Serious Head Injuries From Lawn Darts Jean S. Tay, MD, and Jeffery S. Garland, MD From the Department of Pediatrics, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee ABSTRACT. Serious injuries secondary to lawn darts have not been reported. In this article two cases of penetrating skull injuries are reported. One patient developed a polymicrobial brain abscess necessitating surgical drainage and a prolonged hospitalization. Psychologic function was diminished at discharge. The second child required surgical repair of a depressed skull fracture. Thirteen lawn dart head injuries have been reported to the Consumer Product Safety Commission between 1983 and 1985. These injuries are summarized along with the reported cases to point out the seriousness (neurologic impairment in 5/10 head injuries) of such injuries and warn parents and physicians of the potential dangers of this game. Pediatrics 1987;79:261-263; lawn dart, brain abscess, penetrating head trauma. Lawn darts is an adult game played with metalweighted darts (Figure), thrown underhand from a distance of 750 to 1050 cm (25 to 35 ft) toward a small circle. Since the introduction of the game as an outdoor sport, no injuries associated with lawn darts have been reported in the medical literature. However, the US Consumer Product Safety Commission (CPSC) has received a number of reports of serious injuries related to lawn darts.1 As a result, the CPSC has banned its sale in toy stores and required warning labels on all games.2 Lawn darts currently are sold in sporting good stores and sports sections of department stores. We report two cases of penetrating head injuries and summarize head injuries reported to the CPSC to alert physicians and parents to these potentially serious and preventable injuries. Received for publication Feb 24, 1986; accepted May 2, 1986. Reprint requests to (J.S.G.) Department of Pediatrics, Children's Hospital of Wisconsin, 1700 W Wisconsin Ave, Milwaukee, WI 53233. PEDIATRICS (ISSN 0031 4005). Copyright © 1987 by the American Academy of Pediatrics. CASE REPORTS Case 1 L.U., a previously well 3-year-old girl, was struck in the head with a lawn dart that imbedded into the left parietal region about 4 cm. The dart was removed immediately by her father and she was taken to an emergency room. Physical examination at admission revealed a quiet, white girl in no distress. Vital signs were normal and she was afebrile. There was a 1.5-cm laceration over the left parietal region where the lawn dart had entered. Findings from the rest of her physical examination, including neurologic examination, were normal. A skull radiograph revealed a depressed fracture anterior to the coronal suture. Results of complete blood cell count were normal. She was immediately taken to the operating room where a jagged puncture wound was incised, bone fragments debrided, and a small epidural hematoma drained. Bone fragments, macerated brain, hair and dirt were removed from beneath a 1.5-cm laceration in the dura. After cultures were obtained from the site, the dura was closed using temporal muscle fascia. All surrounding periosteum and devitalized tissues were removed. Although cultures were negative, antibiotic therapy with methicillin, penicillin, and chloramphenicol was given for ten days. The patient was discharged after an 11-day hospital stay without evident residual neurologic damage. She continues to be entirely normal 4 years after the accident. Case 2 M.S., a 4-year-old black boy, was taken to an emergency room after he was struck in the head with a lawn dart. Findings on his physical examination were normal except for a small, 2-cm laceration to his midforehead. A skull radiograph was interpreted as normal. After the wound was thoroughly cleansed and sutured, he was given a tetanus toxoid booster injection, and his parents were instructed to follow up with his pediatrician in several days. Ten days later, he developed a low grade temperature and purulent discharge from the wound. Sutures were removed and oral penicillin was begun. The following day he was more lethargic and was noted to have marked nuchal rigidity. Results of a lumbar puncture showed WBC 1,600/μL with 63% segmented neutrophils, PEDIATRICS Vol. 79 No. 2 February 1987 261 1% band neutrophils, 23% lymphocytes, and 7% monocytes. A CT scan showed a depressed fracture and rimmed area of hypodensity in the left frontal area adjacent to the left anterior horn of the lateral ventricle, suggesting a brain abscess. The patient was transferred to our hospital where he was found to be lethargic with a heart rate of 110 beats per minute, respiratory rate of 24 breaths per minute, a BP recording of 112/58 mm Hg, and a temperature of 38.0°C. An area of cellulitis, 3 cm in diameter with a 3-mm puncture wound at the center, was present over the left mid-forehead. Greenish-yellow discharge was draining from the puncture site. Nuchal rigidity was present and except for his lethargy, the findings on neurologic examination were normal as were the rest of the physical examination findings. Treatment with intravenous penicillin G, nafcillin, and chloramphenicol was started. The brain abscess was aspirated and surgically debrided. Cultures taken from the aspirate grew Escherichia coli, Klebsiella, Clostridium septicum, Enterobacter, enterococci, and Staphylococcus aureus. All organisms were sensitive to the antibiotics selected. His postoperative course was complicated by a left epidural fluid collection at day 15 that required drainage. After 39 days of treatment with intravenous antibiotics, he was discharged. A CT scan prior to discharge showed resolution of the brain abscess with left frontal lobe atrophy. Except for a Stanford-Binet test showing mild loss of memory, he was left without evident neurologic deficit. DISCUSSION Fifteen cases of head injuries from lawn dartsthe two we report, as well as the 13 reported to the CPSC-are summarized in the Table. Of the cases reported to the CPSC, only one was reported by a physician. All others were reported by consumers or attorneys. TABLE. Summary of Lawn Dart Head Injuries Reported to the US Consumer Product Safety Commission and Two Reported Cases Age was not specified in three patients. Seven of 15 (46%) patients were younger than 5 years of age. Ten of 15 sustained head injuries. There were one facial, one neck, and three eye injuries. Although head injuries are more likely to be reported than other injuries, the nature of the game lends itself to head trauma. The weighted dart thrown from variable distances acts like a low velocity missile that accelerates as it falls from the air. Children 5 years and younger playing about the area or even watching others play the game may not be aware of the darts in the air above them. The part of the body most likely to be injured is the head, and in most cases, it is struck with sufficient force to penetrate the skull. Older children and adults are usually more aware of the darts or can better dodge a poorly thrown dart. Skull fractures occurred in at least four of the reported cases as well as in both of our patients. Of the children having skull injuries, brain injury occurred or was mentioned in 70%, and permanent neurologic damage occurred in at least 50% of the patients. It is quite likely that these patients had penetrating skull injuries. Due to the thinness of the incompletely ossified pediatric skull, relatively "minor" injuries may be associated with serious injuries to the dura and brain. In one review of intracranial pencil injuries, permanent neurologic impairment occurred in approximately 50% of patients sustaining penetrating injuries to the skull, thus substantiating the seriousness of such injuries.* Eye and neck injuries resulted from accidental trauma to an unsuspecting child during a game or from a dart that was thrown toward the victim by a playmate. Permanent eye injury occurred in two of three cases. Insufficient information was reported in the other cases to comment on outcome. Because of their seriousness, all lawn dart injuries to the head should be treated with aggressive care. A deeply embedded dart should not be removed until intracranial control of its passage has been obtained surgically. If the dart is not embedded, a skull radiograph should be taken to rule out a depressed fracture. A CT scan should be obtained on any child with a fracture to rule out an epidural bleed or dural penetration. Early exploration by a neurosurgeon of an injury is important to debride and repair the wound. In the series of patients with penetrating head injuries of Dujovny et al, all four children receiving early operative intervention did well. Miller et al3 reported similar results with early intervention. Besides the direct injury to the brain, the contaminated dart is also a source of infection. A dart contaminated with ground flora may result in a polymicrobial CNS infection similar to the abscess our patient developed. Adequate cultures should be obtained from the wound when it is debrided and broad spectrum antibiotic therapy initiated pending culture results. Delayed complications following a penetrating wound to the head are not uncommon, necessitating careful follow-up of any child with such a wound. 4,6 The cases we report, as well as those summarized, are presented to warn physicians and parents of the dangers in the lawn dart game. Although the CPSC requires a strict warning label stating, "Warning: not a toy for use by children. May cause serious or fatal injury. Read instructions carefully. Keep out of reach of children," injuries may still occur. Prevention of such injuries should include prohibiting all children from the area while the game is being played. When the game is not in use, it should be kept out of reach of all children. ACKNOWLEDGMENTS We thank Frances Sommer for secretarial assistance and Cynthia Garland for editing this manuscript. We also would like to thank Dr Allan E. Kagen and Dr David K. Dunn for allowing us to report these cases. REFERENCES 1. US Consumer Product Safety Commission, National Injury Information Clearinghouse Accident Investigations: Dart head injuries. 1983 to Present 2. Consumer Product Safety Commission: Subchapter C-Federal Hazardous Substance Act Regulations. Code of Federal Regulations 1985:373 3. Dujovny M, Osgood C, Maroon J, Jannetta P: Penetrating intracranial foreign bodies in children. J Trauma 1975; 15:981-986 4. Bursick DM, Selker RG: Intracranial pencil injuries. Surg Neurol 1981;16:427-431 5. Miller CF, Brodkey JS, Colombi BJ: The danger of intracranial wood. Surg Neurol 1977;7:95-103 6. Cross JN, Morgan OS: Delayed presentation of brain abscess following penetrating cranial wound. West Indian Med J 1984;33:201-203 Mr. FLORIO. Mr. Snow, thank you very much. Mr. SNOW. Thank you. Mr. FLORIO. We are now pleased to have as our next panel of witnesses the Consumer Product Safety Commission Commissioners. We are pleased to have the Chairman, Mr. Terrence Scanlon, Commissioner Carol Dawson, and Commissioner Anne Graham. Ladies and gentlemen, we are pleased to have you back with us. The formal statements that you have will be placed in the record. You may feel free to proceed as you see fit. Mr. Chairman, we would be happy to hear from you first. STATEMENTS OF HON. TERRENCE SCANLON, CHAIRMAN; CAROL G. DAWSON, VICE CHAIRMAN; AND ANNE GRAHAM, COMMISSIONER, CONSUMER PRODUCT SAFETY COMMISSION, ACCOMPANIED BY LEONARD DeFIORE, EXECUTIVE DIRECTOR; JAMES V. LACY, GENERAL COUNSEL; AND DAVE SCHMELTZER, DIRECTOR, COMPLIANCE AND ADMINISTRATIVE LITIGATION Mr. SCANLON. Thank you, Mr. Chairman and members of your subcommittee. I would like to introduce our panel. On my right is Jim Lacy, the General Counsel; on my far left is Doug Noble, our Associate Executive Director for the Office of Program Management and Budget. On Doug's right is Commissioner Anne Graham; on Commissioner Graham's right is Vice Chairman Carol Dawson; and on Vice Chairman Dawson's right is Dr. Len DeFiore, our Executive Director. Mr. FLORIO. We welcome you all to our committee. Mr. SCANLON. Thank you. It is a pleasure for my colleagues and me to appear before the subcommittee today to discuss reauthorization of the Consumer Product Safety Commission and its role in protecting people from unreasonable risks of injury associated with consumer products. Although no reauthorizing legislation has been enacted for the CPSC since 1981, the Senate and House have passed differing reauthorization bills in each of the last two Congresses. We hope this will be the year that a single reauthorization bill for the CPSC can be agreed on by both bodies. While our statutes are permanent law, reauthorizing legislation gives renewed congressional sanction, direction and public assur ance. When such a bill is considered, we request that it be of at least 3 years duration, or 4 years if 2 year budget cycles are to be adopted. Also, we request that authorized funding be maintained at levels sufficient to support current activities, as well as future pay and benefit increases, rent adjustments, and other such items over which we would have little or no control. Mr. Chairman, I have a brief personal statement, and I know that you are having some time problems. I would be happy to submit the rest of the Commission's statement for the record and then, if I could have 2 or 3 minutes, I would like to read a personal statement. Is that all right? Mr. FLORIO. Proceed as you see fit. Mr. SCANLON. Thank you very much. I would just like to add a few personal observations to the statement which I have just submitted for the record. Initially, let me expand on the recalls I refer to in the Commission's opening statement. In addition to the 60 recalls of items intended for use by children, there were 112 other product recalls in fiscal year 1986, bringing the total number of recalls to 172 for that year. Also, I might mention that the Commission collected $250,000 in civil penalties in fiscal year 1986, less than was collected in 1985, which was a record year, but more than in 5 of the previous 8 years. One reason I mention these figures is that concerns have been expressed about the extent to which the Commission relies on voluntary standards and voluntary corrective action plans, as opposed to mandatory action. As I see it, there are four reasons why voluntary action is preferable to mandatory rulemaking or compulsory enforcement. First, as noted in the Commission's statement, voluntary action generally produces safety benefits more quickly. Due to litigation and procedural concerns, mandatory standards can take substantially longer to develop than voluntary standards. Second, the voluntary standards system is more flexible and, therefore, can be more responsive to technological change. Mandatory standards, on the other hand, can be as time consuming to adjust as they were to implement in the first place. Third, the voluntary approach is cheaper, not only for industry and ultimately consumers, to whom the cost of doing business is always passed, but for the Commission, as well. And finally, the law points us in that direction. Section 7(b) of the Consumer Product Safety Act, as amended in 1981, specifically provides that the Commission should defer to a voluntary standard whenever it would, and I quote, "eliminate or adequately reduce the risk...and it is likely that there will be substantial compliance." However, there are occasions when a firm or industry is unwilling to develop an adequate voluntary standard or, in the case of ATV's, doesn't make timely progress in that direction. In such instances, I believe the Commission should go mandatory, which is why I supported the publication of an advanced notice of proposed rulemaking on ATV's, the first in several years, continuation of technical work leading to a mandatory performance standard on ATV's, and filing of a section 12 action on ATV's that sought public notice, vehicle labeling and rider training as remedies. If industry isn't willing to act on a product safety problem, such as providing adequate rider training for ATV's, then the Commission can and should take whatever mandatory steps may be necessary to reduce the risk. Proof that the Commission has been doing that lies in the recall and civil penalty figures that I just cited. But, for everybody's sake, let us hope that the Commission doesn't have to resort to mandatory action in every case, or even in most cases. Too many people could get hurt while the lawyers were positioning themselves and arguing in court. |