Primary care and emergency physicians frequently see young children who have fractured a bone after a fall from a low height. The child's caregiver may describe a fall from furniture, play equipment, stairs, and various other structures—or the child may have even been dropped while being carried. The clinician then has to decide whether the explanation for the fall is plausible—or whether a child abuse investigation should be pursued.
Here we review the types of fractures that are possible in an accidental fall, depict the most common mechanism of fracture, and provide recommendations about when child protective services should be alerted.
We also describe 5 cases of fractures resulting from witnessed falls from relatively low heights with corroborated histories. Our goal with these cases is to describe clues that point to an accidental injury.THE EPIDEMIOLOGY OF SHORT FALLS
When children fall from a significant height—such as from a window or a balcony—they are typically evaluated in the emergency department and treated as a trauma patient.1,2 These patients are not our focus here. Instead, we concentrate on the child who sustains a fracture from a seemingly insignificant fall. The epidemiology of fractures sustained by children who have fallen short distances can help you determine the plausibility of the caregiver's explanation.
Accidents are the leading cause of death in preschool children (aged 1 to 4 years).3 In 2001, over 2 million children in this age group suffered accidental injuries: 3000 died as a result. While falls accounted for only 2% of all fatal injuries, they were responsible for almost half of all nonfatal injuries.4
The skull, the long bones of the extremities, and the clavicle are most susceptible to injury following a seemingly insignificant accidental fall.5,6 However, these are the same bones, along with the ribs, that are fractured when a child is intentionally injured. Although serious sequelae, such as depressed skull fractures, can result from a low fall, the vast majority of children do not sustain major injury.5-8
Table 1 cites reports that include young children who have sustained fractures from falls of heights of less than 5 feet.5-15 Many of these studies are retrospective reviews in which child abuse could not be definitely ruled out in all instances. When reviewing these reports, it is important to note whether the caregiver's history was corroborated to obtain a true picture of the actual injuries that can result from accidental falls.
Falling or rolling out of bed is not unusual—and it is the explanation most often provided by caregivers as the cause of an infant's injury from a short fall.7 Being dropped by a caregiver and rolling off a sofa are the second and third most common explanations, respectively, for short falls that lead to a fracture in an infant. Toddlers are at greater risk for accidental fracture than are non-ambulating children because of their unsteady gaits; their fearless, explorative nature; and their tendency to climb and fall. Wang and colleagues15 found that the beginning of ambulation is a particularly vulnerable time and that the peak age for a child to experience an accidental injury from a fall is in the second year of life. More than half of all fractures in children are described as occurring secondary to a fall: Leventhal and coworkers16 determined that approximately one tenth of these children are classified as being abused.