeley E: Using test dummy experiments to investigate pediatric injury risk in simulated short-distance falls. Arch Pediatr Adolesc Med 157:480486, 2003

    • Search Google Scholar
    • Export Citation
  • 9

    Chadwick DL, , Bertocci G, , Castillo E, , Frasier L, , Guenther E, & Hansen K, : Annual risk of death resulting from short falls among young children: less than 1 in 1 million. Pediatrics 121:12131224, 2008

    • Search Google Scholar
    • Export Citation
  • 10

    Chadwick DL, , Chin S, , Salerno C, , Landsverk J, & Kitchen L: Deaths from falls in children: how far is fatal?. J Trauma 31:13531355, 1991

  • 11

    Chang LT, & Tsai MC: Craniofacial injuries from slip, trip, and fall accidents of children. J Trauma 63:7074, 2007

  • 12

    Coats B: Mechanics of head impact in infants. Bioengineering [dissertation] Philadelphia, University of Pennsylvania, 2007

  • 13

    Coats B, & Margulies SS: Material properties of human infant skull and suture at high rates. J Neurotrauma 23:12221232, 2006

  • 14

    Coats B, & Margulies SS: Potential for head injuries in infants from low-height falls. Laboratory investigation. J Neurosurg Pediatr 2:321330, 2008

    • Search Google Scholar
    • Export Citation
  • 15

    Cory CZ, & Jones MD: Development of a simulation system for performing in situ surface tests to assess the potential severity of head impacts from alleged childhood short falls. Forensic Sci Int 163:102114, 2006

    • Search Google Scholar
    • Export Citation
  • 16

    Deemer E, , Bertocci G, , Pierce MC, , Aguel F, , Janosky J, & Vogeley E: Influence of wet surfaces and fall height on pediatric injury risk in feet-first freefalls as predicted using a test dummy. Med Eng Phys 27:3139, 2005

    • Search Google Scholar
    • Export Citation
  • 17

    Dekaban AS: Changes in brain weights during the span of human life: relation of brain weights to body heights and body weights. Ann Neurol 4:345356, 1978

    • Search Google Scholar
    • Export Citation
  • 18

    Demetriades D, , Murray J, , Brown C, , Velmahos G, , Salim A, & Alo K, : High-level falls: type and severity of injuries and survival outcome according to age. J Trauma 58:342345, 2005

    • Search Google Scholar
    • Export Citation
  • 19

    Egan JP: Signal Detection Theory and ROC-Analysis New York, Academic Press, 1975

  • 20

    Eppinger RH, , Sun E, , Bandak FA, , Haffner M, , Khaewpong N, & Maltese MR, : Development of Improved Injury Criteria for the Assessment of Advance Automotive Restraint Systems— II Washington, DC, National Highway Traffic Safety Administration, 2000

    • Search Google Scholar
    • Export Citation
  • 21

    Federal Motor Vehicle Safety Standards: Occupant Crash Protection Washington, DC, National Highway Traffic Safety Administration, NHTSA publication 2000-7013-1, 2000

    • Search Google Scholar
    • Export Citation
  • 22

    Galford JE, & McElhaney JH: A viscoelastic study of scalp, brain, and dura. J Biomech 3:211221, 1970

  • 23

    Gruskin KD, & Schutzman SA: Head trauma in children younger than 2 years: are there predictors for complications?. Arch Pediatr Adolesc Med 153:1520, 1999

    • Search Google Scholar
    • Export Citation
  • 24

    Hall JR, , Reyes HM, , Horvat M, , Meller JL, & Stein R: The mortality of childhood falls. J Trauma 29:12731275, 1989

  • 25

    Hennrikus WL, , Shaw BA, & Gerardi JA: Injuries when children reportedly fall from a bed or couch. Clin Orthop Relat Res 407 148151, 2003

  • 26

    Holsti M, , Kadish HA, , Sill BL, , Firth SD, & Nelson DS: Pediatric closed head injuries treated in an observation unit. Pediatr Emerg Care 21:639644, 2005

    • Search Google Scholar
    • Export Citation
  • 27

    Hubbard RP, , Melvin JW, & Barodawala IT: Flexure of cranial sutures. J Biomech 4:491496, 1971

  • 28

    Ibrahim NG: Head injury biomechanics in toddlers: integrated clinical, anthropomorphic dummy, animal and finite element model studies. Bioengineering [dissertation] Philadelphia, University of Pennsylvania, 2009

    • Search Google Scholar
    • Export Citation
  • 29

    Irwin AL, & Mertz HJ: Biomechanical bases for the CRABI and HYBRID III child dummies. Proceedings of the 41st Stapp Car Crash Conference Warrendale, PA, Society of Automotive Engineers, 1997

    • Search Google Scholar
    • Export Citation
  • 30

    Johnson K, , Fischer T, , Chapman S, & Wilson B: Accidental head injuries in children under 5 years of age. Clin Radiol 60:464468, 2005

  • 31

    Kapoor T, , Altenhof W, , Howard A, , Rasico J, & Zhu F: Methods to mitigate injury to toddlers in near-side impact crashes. Accid Anal Prev 40:18801892, 2008

    • Search Google Scholar
    • Export Citation
  • 32

    Kim KA, , Wang MY, , Griffith PM, , Summers S, & Levy ML: Analysis of pediatric head injury from falls. Neurosurg Focus 8:1 e3, 2000

  • 33

    Kleinberger M, , Sun E, , Eppinger R, , Kuppa S, & Saul R: Development of Improved Injury Criteria for the Assessment of Advanced Automotive Restraint Systems Washington, DC, National Highway Traffic Safety Administration, 1998

    • Search Google Scholar
    • Export Citation
  • 34

    Koenig WJ, , Donovan JM, & Pensler JM: Cranial bone grafting in children. Plast Reconstr Surg 95:14, 1995

  • 35

    Kriewall TJ, , McPherson GK, & Tsai AC: Bending properties and ash content of fetal cranial bone. J Biomech 14:7379, 1981

  • 36

    Lallier M, , Bouchard S, , St-Vil D, , Dupont J, & Tucci M: Falls from heights among children: a retrospective review. J Pediatr Surg 34:10601063, 1999

    • Search Google Scholar
    • Export Citation
  • 37

    Lehman D, & Schonfeld N: Falls from heights: a problem not just in the northeast. Pediatrics 92:121124, 1993

  • 38

    Levene S, & Bonfield G: Accidents on hospital wards. Arch Dis Child 66:10471049, 1991

  • 39

    Lyons TJ, & Oates RK: Falling out of bed: a relatively benign occurrence. Pediatrics 92:125127, 1993

  • 40

    Macgregor DM: Injuries associated with falls from beds. Inj Prev 6:291292, 2000

  • 41

    Margulies SS, & Thibault KL: Infant skull and suture properties: measurements and implications for mechanisms of pediatric brain injury. J Biomech Eng 122:364371, 2000

    • Search Google Scholar
    • Export Citation
  • 42

    McPherson GK, & Kriewall TJ: The elastic modulus of fetal cranial bone: a first step towards an understanding of the biomechanics of fetal head molding. J Biomech 13:916, 1980

    • Search Google Scholar
    • Export Citation
  • 43

    Murray JA, , Chen D, , Velmahos GC, , Alo K, , Belzberg H, & Asensio JA, : Pediatric falls: is height a predictor of injury and outcome?. Am Surg 66:863865, 2000

    • Search Google Scholar
    • Export Citation
  • 44

    Nightingale RW, , Winkelstein BA, , Knaub KE, , Richardson WJ, , Luck JF, & Myers BS: Comparative strengths and structural properties of the upper and lower cervical spine in flexion and extension. J Biomech 35:725732, 2002

    • Search Google Scholar
    • Export Citation
  • 45

    Nimityongskul P, & Anderson LD: The likelihood of injuries when children fall out of bed. J Pediatr Orthop 7:184186, 1987

  • 46

    Nuckley DJ, & Ching RP: Developmental biomechanics of the cervical spine: tension and compression. J Biomech 39:30453054, 2006

  • 47

    Nuckley DJ, , Eck MP, , Carter JW, & Ching RP: Spinal maturation affects vertebral compressive mechanics and vBMD with sex dependence. Bone 35:720728, 2004

    • Search Google Scholar
    • Export Citation
  • 48

    Nyquist GW, , Cavanaugh JM, , Goldberg SJ, & King AI: Facial impact tolerance and response. Proceedings of the 30th Stapp Car Crash Conference San Diego, CA, Society of Automotive Engineers, 1986

    • Search Google Scholar
    • Export Citation
  • 49

    Oehmichen M, , Meissner C, & Saternus KS: Fall or shaken: traumatic brain injury in children caused by falls or abuse at home—a review on biomechanics and diagnosis. Neuropediatrics 36:240245, 2005

    • Search Google Scholar
    • Export Citation
  • 50

    Ommaya A, , Faas F, & Yarnell P: Whiplash injury and brain damage: an experimental study. JAMA 204:285289, 1968

  • 51

    Ommaya AK, & Hirsch AE: Tolerances for cerebral concussion from head impact and whiplash in primates. J Biomech 4:1321, 1971

  • 52

    Ommaya AK, , Hirsch AE, & Martinez J: The role of ‘whiplash’ in cerebral concussion. Proceedings of the 10th Stapp Car Crash Conference New York, Society of Automotive Engineers, 1966. 191203

    • Search Google Scholar
    • Export Citation
  • 53

    Ommaya AK, , Rockoff SD, & Baldwin M: Experimental concussion; a first report. J Neurosurg 21:249265, 1964

  • 54

    Ommaya AK, , Yarnell P, , Hirsch AE, & Harris EH: Scaling of experimental data on cerebral concussion in sub-human primates to concussion threshold for man. Proceedings of 11th Stapp Car Crash Conference Los Angeles, CA, Society of Automotive Engineers, 1967. 7380

    • Search Google Scholar
    • Export Citation
  • 55

    Ouyang J, , Zhu Q, , Zhao W, , Xu Y, , Chen W, & Zhong S: Biomechanical assessment of the pediatric cervical spine under bending and tensile loading. Spine 30:E716E723, 2005

    • Search Google Scholar
    • Export Citation
  • 56

    Park SH, , Cho BM, & Oh SM: Head injuries from falls in preschool children. Yonsei Med J 45:229232, 2004

  • 57

    Pellman EJ, , Viano DC, , Tucker AM, , Casson IR, & Waeckerle JF: Concussion in professional football: reconstruction of game impacts and injuries. Neurosurgery 53:799814, 2003

    • Search Google Scholar
    • Export Citation
  • 58

    Phelan KJ, , Khoury J, , Kalkwarf HJ, & Lanphear BP: Trends and patterns of playground injuries in United States children and adolescents. Ambul Pediatr 1:227233, 2001

    • Search Google Scholar
    • Export Citation
  • 59

    Pincemaille Y, , Trosseille X, , Mack P, , Brun-Cassan F, , Tarriere C, & Renault B, : Investigation of Relationships Between Physical Parameters and Neurophysiological Response to Head Impact. Final Report Washington, DC, DOT contract DTRS-57-86-C-00037, 1988

    • Search Google Scholar
    • Export Citation
  • 60

    Pintar FA, , Mayer RG, , Yoganandan N, & Sun E: Child neck strength characteristics using an animal model. Stapp Car Crash J 44:7783, 2000

  • 61

    Pitone ML, & Attia MW: Patterns of injury associated with routine childhood falls. Pediatr Emerg Care 22:470474, 2006

  • 62

    Prange MT: Biomechanics of traumatic brain injury in the infant. Bioengineering [disseration] Philadelphia, University of Pennsylvania, 2002

    • Search Google Scholar
    • Export Citation
  • 63

    Prange MT, , Coats B, , Duhaime AC, & Margulies S: Anthropomorphic simulations of falls, shakes, and inflicted impacts in infants. J Neurosurg 99:143150, 2003

    • Search Google Scholar
    • Export Citation
  • 64

    Prange MT, & Margulies SS: Regional, directional, and age-dependent properties of the brain undergoing large deformation. J Biomech Eng 124:244252, 2002

    • Search Google Scholar
    • Export Citation
  • 65

    Reed MP, , Ebert SM, , Sherwood CP, , Klinich KD, & Manary MA: Evaluation of the static belt fit provided by belt-positioning booster seats. Accid Anal Prev 41:598607, 2009

    • Search Google Scholar
    • Export Citation
  • 66

    Rivara FP, , Alexander B, , Johnston B, & Soderberg R: Population-based study of fall injuries in children and adolescents resulting in hospitalization or death. Pediatrics 92:6163, 1993

    • Search Google Scholar
    • Export Citation
  • 67

    Root I: Head injuries from short distance falls. Am J Forensic Med Pathol 13:8587, 1992

  • 68

    Sances A Jr: Biomechanical analysis of injury criterion for child and adult dummies. Crit Rev Biomed Eng 28:213217, 2000

  • 69

    Schneider LW, , Lehman RL, , Pflug MA, & Owings CL: Size and Shape of the Head and Neck From Birth to Four Years Ann Arbor, MI, The University of Michigan, 1986

    • Search Google Scholar
    • Export Citation
  • 70

    Sherwood CP, , Shaw CG, , Van Rooij L, , Kent RW, , Crandall JR, & Orzechowski KM, : Prediction of cervical spine injury risk for the 6-year-old child in frontal crashes. Traffic Inj Prev 4:206213, 2003

    • Search Google Scholar
    • Export Citation
  • 71

    Smith GA, , Dietrich AM, , Garcia CT, & Shields BJ: Injuries to children related to shopping carts. Pediatrics 97:161165, 1996

  • 72

    Snyder RG, , Schneider LW, , Owings CL, , Reynolds HM, , Golomb DH, & Schork MA: Anthropometry of Infants, Children and Youths to Age 18 for Product Safety Design. Final Report, May 31, 1977 Ann Arbor, MI, Highway Safety Research Institute, 1977. (http://mreed.umtri.umich.edu/mreed/downloads/anthro/child/Snyder_1977_Child.pdf) [Accessed March 25, 2010]

    • Search Google Scholar
    • Export Citation
  • 73

    Timoshenko S: Theory of Plates and Shells ed 1 New York, McGraw-Hill, 1940

  • 74

    Vilke GM, , Stepanski BM, , Ray LU, , Lutz MW, , Murrin PA, & Chan TC: 9-1-1 responses for shopping cart and stroller injuries. Pediatr Emerg Care 20:660663, 2004

    • Search Google Scholar
    • Export Citation
  • 75

    Wang MY, , Kim KA, , Griffith PM, , Summers S, , McComb JG, & Levy ML, : Injuries from falls in the pediatric population: an analysis of 729 cases. J Pediatr Surg 36:15281534, 2001

    • Search Google Scholar
    • Export Citation
  • 76

    Williams RA: Injuries in infants and small children resulting from witnessed and corroborated free falls. J Trauma 31:13501352, 1991

  • 77

    Yoganandan N, , Pintar FA, , Sances A Jr, , Walsh PR, , Ewing CL, & Thomas DJ, : Biomechanics of skull fracture. J Neurotrauma 12:659668, 1995

  • 78

    Zitelli BJ, & Davis HW: Atlas of Pediatric Physical Diagnosis ed 2 New York, Gower Medical Publishing, 1992

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