Toddlers at Risk for Paper Shredder Injury in the Home: Easy Access and Severe Injury

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EXPERIENCE & REASON

Toddlers at Risk for Paper Shredder Injury in the

Home: Easy Access and Severe Injury

Ramona C. Warren, MD, MPH, George L. Foltin, MD

Departments of Pediatrics and Emergency Medicine, Division of Pediatric Emergency Medicine, New York University School of Medicine, Bellevue Hospital Center, New York, New York

The authors have indicated they have no ﬁnancial relationships relevant to this article to disclose.

ABSTRACT

A 2-year-old girl sustained severe injury to 2 fingers from a home paper shredder. This case illustrates the risk of injury from paper shredders, which are increasingly common household items. Toddlers are at risk of finger injury and amputation. The US Consumer Product Safety Commission performed an investigation of reported injuries and the characteristics of paper shredders that might have contributed to the injuries, and we summarize their findings.

T

HE PURPOSE OFanticipatory guidance is to counsel and to guide parents to avoid preventable health risks. Injury prevention counseling, one aspect of antic-ipatory guidance, ideally is targeted to reflect changing risks as children grow and as their environments change with time and technology. This case draws attention to paper shredder injuries, a household risk for toddlers that has become increasingly common and has the po-tential for devastating lifelong injury.

CASE REPORT

A 2-year-old girl presented to our pediatric emergency service with a chief complaint of severe trauma to 2 fingers of her right hand. The parents were at home operating their new paper shredder. The child walked by and placed her hand on top of the shredder while papers were being shredded actively. Her fingers were drawn into the shredder opening along with the papers, far enough to allow her fingers to contact the cutting mech-anism. The father unplugged the machine immediately, broke open the plastic top, and, with a great deal of effort, pried the shredder blades apart to release the girl’s fingers. The distraught parents did not call emergency medical services but bundled the hand in a towel and proceeded directly to the pediatric emergency service.

The patient arrived awake and in stable condition but in obvious pain. An intravenous line was placed quickly, and morphine was administered. Examination of the right hand revealed severe crush injuries, with multiple lacerations, of the distal aspects of the third and fourth digits. There was significant damage to the distal tip of the third digit, which was splayed open longitudinally,

with laceration through the nail bed and matrix and destruction of the nail. The nail on the fourth digit was spared. A radiograph demonstrated comminuted frac-tures of the third and fourth distal phalanges, including a longitudinal split of the distal tuft of the third digit extending to involve the articular surface, a Salter-Harris II fracture on the ulnar side of the base of the fourth distal phalanx, and multiple small bony chips in both distal tips (Fig 1).

The hand surgeon closed the soft tissues, repaired the nail bed laceration, and splinted the hand in the emer-gency department, with ketamine sedation. The repair required ⬎1 hour. The fingertips were cyanotic at the time of the repair, and it was not clear whether distal perfusion would return. The patient was admitted for intravenous pain-control therapy, because postsedation emesis prevented the use of orally administered pain medication. The patient was given parenterally admin-istered antibiotic (cefazolin), intravenously adminadmin-istered morphine, and then rectally administered acetamino-phen overnight; by morning, she was tolerating orally administered medication. She was discharged with cephalexin, to complete a 7-day course of antibiotics.

Key Words:paper shredder, ﬁnger, amputation

Abbreviation:CPSC, Consumer Product Safety Commission www.pediatrics.org/cgi/doi/10.1542/peds.2005-1711 doi:10.1542/peds.2005-1711

Accepted for publication Nov 3, 2005

Address correspondence to George L. Foltin, MD, Bellevue Hospital Center, 27th St and First Avenue, New York, NY 10016. E-mail: gf16@nyu.edu

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When the patient was seen for follow-up care 5 days after the injury, the fingertips appeared to be well per-fused, and a final decision for or against amputation was deferred in hopeful anticipation of successful healing. The patient’s pain at home was controlled successfully with acetaminophen. We expect that the fingertips, in particular the third digit, will never be functionally or cosmetically normal even if amputation is avoided, be-cause of the extensive bone and nerve disruption.

DISCUSSION

As far as we can determine, this is the first report in the medical literature of a serious injury related to a paper shredder, despite the fact that ⬎2000 persons were treated in hospitals for injuries related to business and office machines in 2003.1_{Thirty percent of those injuries}

involved finger lacerations attributable to paper shred-ders.1 _{A formal US Consumer Product Safety}

Commis-sion (CPSC) investigation into home paper shredder in-juries was completed recently.2 _{The authors examined}

the scenarios that led up to the injuries and the charac-teristics of home paper shredders currently on the mar-ket. They also evaluated the voluntary safety standards used by all manufacturers to test shredder designs. At our request, the CPSC performed a current search of the National Electronic Injury Surveillance System database. We summarize the findings from the December 2004 report2_{and our requested current database inquiry}

be-low.

Between January 2000 and December 2003, the CPSC received 31 reports of injuries attributable to paper shredders in the home.2 _{Twenty-two (71%) of the 31}

injuries involved children ⱕ12 years of age, and 12 (54%) of the 22 injuries involved children⬍3 years of age. Injuries included 3 contusions, 23 lacerations, and 5 partial finger amputations. Four of the 5 partial finger

amputations occurred among childrenⱕ6 years of age. In the National Electronic Injury Surveillance System database search, we found 5 additional laceration inju-ries among childrenⱕ5 years of age that were reported between January 2004 and March 2005. Because these were incident reports, the final outcomes of these inju-ries are not known.

The CPSC investigation of the circumstances sur-rounding the injuries found that, surprisingly, injuries among children occurred frequently while the children were under adult supervision. One of 3 in-depth inves-tigations reported by the CPSC described a mother who, while attempting to teach her children how to use the paper shredder in a safe manner, had the children place paper into the shredder under her direct supervision. Her 6-year-old daughter was operating the machine, and the mother turned her head for just a few seconds to get another piece of paper. The 6-year-old child became distracted by a younger sibling, and her fingers were drawn into the shredder mechanism, which resulted in amputation of 3 fingertips.2_{The CPSC concluded from its}

investigation of multiple cases that inattention or dis-traction played a role in the injury for older, school-aged children and that younger children were most likely unaware of the risk and lacked the physical coordination to release the paper in time to avoid catching their fingers in the machine.2

Home paper shredders are made to sit on top of a waste container or include a fitted container for collec-tion of the shredded paper. There are 2 types of cutting mechanisms, ie, 1 that cuts paper into long thin strips and 1 that cuts paper with intermeshed blades, creating smaller pieces (cross-cutting). The CPSC examined sev-eral home paper shredder machines to assess the char-acteristics of machines currently on the market. The sample was not inclusive of every machine; only those readily available for home purchase from area retailers were studied.

The test probe used voluntarily by all manufacturers to test paper shredder safety is a semicompressible probe made to represent a finger. The CPSC concluded that, on the basis of standardized anthropomorphic measures, the length and diameter of the voluntary test probe are intended to represent the worst-case scenario for a 12-year-old child and are not designed to test for possible injury risk for younger children.2_{The voluntary standard}

probe is the same for paper shredders sold in the United States and internationally and is intended for adult operators. For its in-depth investigation to assess the hazard for younger children, the CPSC also used an articulated probe that is referenced in many of the Un-derwriters Laboratories’ other standards but is not used for paper shredders. The articulated probe diameter rep-resents a larger age range (and finger size) than does the voluntary probe diameter. The CPSC also used rigid and compressible rods of different diameters, which were

FIGURE 1

Radiograph of the patient’s hand.

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selected on the basis of established anthropomorphic data to represent both children and adults. Extensive technical information about the probes and tests that the CPSC used in its investigation are provided in detail in its December 2004 report.2 _{The conclusions based on its}

assessment and testing are provided here.

The CPSC assessment of the sample of home paper shredders showed that the heights of most models ranged from 13 inches to 16.5 inches, allowing easy access to the paper opening for the average 15-month-old child. The paper opening was wider in the cross-cutting type of machine than in the strip-cross-cutting type of machine, and the material around the opening was more flexible in some models, which allowed the open-ing to spread wider when force was applied. The cross-cutting mechanism created more force to draw in papers than did the strip-cutting mechanism. The distance from the paper opening to the cutting blades ranged from 0.08 to 1.29 inches. Because the estimated 95th percentile index finger length of 13- to 18-month-old children is 1.77 inches, the CPSC determined that every machine tested could potentially allow a child’s fingers to contact the cutting blades. When using a probe that represented the fingers of a 15-month-old child, the CPSC authors determined that the fingers were unlikely to enter the opening without some force being applied; however, the width and flexibility of the opening, combined with the force generated by the action of the mechanism while drawing in paper, were sufficient to draw the probe into the cutting blades once it was placed against the paper and entered the paper opening. The CPSC determined that, of the established probes used for risk assessment by manufacturers, none assessed adequately the hazard to children as young as 15 months.2

In addition to the accessibility features of the ma-chines, the CPSC found other characteristics of machines that may pose a hazard. The control switches on many models did not include an “off” position. It was more common to find only 3 switch positions, namely, “for-ward,” “auto,” and “reverse.” The “auto” start setting activates the cutting blades when papers are placed in the opening. This switch position poses a hazard to chil-dren when parents are not in the room. Commonly the switch positions were not marked in contrasting colors, which presents a hazard if the position needs to be changed in an emergency. None of the machines the CPSC examined had an “on/off” switch separate from the function switch. In the CPSC-investigated incidents, frequently parents pushed the switch to “reverse” or needed to unplug the machine to make the cutting blades stop rotating. The cutting blades on all machines were fixed to the part of the machine just below the paper opening. No machine had a release mechanism to allow easy separation of the cutting blades from the rest of the machine or to allow separation of the blades from one another, which made it difficult even for emergency

personnel to remove the children’s fingers from the blades. Children were often transported to the hospital with the mechanism still attached, and one of the CPSC in-depth investigations reported that the doctors at the receiving hospital needed to use the building mainte-nance personnel’s tools to remove the machine. Hazard warnings, when present on the machine, were not pre-sented in a contrasting color, which made it difficult to identify the risks.2

CPSC authors concluded that, on the basis of the reports they have received, children between the ages of 15 and 30 months are at greatest risk for injury, because of their lack of risk awareness and physical coordination, their natural curiosity, and the accessibility and hazards posed by the machines.2_{The CPSC issued a paper}

shred-der safety alert in May 2004, clearly identifying the risk to young children.3_{Manufacturers are not required to}

place the safety alert in the product packaging, but the CPSC is aware of at least 1 manufacturer that does (A. Lee, written communication, 2005).

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The US CPSC was created in 1972 to protect the public from unreasonable risks of serious injury and death resulting from consumer products. Its work has resulted in a⬃30% decrease in rates of product-related death and injury.2 _{The CPSC welcomes reports from}

physicians about unsafe products. The information pro-vided by physicians and consumers becomes part of the CPSC database and allows the CPSC to detect patterns of injury and hazards associated with particular products. The CPSC can then correct potentially unsafe products by using the wide range of tools at its disposal (M. Greene, PhD, written communication, 2005). We rec-ommend that pediatricians routinely make reports to the CPSC of injuries and incidents involving consumer prod-ucts, to enable better protection of children from pre-ventable risks. Reports may be made at the CPSC Web site (www.cpsc.gov), by calling toll-free (1-800-638-8095), or by sending e-mail (to info@cpsc.gov).

ACKNOWLEDGMENT

We thank our colleague Dr Jeff Fine for his contributions to this article through careful editing and constructive commentary.

REFERENCES

1. University of California, Research and Extension Centers– Administrative Office, Environmental Health and Safety.Safety Note 52: Paper Shredder Safety. Davis, CA: University of California, Research and Extension Centers–Administrative Office, Envi-ronmental Health and Safety; 2005

2. Lee A, White S, Rutherford G. An Evaluation of Finger Injuries Associated With Home Document (Paper) Shredder Machines. Wash-ington, DC: US Consumer Product Safety Commission; 2004. Report CPSC-ES-501

3. US Consumer Product Safety Commission.Paper Shredder Safety Alert. Washington, DC: US Consumer Product Safety Commission; 2004. Alert 5127

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DOI: 10.1542/peds.2005-1711

2006;117;535

Pediatrics

Ramona C. Warren and George L. Foltin

Severe Injury