title: In-depth evaluation of real-world car collisions: fatal and severe injuries in children are predominantly caused by restraint errors and unstrapped cargo.
abstract: OBJECTIVE
  Major improvements have taken place in the development of child restraint systems and in-car safety in general, but motor vehicle accidents remain the leading cause of death and disability in children. An interdisciplinary study was therefore performed to investigate the injury mechanisms in car collisions involving children.
  
  
  METHODS
  Motor vehicle collisions (MVCs) resulting in death or serious injuries to the drivers or their passengers in the southeastern part of Norway in the period 2007-2009 were included in the study if children less than 16 years of age were passengers. An investigation team examined the crash scene within 24 h of the accident. The internal and external environment of the vehicle was investigated, with particular focus on safety equipment and registration of child occupant contact points. Information was collected from witnesses, crash victims, the police, road authority reports, and medical records. Clinical or postmortem examinations were performed on the child occupants.
  
  
  RESULTS
  Fifteen high-impact car crashes involving 27 child occupants were investigated: 7 children died (median [range] age 8 (0-15) years), 8 were severely injured (8 [5-13] years), and 12 sustained minor or no injuries (3.5 [0-14] years). Fourteen out of 15 fatalities or severe injuries (MAIS ≥3) were found to be due to various safety errors: harness straps or seat belts incorrectly routed (5/15) or poorly adjusted (4/15), unstrapped luggage (4/15), or technical errors (1/15). All 7 of the fatally injured children died at the crash scene, and 6 died due to head/upper neck trauma. No safety errors were found among the 12 children with either minor or no injuries. No association was found between the instantaneous change in velocity (ΔV) and the injury severity.
  
  
  CONCLUSIONS
  The risk of child passengers being severely or fatally injured in MVCs is significantly higher when they are incorrectly restrained or exposed to unsecured heavy luggage. Appropriate crash investigations may provide important information regarding the injury mechanisms, which will be necessary for the implementation of preventive measures to reduce future fatalities.
authors.affiliation: Department of Forensic Medicine, Norwegian Institute of Public Health and University of Oslo, Oslo, Norway. m.s.martinsen@medisin.uio.no
authors.forename: Marianne
authors.initials: M
authors.lastname: Skjerven-Martinsen
authors.forename: Pal Aksel
authors.initials: PA
authors.lastname: Naess
authors.forename: Trond Boye
authors.initials: TB
authors.lastname: Hansen
authors.forename: Torleiv Ole
authors.initials: TO
authors.lastname: Rognum
authors.forename: Inggard
authors.initials: I
authors.lastname: Lereim
authors.forename: Arne
authors.initials: A
authors.lastname: Stray-Pedersen
mesh_terms: D000063:Accidents, Traffic / Q000401:mortality / Q000706:statistics & numerical data*; D000293:Adolescent; D002648:Child; D057207:Child Restraint Systems; D002675:Child, Preschool; D006801:Humans; D007223:Infant; D009664:Norway / Q000453:epidemiology; D012307:Risk Factors; D015599:Trauma Severity Indices; D014947:Wounds and Injuries / Q000453:epidemiology* / Q000401:mortality