Pediatric Head Injury Resulting From All-Terrain Vehicle Accidents

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Vol. 78 No. 5 November

1 986 933




“In Medicine one must pay attention not to plausible theorizing but to experience and reason

together. . ..I agree that theorizing is to be approved, provided that it is based on facts, and systematically makes its deductions from what is observed. . . .But conclusions drawn from

unaided reason can hardly be serviceable; only those drawn from observed fact.’‘Hippocrates:

Precepts. (Short communications of factual material are published here. Comments and criticisms

appear as Letters to the Editor.)









During the past 6 years we have observed an increasing number of brain injuries in children

caused by all-terrain vehicles. The cases that are reported here have been selected from 93

consecu-tive cases on the Gillette Children’s Hospital

Pe-diatric Head Injury Service and from the St

Paul-Ramsey Medical Center Trauma program during a period from July 1979 to July 1985.


Demographic features are summarized in the Table.

Case I

The first child was a 14-year-old girl who was a pas-senger on a three-wheel all-terrain vehicle. The driver lost control on an embankment, and the child fell into a

ravine and the all-terrain vehicle overturned on top of her. On her initial computed tomographic (CT) sean, a left frontal parenchymal hematoma was seen. Her clinical

course was complicated by seizures and increased intra-cranial pressure. Additional injuries included facial lac-erations and right humeral fracture. She was comatose for approximately 8 months and remains in a residential facility 4 years after her injury. Although she is nonverbal and nonambulatory, she at times can follow simple

spo-ken commands.

Received for publication Nov 13, 1985; accepted March 4, 1986. Reprint requests to (M.S.) Department of Rehabilitation, Gil-lette Children’s Hospital, 200 E University Aye, St Paul, MN 55101

PEDIATRICS (ISSN 0031 4005). Copyright © 1986 by the American Academy of Pediatrics.



The second patient was a 9-year-old boy who was

struck by a car while riding a three-wheel all-terrain vehicle. He sustained a basilar skull fracture, with blood

exuding from his left ear, and multiple injuries including

a C-2 fracture with dislocation, right compound tibia-fibula fracture, and right femoral fracture. His pupils

were fixed and dilated, and there were no brainstem

reflexes. After a period of observation, supported

respi-ration was discontinued because of a diagnosis of brain death.



Patients 3 and 4 were involved in the same accident.

Both were experienced drivers operating separate

three-wheel all-terrain vehicles. They collided head-on. Patient

3, a 14-year-old boy, had multiple facial and skeletal injuries and sustained a dural tear. CSF rhinorrhea per-sisted for 1 week. On initial CT scans, small areas of superficial cerebral contusion were demonstrated. Within

three days of his injury, he was responsive to verbal commands and recognized his family members.

Forty-three days after his injury, a fever, vomiting, and headache abruptly developed. He was found to have a

pneumococcal meningitis and was treated with a regimen

of antibiotics. The patient had no obvious sequelae from this infection. A radioisotopic study failed to demonstrate

a CSF leak. The patient has been followed for 1 year following his injury and has had no further recurrence of intracranial infection. He has normal findings on neuro-logic examination, and his academic achievements are unchanged. He has resumed driving his all-terrain vehicle

against the advice of our medical staff.

Case 4

This 15-year-old boy was purposefully following corn-mands within 24 hours of his injury. He sustained exten-sive facial injuries with a frontal skull fracture that

required reconstructive surgery and repair of a dural tear.

On CT scan bifrontal subdural hematomas were demon-strated. Forty-seven days after his injury, pneumococcal

meningitis developed. On radioactive cisternogram a CSF leak was not found. One year following his injury, his

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TABLE. Demographic Features



Vol. 78 No. 5 November1986

Case No. Age (yr) Experienced Driver

3- or 4-Wheel Vehicle Length of Coma Outcome and Complications Length of Hospitalization

1 14 Passenger 3 8 mo Nonverbal,


4+ yr

2 9 ? 3 Until death Death 1 d

3 14 Yes 3 3 d Meningitis 51 d

4 15 Yes 3 1 d Meningitis, hearing

and vision deficits

63 d

5 16 Yes 3 2 d Learning disabled 22 d


12 No 4 12+ mo Vegetative state 12+ mo

7 16 Yes 3 10 d Learning disabled 53 d

cognitive status is normal; however, he has severe im-pairment of vision in the left eye and a sensonineural hearing loss in the right ear, and he is anosmic. This patient also returned to driving his all-terrain vehicle.

Case 5

This 16-year-old boy was riding a three-wheeler on the side of a road when he lost control of the vehicle and went into a ditch. CSF and blood were noted to be draining from his left ear. On CT scan a petrous ridge fracture extending through the left tympanic cavity was found. He was comatose approximately 48 hours and

remained hospitalized for 22 days. Deficits at discharge

included a permanent hearing impairment of the left ear, impaired coordination, and mildly decreased cognitive functioning. He required special education classes on return to school. This boy had a history of chemical

dependency and has resumed various risk-taking

behav-iors including riding his all-terrain vehicle.

Case 6

The sixth patient was a 12-year-old boy who was

driving a four-wheel all-terrain vehicle with his brother

as a passenger. This was the patient’s first experience on an all-terrain vehicle, and he had received minimal

in-struction for its usage. The vehicle rolled over. His brother was able to jump free and suffered no significant

injury. The patient was crushed by the toppling machine.

During his transit to the hospital, he suffered a cardiac

arrest requiring 40 minutes of cardiopulmonary resusci-tation. Initial evaluation confirmed the presence of a markedly depressed right temporal skull fracture

requir-ing emergency craniotomy and decompression. Seven days later, the patient deteriorated clinically, and a

tem-poral hematoma was discovered, necessitating repeat craniotomy and further decompression. Twenty-one days after his injury, severe hydrocephalus developed, and a

ventriculoperitoneal shunt was performed. During his

initial course, he had multiple seizures requiring treat-ment with a regimen of phenytoin, phenobarbital, paral-dehyde, and diazepam.

The patient eventually required both a tracheostomy and a feeding gastrostomy for long-term care. He is residing in a chronic care facility in a vegetative state.

Case 7

This 16-year-old boy was an experienced all-terrain

vehicle driver. His accident occurred during the nighttime while driving on the shoulder of a road. He was fleeing from a truck at high speed when he lost control of his three-wheel all-terrain vehicle. The patient was found unconscious, transported to his community hospital, and later transported to our medical center for further

ther-apy. Findings on a CT brain scan on admission were

normal. The patient was comatose for ten days. On CT scans repeated 6 weeks following his injury there was

evidence of very mild cerebral atrophy. His cognitive

status, although at a high level of function, had not

recovered to his preaccident status by 3 months following his injury. His deficits included memory, judgment, and disorganization of thought and language. Although this boy was receiving some learning-disabled services in school prior to his accident, he has required more inten-sive programming following his injury. Despite admoni-tions of our staff to prevent recurrences of repeated head injury, the patient returned to driving his all-terrain

vehicle within 3 months following his injury.


It is well recognized that brain injuries can be caused by recreational activities. In one report, recreational injuries accounted for 9.4% of head injuries in all age groups.1 In a subsequent publi-cation, Annegens2 reported that recreational

activ-ities were responsible for 11.5% of head injuries in

children. In our pediatric series, recreational activ-ities have been responsible for ten of 93 cases. We

have experienced a marked increase in injuries me-sulting from all-terrain vehicles in 1984 and 1985. Prior to 1984, only one all-terrain vehicle-related injury was seen out of a total of 66 cases. In 1984 and 1985, we have had four all-terrain vehicle-related injuries, representing 15% of all cases in

these 2 years.

In Alaska, 20 deaths and more than 500 injuries caused by all-terrain vehicles during a 2-year period have been neported.l3a Six persons became perma-nently disabled by severe neurologic injuries. Head

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injuries accounted for 50% of the fatalities.

Chil-dren from 10 to 14 years of age accounted for 24% of the accidents. Only 9% of riders wore helmets at

the time of the accident. In a 1985 report from

Arkansas covering a 1-year period, Golladay et al4 reported 12 preadolescent children ranging from 3 to 12 years of age who were seriously on fatally

injured in three-wheeler accidents.

The US Consumer Product Safety Commission

has surveyed and reviewed the national statistics for all-terrain vehicles.57 Emergency room visits related to all-terrain vehicle accidents increased

from 4,929 in 1980 to 78,000 for the first 9 months of 1985. There has been a similar increase in all-terrain vehicle-associated deaths. Forty-nine per-cent of the fatalities have been children younger than 16 years of age. In testimony before the Com-merce, Consumer, and Monetary Affairs Subcom-mittee, the Commission summarized the unique handling difficulties of all-terrain vehicles and em-phasized “hidden hazards” for young drivers of

these vehicles. The vehicles’ inherently unstable design coupled with a relatively high center of

gray-ity contributes to a high accident rate.

All-terrain vehicle use is increasingly popular and would appear to have almost addictive attraction. Even though our patients were advised of the

p0-tential for cumulative deficits resulting from re-peated head injury, four of our patients returned to driving their all-terrain vehicles following conva-lescence from their accidents. Such driving was generally condoned by their families.

In response to our experience, we make the fol-lowing recommendations. Because all-terrain

vehi-des are a particular hazard for the young driver, we

believe that children younger than 16 years of age

should not operate all-terrain vehicles; certainly

parents must be strongly informed of all-terrain vehicle hazards for the young operator.

Safety-training programs are available in some areas; we

suggest that they be required for all operators

younger than 18 years of age. We, of course, would hope that helmets be used for all all-terrain vehicle

drivers and urge that they be mandatory for those

younger than 18 years of age. We argue that there


more responsible advertisements that do not demonstrate use of all-terrain vehicles by children. To define risks, hazards, and improvements in

ye-hide design, we urge that all all-terrain vehicle accidents resulting in personal injury or fatality be reported to state health authorities for both

on-and off-road accidents.


In our experience, accidents involving all-terrain

vehicles are an increasingly frequent cause of brain injury in children. The risk associated with

opera-tion of these vehicles is not fully appreciated and

should be better publicized. We believe that it is possible to delineate several steps that could signif-icantly reduce the risk to the pediatric population without curtailing the recreation altogether. Al-though construction design has promised to pro-duce safer vehicles, our experience has shown that extreme injury is still possible with the newer four-wheel machine.


This research was supported, in part, by the Medical

Education and Research Association at Gillette

Chil-dren’s Hospital and by the Medical Education and

Re-search Foundation at Ramsey Clinic.

The authors acknowledge the assistance of Debbie Edlund of the Department of Surgery, St Paul-Ramsey Medical Center.






Gillette Pediatric Head Injury Service of Gillette Children’s Hospital

St Paul-Ramsey Medical Center St Paul


1. Annegers JF, Grabow JD, Kurland LT, et al: The incidence, causes and secular trends of head trauma in Olmstead County, Minnesota, 1935-1974. Neurology 1980;30:912 2. Annegers JF: The epidemiology of head trauma in children,

in Shapiro K (ed): Pediatric Head Trauma. New York, Futura Publishing Co, 1983, pp 1-10

3. Jenkerson 5, Middaugh J: Injuries associated with three-wheel all-terrain vehicles-Alaska. MMWR 1985;34:213

3a.Smith SM, Middaugh JP: Injuries associated with three-wheeled all-terrain vehicles, Alaska, 1983 and 1984. JAMA


4. Golladay ES, Slezak JW, Mollitt DL, et a!: The three-wheeler-A menace to the preadolescent child. J Trauma


5. Hearing Before the US House Committee on Government

Operations, Consumer and Monetary Affairs Subcommittee:

Risks From 3-Wheeled ATV’S, Congressional hearing (May 21, 1985) (testimony of S. M. Statler)

6. Newman R: Update of ATV Injuries and deaths, US Con-sumer Product Safety Commission Memorandum. October 10, 1985

7. Newman R: Hazard analysis: Survey of All Terrain Vehicle

Related Injuries (1985) (preliminary report), US Consumer

Product Safety Commission, Directorate for Epidemiology, Division of Hazard Analysis. Washington, DC, December 1985

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Pediatric Head Injury Resulting From All-Terrain Vehicle Accidents


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