Neurology India Medknow Publications on behalf of the Neurological Society of India ISSN: 0028-3886 EISSN: 1998-4022 Vol. 58, Num. 5, 2010, pp. 752-755

Neurology India, Vol. 58, No. 5, September-October, 2010, pp. 752-755

Brief Report

Television tip-over head injuries in children

Sujit Kumar G Samson¹, Pratheesh R Nair², Manish Baldia¹, Mathew Joseph²

¹ Department of Neurosurgery, Narayana Medical College and Hospital, Nellore, A. P., India
² Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India

Correspondence Address:
Mathew Joseph
Professor of Neurosurgery, Department of Neurological Sciences, Christian Medical College, Vellore - 632 004, Tamil Nadu
India
mjoseph@cmcvellore.ac.in

Date of Acceptance: 22-Jul-2010

Code Number: ni10205

PMID: 21045503

DOI: 10.4103/0028-3886.72171

Abstract

Keywords: Head injury, skull fracture, television, tip over

Introduction

Television (TV) has become an integral part of every household, even in developing countries like India. Starting with 41 sets and one channel in 1962 (Audience Research Unit, 1991) the number of TV sets in India has increased to 105 million in 2007 (New York Times, Feb. 11, 2007; Business, Dec. 27, 2003). These numbers are rapidly increasing across all the income groups with the distribution of free TV sets by the local government in some states like Tamil Nadu. The average child in United States watches TV for 20 hours a week ^[1] ; and though similar data is not available on TV-watching habits in India, there is no reason to believe, given the appetite for video games, daily serials, reality shows, sports and movies, that the average Indian child spends less time with a TV set. The center of gravity of a television set lies towards the screen (more so in the case of conventional TV sets with flat screens); and therefore when children play near TV sets that are kept on unstable stands, the sets tend to fall forwards onto them causing significant head injuries. We report eight children with head injury due to TV tip-over and discuss the pattern of head injuries and their prevention.

Case Reports

Eight children were brought to our emergency departments with an alleged history of a TV set having fallen onto them. The clinical and radiological presentation, management and outcome of these children are summarized in [Table - 1], [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]. Several patients required transfusion due to sequestration of significant volumes of blood in the subgaleal hematomas. The child who died postoperatively initially made a good recovery and obeyed commands but then developed severe airway obstruction due to lower cranial nerve palsies and developed cardiac arrest before a surgical airway could be established.

Discussion

The first commercial cathode-ray tube for TV set was made by Allen Dumont in 1931. The subsequent discovery of selenium and invention of oscilloscopes and kinescopes have all paved the way towards the development of more advanced TV sets and their popularity in India. In India the first television transmission was started in Delhi in 1959 with 20 sets. Children, especially toddlers, tend to hold on to any available object for support and are at increased risk of injury by any article placed higher than them, including TV sets. ^[2] There are several factors that make "the toddler and TV set" a dangerous combination. Toddlers are capable of moving around the house independently; have enough strength to pull things off shelves, tables and stands; and have not developed any judgment of risk. The pull they generate on commonly available and poorly designed TV set stands is sufficient, with the torque generated by tall screens with the heavy cathode-ray tube towards the front, to topple the TV sets. Toddlers have developing thin skulls and a large head-to-body ratio, making them more susceptible to head injuries. ^[3] The most frequent part of the body injured in these accidents is the head (68%-72%), ^[4],[5] with the TV tip-over usually resulting in a low-velocity crushing type of head injury. These injuries can result in both short-term and long-term sequelae. Short-term sequelae include shock in small children with large subgaleal hematomas, intracranial hematomas that might require surgical evacuation, cranial nerve deficits, temporary hemiplegia, cerebrospinal fluid leak and meningitis. In the longer term, these patients can have extensive disabilities ^[6] with potential serious effects on their socio-psychological development. Mortality has been reported in the series of television tip-over injuries by Bernard (1 out of 5 cases) and DiScala (2.7%). ^[4],[5] In our series, 1 patient (case 4) died in the postoperative period, and 1 patient (case 8) with poor neurological status and devastating injuries on CT scan was discharged from the emergency room on request by parents after explanation of the poor prognosis.

The most common pathology found in TV tip-over injury is skull fractures, usually of the base. ^[6],[7] Of the eight children in this series, six had skull fractures. Bones commonly involved are the orbital roof, petrous and vault. ^[2],[6],[7] These fractures can cause periorbital ecchymosis, hemosinus, cerebrospinal fluid (CSF) leak and cranial nerve palsies. These are also associated with varying degrees of intracranial injuries, sometimes requiring surgical intervention. In the series reported by Yahya, 4 out of the 18 patients required surgical intervention. ^[6] In our series, one patient required surgical evacuation of the hematoma. If the electrical connections of the TV set are not secure, children are at further risk of electrical burns. Traumatic cranial nerve deficits may be transient or permanent. In our series, the boy with sixth nerve palsy due to petrous apex hematoma had complete recovery from the initial deficit. Clival epidural hematomas have been reported as a distinct entity in children with posttraumatic bilateral abducens palsy. ^[8] Spontaneous resolution of the traumatic sixth nerve palsy or paresis has been reported in 12% and 54%, and the recovery is more common in unilateral cases (84%) than in bilateral cases (38%). ^[9]

TV tip-over can result in varying degrees of morbidity and sometimes mortality. There are not many reports on TV tip-over injuries, ^{[2],[4],[5],[6],[7]} and no reports from the Indian subcontinent. Parents, educators, manufacturers and medical care personnel should be aware of this totally preventable injury. Documentation of exact mode of injury is important in preparing guidelines for prevention. In our series, the exact modes of injury were: climbing on to TV stand, pulling or shaking of TV stand, trying to reach for toys on the top of the TV set, and playing near TV stands. Regulatory authorities should ensure that the stands manufactured can adequately support TV sets without overbalancing. There are currently no recommendations by most TV manufacturers to prevent these kinds of injuries, and it should not take a lot of effort to add warnings for customers about TV tip-over injuries. Educators should warn children and educate them regarding this preventable cause of head injury. Consumer protection groups should advocate adequate steps for both manufacturers and customers. Pediatric health care givers should provide recommendations like those of the Benedum Trauma Program of the Children's Hospital of Pittsburgh to parents of small children and should include them in the health education program of their hospitals. ^[2] In the Narayana Medical College and Hospital, Nellore, Andhra Pradesh, India, we have prepared brochures in local language to educate both the health care personnel and public about TV tip-over injuries and have suggested the following preventive measures: (1) Secure TV sets onto stands that can in turn be anchored to the floor or wall. People from lower socioeconomic strata living in kaccha houses are also acquiring TV sets because of free TV set distribution. Children in these houses are at an even greater risk because the floor is uneven and the stands are likely to be makeshift. Placing the TV set on or just off the floor is a good option in these cases. If kept on a shelf, the TV set should be sufficiently far from the edge of the shelf so as to enhance safety; (2) Avoid using movable weak stands that have not been built specifically for TV sets; (3) Avoid keeping other gadgets that the child may want to handle on the same stand as that for the TV set; (4) Avoid keeping decorative items or toys on top of the TV set; (5) Some screens to cover the TV sets hang down and are accessible to children; avoid such screens; (6) Do not keep play items near TV stands and restrict play activities around the TV set; (7) Governments should provide warnings about potential injuries along with the free distribution of TV sets; (8) Manufacturers should specifically provide warning signs in their manuals, and salespersons in TV showrooms should be educated about this entity so that they can teach the customers; and (9) Hospitals and schools should include the topic "Prevention of TV-related Injuries" in their education programs.

In conclusion TV tip-over injuries can lead to significant morbidity and mortality in children. They are completely preventable injuries, but this will require the cooperation of manufacturing companies, parents, teachers, government, voluntary organizations and hospitals.

References

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