• No results found

Odontoid Fracture in a Child Occupying a Child Restraint Seat

N/A
N/A
Protected

Academic year: 2020

Share "Odontoid Fracture in a Child Occupying a Child Restraint Seat"

Copied!
5
0
0

Loading.... (view fulltext now)

Full text

(1)

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

at Viet Nam:AAP Sponsored on September 7, 2020 www.aappublications.org/news

(2)

118

PEDIATRICS Vol. 82 No. 1 July 1988

unusual 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 an

increase 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 accidents

were 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 forces

of 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 program

con-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 as

possible, 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, MD

DAVID 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

at Viet Nam:AAP Sponsored on September 7, 2020 www.aappublications.org/news

(3)

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

at Viet Nam:AAP Sponsored on September 7, 2020 www.aappublications.org/news

(4)

1988;82;117

Pediatrics

DOUGLAS S. DIEKEMA and DAVID B. ALLEN

Odontoid Fracture in a Child Occupying a Child Restraint Seat

Services

Updated Information &

http://pediatrics.aappublications.org/content/82/1/117

including high resolution figures, can be found at:

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtml

entirety can be found online at:

Information about reproducing this article in parts (figures, tables) or in its

Reprints

http://www.aappublications.org/site/misc/reprints.xhtml

Information about ordering reprints can be found online:

at Viet Nam:AAP Sponsored on September 7, 2020 www.aappublications.org/news

(5)

1988;82;117

Pediatrics

DOUGLAS S. DIEKEMA and DAVID B. ALLEN

Odontoid Fracture in a Child Occupying a Child Restraint Seat

http://pediatrics.aappublications.org/content/82/1/117

the World Wide Web at:

The online version of this article, along with updated information and services, is located on

American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 1988 by the

been published continuously since 1948. Pediatrics is owned, published, and trademarked by the

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has

at Viet Nam:AAP Sponsored on September 7, 2020 www.aappublications.org/news

References

Related documents

The findings showed that smartphone usage increases compassionate teaching with significant student engagement through the enhancement of the learner's

If you need an safe cosco convertible car seat scenera next instruction manual affordable car seat for your child, safe cosco convertible car seat scenera next instruction

 nib holdings has agreed to acquire 100% of TOWER Medical Insurance Limited for approximately NZ$102 million (A$80 million) subject to completed accounts..  Net assets

He and his wife Vicki now make their home in the Phoenix area, but they’re regular summer visitors to Medora, and Mike hunts pheasants in North Dakota each fall.. “I’m excited to

Children who have outgrown the rear-facing weight or height limit for their convertible seat should use a forward-facing seat with a harness for as long as possible up to the

Restrictive seat belt or child requirements ontario ministry of car seats and if a globally recognised safety seat belts; car seat manual that seat.. charles dickens on the

Additionally, most of these vehicles are used at night and on weekends by shift personnel to cover inmate movement?.  Are the vehicles currently segregated to accommodate

Έ νας Αφανής Τζουντ* που αναζητούσε τη γνώση· που μοχθούσε με το σώμα τη μέ­ ρα και μελετούσε τις νυχτερινές ώρες· που είχε όνειρα και α­