The terrible truth about toppling televisions

Abstract

OBJECTIVE

To determine the profile of children’s injuries resulting from television tipovers and to evaluate the potential in a paediatric health centre for television sets to be tipped by young children.

DESIGN

The present study was conducted by case report review, a retrospective audit of a regional subset of the Canadian Hospitals Injury Reporting and Prevention Program database, and prospective testing of all child-accessible television sets for potential tipping using a static model of a climbing child.

SETTING

Children attending the emergency department of a regional paediatric health centre who reported injuries resulting from a television tipover to the Canadian Hospitals Injury Reporting and Prevention Program were studied. All child-accessible television sets within the same regional paediatric health centre were included in the study.

MAIN OUTCOME MEASURES

The main study outcome measures were the demographics and profile of television tipover injuries encountered, and the failure rate of child-accessible televisions to maintain stability when tested using a static model of a climbing child (four years of age at the 90th weight percentile).

RESULTS

At least 104 children reported injuries related to televisions tipovers between 1990 and 2002. The majority occurred in two-to four-year-old children, and 61% occurred in boys. The most common areas to be injured were the head and neck. Within the hospital, 90% of child-accessible televisions were tippable by children four years of age or younger.

CONCLUSIONS

Television tipovers have the potential to cause significant childhood injuries. Because television sets were not safely maintained within one paediatric health centre, one can only speculate about television safety in homes. Parents need to be educated about this injury risk, and standards for the anchoring of televisions are needed.

In 2000, 98.9% of Canadian households had at least one television set (1). Over the past decade, television screen sizes have increased. This has created a hidden danger in many households, of which many parents and medical professionals are unaware. Cathode ray tube (CRT) televisions, by nature of their anterior weight placement, are very easily tipped, putting children at risk of injury. Significant injuries and deaths have occurred due to tipped televisions. There is evidence that the number of these injuries has been increasing (2,3). In 2005, the popular press reported two cases of significant injury related to televisions in Ontario, in which one child died and the other was sent to the intensive care unit (ICU) (4,5).

CASE PRESENTATION

A four-year-old boy pulled a 68.5 cm television onto himself, with the television landing on his face. He spoke a few words and then lost consciousness. His mother was at home but did not witness the accident. She reported that the television sat on a homemade stand 81 cm high, with a ledge at the front that her son would often grab to pull himself up.

The boy was taken to a regional health care facility. His left pupil was dilated, and mannitol was administered. He was transported via air to a paediatric tertiary care hospital.

A computed tomography scan on arrival to the hospital indicated large bilateral extradural hematomas, with the right greater than the left in the posterior occipital areas and anterior elevation of the torcula. The left tonsils were nearly herniated and there was associated lateral and third ventricle dilation. Bone views show occipital fracture extending from just to the right of the midline at the foramen magnum ascending up to the lambdoidal suture.

The patient was taken immediately to the operating room, where he had evacuation of epidural hematoma and occipital craniotomy. He was managed in the ICU post-surgery. He was discharged from the hospital after 109 days with significant neurological deficits. He could walk a few steps independently, and his speech consisted of gesture and a few single words.

METHODS

As a result of the authors’ experience with this patient, a retrospective analysis of all television-related injuries in the local health region between 1990 and 2002 was obtained from the local Canadian Hospitals Injury Reporting and Prevention Program database (CHIRPP).

The CHIRPP is a computerized injury surveillance program that operates in the emergency departments of selected Canadian hospitals (6). It began in 1990 in 10 Canadian paediatric hospitals and has since expanded to include six general hospitals. When an injured child is brought to the emergency department of a participating paediatric institution, the accompanying adult (or child, if he or she is old enough) is asked to complete a one-page questionnaire. The attending physician completes the other side of the questionnaire. In this way, important information is collected about the mechanism and nature of the injury, and any body parts affected. In 2001, it was estimated that the completion rate for CHIRPP forms at the IWK Health Centre (Halifax, Nova Scotia) was 69% (Merida MacNeil, IWK Health Centre CHIRPP Information Officer, personal communication). The emergency department at the IWK Health Centre provides injury care for children under the age of 16 years, and for older children whose health problems are being actively followed within the health centre. Not all injured children attend this health centre because there are two other emergency facilities within Halifax county, both of which provide care to children.

In addition, a static model of a climbing child at different ages was constructed (Figure 1). This model was created for children at two, four, six and eight years of age, with age-appropriate proportions including weight at the 50th and 90th percentiles (7,8). The model was constructed from a piece of wood with holes drilled at the age-appropriate centre of gravity and heel-shoulder length. Pieces of rope with appropriate arm length were attached to the board at one end and C-clamps were attached to the other end to simulate hands. Feet were also simulated by using C-clamps; these clamps were attached to the console/floor, and then the board rested on these clamps. This allowed for the simulation of a child standing on the console. Weights for the 50th and 90th percentiles were then attached at the centre of gravity. This static model was attached to all child-accessible (eg, any television that was not bolted to the ceiling or within 60 cm of the ceiling) television consoles within the hospital to determine whether they could be tipped. Any television that could be tipped by a child four years of age or younger with a weight in the 90th percentile or less was considered to be a failure.

Figure 1.

Television tipping model

RESULTS

At least 104 childhood injuries related to televisions were encountered between 1990 and 2002. Thirty-eight per cent of these accidents occurred in the two- to four-year-old age range (95% CI 29 to 49), with 65% occurring in children four years of age or younger (95% CI 55 to 74). Over one-half of the accidents occurred in boys (61%), and 91% of the accidents occurred at home. Head and neck injuries were the most frequently encountered (47%), followed by those to the hip and leg (28%) (Table 1).

TABLE 1.

Relative distribution of injuries by site

Body parts injured	Number of children	Proportion, %	95% CI
Head and neck	49	47.1	37.3 to 57.1
Trunk	7	6.7	3.0 to 13.9
Shoulder and arm	14	13.5	7.8 to 21.9
Hip and leg	29	27.9	19.8 to 37.7
Other	5	4.8	1.8 to 11.4
Total	104

Within the hospital, 49 child-accessible televisions were found and tested with the static climbing model. The median television screen size was 53 cm, with the average height above ground being 92 cm (range 55 cm to 134 cm). Fifty-seven per cent of the televisions were on metal (22 of 49) or plastic (six of 49) trolleys with wheels. Other types of consoles included wooden cabinets and console furniture, as well as on top of cupboards. One unrestrained television on console furniture had cracks in the plastic shell at the upper corners, which indicated a previous tipping event. Only 37% of televisions were anchored, either via screws or tethers.

Using the static model of a child, 90% of the accessible televisions were found to be tippable by a child four years of age or younger, and 39% of the consoles were able to be tipped by a two-year-old child (95% CI 25 to 54).

Of the five accessible televisions that were deemed safe, one was able to be tipped by an eight-year-old child. Of the remaining four televisions, one was on a large trolley, two were in custom-built enclosures with smooth laminate surfaces (deemed unclimbable), and one was on top of a large box-like structure (also deemed unclimbable).

The weight of a two-year-old child was able to tip 25% of anchored televisions versus 52% of unanchored televisions. This difference failed to reach statistical significance.

DISCUSSION

Televisions are now a mainstay for entertainment in our society. Over the past several years, televisions have become larger and heavier (3,9). Conventional CRT televisions are remarkably front-heavy, with almost all of their weight located in the glass CRT funnel and the panel. Televisions are often placed in an elevated position to maximize viewing. Because these televisions are larger, heavier and elevated with a tendency to topple anteriorly, the potential for significant injury to children is substantial.

Although the literature related to this topic is scarce, previous papers have noted an increase in the number of television-related injuries from 1994 and beyond (2,3). In the past year in Canada, the popular press has reported at least two cases of television-related injuries, one resulting in long-term stay in an ICU and the other in death (4,5). The majority of television-related injuries occurred between the ages of one and four years, and the majority of these injuries involved boys (2,3,10–12). The most common area of injury was the head (2,3,10,12). Scheidler et al (2) noted that 93% of television-related injuries are unwitnessed. Mortality rates range from 0% to 11%, and permanent neurological sequelae occurs in 50% of the children (2,3,10,11). Our patient, who suffered permanent neurological sequelae from his injury, seems to fit this profile. Bernard et al (12) commented that television stands and dressers are the most popular type of console, yet there was no comment with respect to the prevalence of restraints. There is a consensus in the literature that televisions should be anchored, placed either on the ground or appropriate console, and that more public awareness is required (2,3,10–14).

Television-related accidents are likely more frequent than appreciated. Looking at the CHIRPP data from the Nova Scotia region, 104 children have sustained injuries related to tipping televisions, 65% of which occur in children four years of age or younger. Furthermore, the majority of these incidents occurs in boys. Similar to the aforementioned data, head and neck injuries were most frequently encountered. An examination of the child-accessible televisions within our regional paediatric hospital found that 90% were tippable by a four-year-old child with weight in the 90th percentile, and that 39% were tippable by a two-year-old child with weight in the 90th percentile. We were able to show a trend toward increased safety for younger children with anchored sets. Even with anchored televisions, it is obvious that television sets may not be safely stored in paediatric hospitals. Thus, one can only speculate about the state of television storage and the risk of television tipover injuries in Canadian households with children.

The data from the local CHIRPP database, although useful in profiling these injuries, represented information from one regional paediatric hospital from one province, and may not be generalizable. Data entry forms are completed by parents on a voluntary basis. When significant injury occurs that requires immediate care, the forms are often not completed (as occurred in our case presentation). This results in fewer injuries being reported, particularly the more severe injuries. Finally, there is no denominator available, resulting in an inability to calculate injury rates.

We chose to use a four-year-old child as the standard for tipping televisions using our static model because our CHIRPP data and the medical literature suggest that children four years of age or younger are most frequently injured by tipped televisions. We used a weight in the 90th percentile to be inclusive of most four-year-old children. Our static model of a climbing child was somewhat flawed because climbing children can generate greater forces and torque than we tested. Thus, the failure rate for the tested televisions could only have been higher. To best simulate a child, a dynamic model should have been used.

CONCLUSION

Paediatricians need to be aware of this silent epidemic and to act to prevent future tragedy. Anticipatory guidance about television tipping injuries should be provided to the parents of toddlers and younger children. The public needs to be educated about this injury risk, and standards requiring the anchoring and storage of televisions are required.