PEDIATRICS Vol. 82 No. 1 July 1988 117
REFERENCES
1. Perwein E: Incidence of Klinefelter’s syndrome, in Band-mann HJ, Breit R (eds): Klinefelter’s Syndrome. Heidel-berg, West Germany, Springer-Verlag, 1984, pp 8-11
2. Zang KD: Genetics and cytogenetics of Klinefelter’s syn-drome, in Bandmann HJ, Breit R (eds): Klinefelter’s Syn-drome. Heidelberg, West Germany, Springer-Verlag, 1984, pp 12-23
3. Roy A: Psychiatric disorders in relation to Klinefelter’s syndrome, in Bandmann HJ, Breit R (eds): Heidelberg, West Germany, Springer-Verlag, 1984, pp 192-201
4. Fineman KR: Firesetting in childhood and adolescence. Psychiatr Clin North Am 1980;3:483-500
5. Gruber AR, Heck ET, Mintzer G: Children who set fires: Some background and behavioral characteristics. Am J Orthopsychiatry 1981;51:484-488
6. Ritvo E, Shanok 5, Lewis DO: Firesetting and nonfireset-ting delinquents-a comparison of neuropsychiatric, psy-choeducational, experimental, and behavioral character-istics. Child Psychiatry Hum Dev 1983;13:259-267 7. Annell AL, Gustavson KH, Tenstam J: Symptomatology
in school boys with positive sex chromatin (the Klinefelter syndrome). Acta Psychiatr Scand 1970;46:71-80
8. Crandall BF, Carrel RE, Sparkes RS: Chromosome find-ings in 700 children referred to a psychiatric clinic. J Pe-diatr 1972;80:62-68
9. Price WH, Brunton M, Buckton K, et a!: Chromosome sur-vey of new patients admitted to the four maximum secu-rity hospitals in the United Kingdom. Clin Genet 1976; 9:389-398
10. Nielsen J: Prevalence and a 2#{189}years incidence of chro-mosome abnormalities among all males in a forensic psy-chiatric clinic. Br J Psychiatry 1971;119:503-512
11. Nielsen J, Tsuboi T, Tuver B, et al: Prevalence and mci-dence of the XYY syndrome and Klinefelter’s syndrome in institutions for criminal psychopaths. Acta Psychiatr Scand 1969;45:402-424
12. DeBault LE, Johnston E, Loeffelholz F: Incidence of XYY and XXY individuals in a security hospital population. Dis Nerv Syst 1972;33:590-593
13. Bartlett DJ, Hurley WP, Brand CR, et al: Chromosomes of male patients in a security prison. Nature 1968; 219:351-354
14. Nielsen J, Sorenson K: The importance of early diagnosis ofKlinefelter’s syndrome, in Bandmann HJ, Breit R (eds): Klinefelter’s Syndrome. Heidelberg, West Germany, Sprin-ger-Verlag, 1984, pp 170-187
Odontoid
Fracture
in a Child
Occupying
a Child Restraint
Seat
General agreement exists regarding the
impor-tance of using infant and toddler car seats.
How-ever, current guidelines regarding the proper
time to change the direction ofa convertible safety
seat are still debated. We report a case in which
an unusual, but preventable, injury was sustained
by a child occupying a “properly” installed child
restraint device. The rarity and potential
seri-ousness of this injury illustrates the safety
ad-vantage of using rearward facing infant car seats
as long as possible during infancy.
CASE REPORT
A 10-month-old girl weighing 8.04 kg (17 lb 14 oz)
occupied a properly installed forward facing convertible safety seat located in the rear seat of an automobile involved in an accident. The driver of the car failed to stop at a stop sign and hit another vehicle while
tray-eling approximately 40 mph.
At the accident site, the child appeared unhurt and
Received for publication May 22, 1987; accepted July 20, 1987. Reprint requests to (D.S.D.) Department of Pediatrics, Uni-versity of Wisconsin School of Medicine, 600 Highland Aye,
Madison, WI 53792.
PEDIATRICS (ISSN 0031 4005). Copyright © 1988 by the
American Academy of Pediatrics.
was removed from the seat by a police officer to expedite
the extrication of her mother from the front seat.
Bi-lateral bruising under the restraint strap was noted.
There were no other apparent injuries. The child was
brought to the emergency room where she was noted
to hold her neck stiffly and to move her right side pref-erentially. Both clavicles were intact when palpated. No other signs of injury were noted except for the
afore-mentioned contusions over the clavicles.
Bilateral clavicular films revealed no fractures.
However, a cross-table lateral radiograph of the
cer-vical spine indicated a radical subluxation, between
#{188}and /8 in, of the C-i vertebrae forward on the
C-2 vertebral body. The odontoid appeared disarticu-lated from its cartilaginous attachment on the C-2 body
and had been carried forward the full length of the
C-2 vertebral body.
Immobilization and traction resulted in a 50%
re-duction in the dislocation (the odontoid moved back to
cover 50% of the second cervical body). Subsequently, the first cervical lamina was surgically secured to the second cervical lamina. After surgery, the child’s
pref-erential use of the right arm resolved gradually and
completely during the next week, leaving no neurologic deficit.
DISCUSSION
This case represents a rare injury in a child this
age. At 10 months of age, the odontoid process is
joined to the second cervical vertebrae by a
car-tilaginous plate. The odontoid does not fuse to the
vertebrae until approximately 4 years of age. As
a result, prior to the age of 4 years the odontoid
is vulnerable to injury and may be the site least
able to resist those forces likely to produce
cer-vical fractures. Thus, while cervical fractures are
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118
PEDIATRICS Vol. 82 No. 1 July 1988unusual in children younger than 4 years,
odon-toid fractures make up a large proportion of
these. Because the odontoid is not yet fused to the
vertebral body, most of these fractures actually
represent the disruption of the epiphyseal plate
between the odontoid process and the second
cervical vertebrae.
During a 7-year period at the Children’s
Hos-pital of Philadelphia only 15 cervical fractures
were reported in children. Of these, 11 were
frac-tures of the odontoid. All were anterior
displace-ments and the average age was 4 years. Nearly
all were secondary to high speed traffic accidents.’
In four other series representing 200 odontoid
fractures, only 13 involved children 7 years or
younger.25 Of these, four were younger than 4
years and none were younger than 2 years.
Sep-arate case reports in the literature further
sub-stantiate the rarity of this injury in infants and
its close association with motor vehicle
acci-dents.6’2 As occurred in our patient, the
diag-nosis of neck injury in young children is often
de-13 The initial presentation may be that of
weakness in one arm which resolves with
reduc-tion of the displacement.
Accidental deaths still overshadow all other
causes of death among children. Motor vehicle
ac-cidents specifically account for more than half of
the deaths among children and significant
mor-bidity among those surviving. Child restraint
seats appear to significantly decrease both
mor-bidity and mortality from motor vehicle accidents.
A
recent report from Michigan indicated that anincrease in restraint use from 12% to 51% in that
state resulted in a 25% reduction in the number
of young children injured in motor vehicle
colli-sions.’4 Another report from New Mexico
con-cluded that unrestrained children younger than
5
years of age involved in motor vehicle accidentswere five times more likely to be killed and two
times more likely to be injured than restrained
children.15 The proper installation of the seat,
however, is crucial to the reduction in morbidity
as well as mortality. A National Highway Traffic
Safety Administration study concluded that the
properly installed child restraint seat reduces
fa-tality risk by 71% and serious injury risk by
67%.16
A
rearward facing car seat distributes the forcesof a collision impact over the child’s body while
supporting the child and holding the child in
place. The forces of a forward directed impact are
distributed over the back and pelvis of an infant
facing rearward while avoiding the
hyperexten-sion/hyperfiexion of the neck which might occur
in the forward position. There is little
disagree-ment that infant seats should be used until they
are outgrown (at approximately 9 kg [20 lb]) and
should be installed facing rearward only.
How-ever, current recommendations about when to
change the direction of a convertible safety seat
from facing rearward to forward vary. In general,
the change in direction has been recommended
when the child reaches the age of9 to 12 months.’6
A
recently reported New Zealand programcon-sidered 6 months of age to be the proper time for
changing to the forward facing dfrection.’
How-ever, the accompanying editorial stressed the
im-portance
of using rear-facing seats for as long aspossible, recommending that seats face rearward
until a weight of 8.1 kg (18 lb) (for convertible
seats) or 9 kg (20 lb) (for Infant Love Seat) is
reached. In either case, the change should be
made only when the infant can sit unsupported
and should depend upon the size, not the age, of
the 8
As many as 33% ofall infant seats are installed
facing in the wrong direction.’9 This child was
properly secured in the rear seat ofthe automobile
in an approved convertible restraint seat.
How-ever, the parents had recently changed the
direc-tion of the seat from backward to forward on the
recommendation of their pediatrician based upon
the child’s weight of nearly 8.1 kg (18 lb). Had
this child been facing rearward, a cervical neck
injury of the sort suffered almost certainly would
not have occurred because the back of the infant
seat would have stabilized the otherwise unsteady
head of the young infant. This case provides
fur-ther evidence of the importance of urging parents
to keep their children in rear-facing child
re-straint seats for as long as possible.
DOUGLAS
S.
DIEKEMA, MDDAVID B. ALLEN, MD
Department of Pediatrics
The University of Wisconsin
School of Medicine Madison
REFERENCES
1. Sherk HH, Nicholson JT, Chung SMK: Fracture of the
odontoid process in young children. J Bone Joint Surg Am 1978;60A:921-924
2. Amyes EW, Anderson FM: Fracture of the odontoid pro-cess: Report of sixty-three cases. Arch Surg 1956;72:377-393
3. Anderson LD, D’Alan.zo RT: Fractures ofthe odontoid pro-cess of the axis. J Bone Joint Surg Am 1974;56A:1663-1674
4. Blockey NJ, Purser DW: Fractures of the odontoid process of the axis. J Bone Joint Surg Br 1956;38B:794-817
5. Nachemson A: Fracture ofthe odontoid process ofthe axis. Acta Orthop Scand 1960;29:185-217
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PEDIATRICS Vol. 82 No. 1 July 1988 119
6. Bhattacharyya 5K: Fracture and displacement of the
odontoid process in a child: A case report. J Bone Joint Surg Am 1974;56A:1071-1072
7. Ewald FC: Fracture ofthe odontoid process in a seventeen-month-old infant treated with a halo. J Bone Joint Surg
Am 1971;53A:1636-1640
8. Hamilton AR: Injuries of the atlanto-axial joint. J Bone Joint Surg Br 1951;33B:434-435
9. Hubbard DD: Injuries of the spine in children and adoles-cents. Clin Orthop 1974;100:56-65
10. Price E: Fractured odontoid process with anterior dislo-cation: Proceedings of the Australian Orthopedic Associ-ation. J Bone Joint Surg Br 1960;42B:410
11. Tuell I: Fracture-dislocation ofthe cervical spine in small children: Proceedings of the Western Orthopedic Associ-ation. J Bone Joint Surg Am 1957;39A:459-460
12. Willard DP, Nicholson JT: Dislocation ofthe first cervical
vertebrae. Ann Surg 1941;113:464-475
13. Griffiths SC: Fracture of the odontoid process in children. J Pediatr Surg 1972;7:680-683
14. Wagenaar AC, Webster DW: Preventing injuries to chil-dren through compulsory automobile safety seat use. Pe-diatrics 1986;78:662-672
15. Sewell CM, Hull HF, Fenner J, et al: Child restraint law effects on motor vehicle accident fatalities and injuries: The New Mexico experience. Pediatrics
1986;78:1079-1084
16. Child Safety in Your Automobile. Washington, DC, Na-tional Highway Traffic Safety Administration
17. Geddis DC, Appleton IC: Establishment and evaluation of a pilot child car seat rental scheme in New Zealand. Pe-diatrics 1986;77:167-172
18. Shelness A, Charles 5: Children and car seats. Pediatrics 1986;77:256-258
19. AnEvaluation ofChildPassengerSafety: TheEffectiveness and Benefits of Safety Seats. Washington, DC, National Highway Traffic Safety Administration, 1986
Emergency
Drug Dosage
Guides
Successful cardiopulmonary resuscitation of
pe-diatric patients is complicated by the fact that
physicians perform such therapy infrequently,
and resuscitative efforts resulting in death or
Se-rious disability are common. For example, in one
study of 91 children who were treated in an
emer-gency department for cardiopulmonary arrest,
only two survived without neurologic handicaps
or death.’ These statistics are particularly
dis-couraging when it is noted that 14 of those
chil-dren had their arrests in the emergency
depart-ment itself.
One factor complicating resuscitation of
pedi-atric patients is that dosages of emergency
med-ications must be adjusted accurately and quickly
for each patient’s body weight. In a crisis
situa-tion, the possibility of a serious error in
calculat-ing dosage of medication exists. In a community
hospital, this problem is complicated by the fact
that initial cardiopulmonary resuscitation may be
administered by physicians who are not
special-ists in pediatrics. Although those physicians may
have familiarity with the pharmacologic basis for
medication therapy, they are frequently
unfamil-iar with pediatric dosage schedules or with
dif-Received for publication May 1, 1987; accepted Sept 17, 1987. Reprint requests to (C.J.O.) Pediatrics and Adolescent Medi-cine, 150 Mansfield Aye, Willimantic, CT 06226.
PEDIATRICS (ISSN 0031 4005). Copyright © 1988 by the
American Academy of Pediatrics.
fering concentrations of medication used in
pe-diatrics.
Various methods of dealing with this problem
have been suggested, including the preparation of
emergency drug charts with precalculated
dos-ages for children of different body weights2 and
the use of emergency drug cards which are to be
attached to each patient’s medical record on
ad-mission.3 For this latter plan, an outline of the
recommended drugs is given in addition to space
for calculating the correct dosage for each patient based on body weight.
Our pediatrics department evaluated these
sys-tems as well as alternatives that would reduce
possible sources of error. We concluded that it
would be preferable to have dosages for
emer-gency drugs calculated and checked prior to each
child’s actual admission and affixed to the medical
record at the time of admission (Figure). Such a
system avoids potential shortcomings in other
plans evaluated. For example, a wall chart of
rec-ommended dosages may work well in an
obste-trical delivery suite but is unsuited for situations
in which older patients go to specialized hospital
departments for scans, roentgenograms, or
phys-ical therapy. Systems that require a nurse or
phy-sician to perform repetitious individual
calcula-tions, even prior to the stressful conditions that
exist during an arrest, are subject to human error.
When a pediatric patient is admitted to our
hos-pital, a preprinted cardiopulmonary resuscitation
dosage guide sheet is selected by the pediatric
ad-mitting nurse based on the child’s weight, and this
card is inserted as the first page of the patient’s
medical record. The patient’s name, diagnosis,
age, and body weight are also entered on the guide
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1988;82;117
Pediatrics
DOUGLAS S. DIEKEMA and DAVID B. ALLEN
Odontoid Fracture in a Child Occupying a Child Restraint Seat
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Pediatrics
DOUGLAS S. DIEKEMA and DAVID B. ALLEN
Odontoid Fracture in a Child Occupying a Child Restraint Seat
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