title: Lower extremity injuries in children seated in forward facing child restraint systems.
abstract: OBJECTIVE
  The lower extremity is among the most frequently injured body regions for children restrained by forward facing child restraint systems (FFCRS), accounting for 28% of their clinically significant injuries, defined as AIS 2 and greater injuries excluding concussions. Despite the prevalence of these injuries, the current U.S. Motor Vehicle Safety Standard governing FFCRS (FMVSS 213) does not provide a direct assessment of the biomechanical risk of lower extremity fracture nor do the current pediatric test devices provide adequate instrumentation to detect the risk of such injuries. Before improvements can be made to the anthropometric test devices (ATDs) or test procedures to address these limitations, understanding of the sources and mechanisms of these injuries is necessary. Therefore, the objective of this study was to document location, source, and crash circumstances of lower extremity injuries in children seated in FFCRS.
  
  
  METHODS
  Utilizing two sources of data, PCPS and CIREN, 20 in-depth investigations of crashes involving children seated in FFCRS with lower extremity injuries were reviewed to determine the nature of the injuries and the circumstances under which they occurred.
  
  
  RESULTS
  Injuries below the knee were the most common, particularly to the tibia/fibula, and they most often occurred due to interaction with the vehicle seatback in front of the child's seating position. These injuries were sustained most commonly in frontal impacts although interaction with the seatback also occurred in other crash types. This interaction with the seatback was exacerbated by possible contributing factors such as intrusion of the front seatback into the child's occupant space or FFCRS misuse resulting in increased excursion of the child during impact.
  
  
  CONCLUSIONS
  This review of cases of children in FFCRS with AIS 2 and greater lower extremity injury points to the role of the seatback in the occurrence of these injuries, suggesting the need to consider this interaction in the seatback design process and to adequately represent this interaction in regulatory procedures assessing the performance of child restraints.
authors.affiliation: Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA. steps@email.chop.edu
authors.forename: Jessica S
authors.initials: JS
authors.lastname: Jermakian
authors.forename: Caitlin M
authors.initials: CM
authors.lastname: Locey
authors.forename: Lexie J
authors.initials: LJ
authors.lastname: Haughey
authors.forename: Kristy B
authors.initials: KB
authors.lastname: Arbogast
mesh_terms: D002675:Child, Preschool; D016208:Databases, Factual; D004867:Equipment Design; D005260:Female; D006801:Humans; D007223:Infant; D015370:Infant Equipment; D035002:Lower Extremity / Q000293:injuries*; D008297:Male; D011482:Protective Devices / Q000592:standards*; D014481:United States