Traumatic Head Injuries from Ceiling Fans at a Pediatric Level I Trauma Center in the United States

Abstract Background/Objective: Several studies describe traumatic head injuries caused by ceiling fans in Australia, the Middle East, and Malaysia. Some injuries required neurosurgical intervention, especially those caused by metallic ceiling fans. This study describes traumatic head injuries caused by ceiling fans at a single pediatric level 1 trauma center in the Southern USA. Methods: Medical records were retrospectively reviewed for patients under 18 years of age who presented with a traumatic injury to the head from a ceiling fan from January 1, 2008, through December 31, 2021. The cohort of patients meeting all inclusion criteria was identified by querying multiple free-text fields derived from the electronic medical record, followed by a manual record review. Results: Of 60 children treated for traumatic head injury from a ceiling fan, the median age was 5.7 years and 53% were female. Laceration was the most common injury (80%), followed by scalp swelling/hematoma (20%), contusion (8%), and skull fracture (7%). Two patients (3%) with intracranial hemorrhage and fracture underwent neurosurgery. One neurosurgical case involved a metal ceiling fan and the other involved an outdoor ceiling fan. Nearly half of the injuries involved bunk or loft beds (47%) and young children were often injured while being lifted up by a caregiver (18%). Conclusion: Although most pediatric traumatic head injuries from ceiling fans resulted in minor injuries, our center saw a similar proportion of cases with skull fractures to what has been reported in Australia (5%). The effects of fan construction and blade material on the severity of head injury may warrant further study. Understanding the most common mechanisms for these injuries may guide injury prevention efforts.


Introduction
Pediatric head trauma is a significant public health concern, resulting in an estimated 600,000 emergency department visits annually in the USA [1].While there are many causes of pediatric head trauma, the leading causes of traumatic brain injury for children aged 0-14 are unintentional falls and being struck by an object [2].Ceiling fans, a common household product used to control temperature, have the potential to strike and cause traumatic head injuries in children.
Few studies have investigated ceiling fan-related head injuries in children; those that do have generally been outside the USA.Injuries often involved bunk beds, other furniture, or children being lifted into the air by an adult [3][4][5][6][7].Lacerations are consistently reported as the most common injury type, many of which require closure.Most studies also describe rare but significant cases of skull fractures and children requiring neurosurgical intervention [3][4][5][6].An analysis in Queensland, Australia, found 136 ceiling fan-related head injuries over a 5-year time span at a single emergency center, with 7 of those patients found to have skull fractures (5.1%) [3].A 2019 case series from Iraq details 29 cases of traumatic brain injuries with skull fractures from metallic ceiling fans, which are reportedly common there and may cause more severe injury than other types of fans [7].The purpose of this study was to describe head injuries caused by ceiling fans at a pediatric level 1 trauma center in the USA, including patient characteristics, injury patterns, and mechanisms of injury.

Methods
Medical records were retrospectively reviewed for patients under 18 years of age who presented with a traumatic head injury from a ceiling fan from January 1, 2008, through December 31, 2021.Hospital encounters potentially eligible for inclusion were identified using a string search of an institutional data warehouse that contains data derived from electronic medical records.Clinical event free-text fields including the history of present illness, mechanism of injury, onset, visit reason, and illness description were searched for fan, AND at least one of the following: ceiling, cieling, cilling, bunk, shoulder, jump, stand, stood, hit, strike, struck, blade, climb, lift, dresser, moving, rotating, or oscillat.These search combinations were designed to maximize the sensitivity of case identification and were validated by examining clinical event fields of known cases.The initial search yielded 171 records.Duplicate encounters were excluded (n = 38).A manual chart review was then conducted and encounters were excluded for the following reasons: no ceiling fan-related injury (n = 65), injury from a ceiling fan to a body region other than the head (n = 5), the patient left without being seen (n = 2), or the patient was 18 years of age or older (n = 1).This left 60 encounters confirmed as eligible for inclusion, with no patient treated more than once during the study timeframe.Each medical record was reviewed by trained data extractors who were not blind to the aims of the study.
Data were collected and managed using REDCap, including predefined variables related to patient demographics, history of injury, diagnoses, imaging, treatments, hospital stay, and outcomes as available.Data were analyzed using Stata SE version 17.This study was determined to be exempt and approved by the Institutional Review Board.

Patient Demographics
There were 60 patients meeting the inclusion criteria, with a median age of 5.7 years and a slight female predominance of 53.3%.The most common insurance type was Medicaid (56.7%), followed by private insurance (31.7%) and uninsured or self-pay (11.7%;Table 1).

History and Injury Types
Most injuries occurred at residential locations (98.2%), rather than in public or at businesses (1.8%).The most common mechanism of injury was a direct impact between the fan and the child's head (90.0%), followed by a fan or part of a fan falling on their head (8.3%).Nearly half of the injuries involved bunk or loft beds (46.7%).Other contributing factors included being lifted into the air by a caregiver (18.3%) or playing or jumping on a regular bed (16.7%).Injuries secondary to riding on someone's shoulders; climbing, standing, or jumping on other furniture; or someone changing a fan each occurred only once (1.7%).Predominantly older children (IQR age 5.5-7.5 years) were involved in bedrelated accidents, while younger kids (IQR age 0.6-1.2years) were more often lifted into the fan's path (Fig. 1).Lacerations were the most frequent injury (80.0%), most of which required closure (89.6%), followed by scalp swelling/hematomas (20.0%), contusions (8.3%), and skull fractures (6.7%).

Imaging and Hospital Course
Imaging was performed in 23.3% of patients.The most common study ordered among those with any imaging was a craniofacial or head CT (92.9%), followed by plain radiographs of the head or neck (14.3%).Three patients (5.0%) required admission to the hospital, with one (1.7%)requiring PICU admission (Table 1).

Neurosurgical Intervention
Two patients required neurosurgical intervention (3.3%), for a skull fracture with epidural hematoma and a depressed skull fracture with subarachnoid hemorrhage, respectively (Fig. 2, 3).Both patients recovered well from their injuries.One case involved a metal ceiling fan (Fig. 2): this presented initially as a straightforward scalp laceration and only when neurologic status deteriorated was the full extent of injury determined.

Discussion
The findings of this study are consistent with previous research, with lacerations the most frequent injury observed after children are struck by ceiling fans, and the majority of those lacerations requiring closure [3][4][5][6].It is difficult to assess the proportion of patients requiring neurosurgery in most publications because only those seen by a neurosurgery service are included, and all publications involve small numbers of children [4][5][6][7].However, we noted a similar proportion of cases with skull fractures to what has been reported in a single center in Australia [3].At least one group of authors has suggested that metal fans have the potential to cause significantly more serious injuries than fans of other materials [7], though few studies report fan material consistently.Despite only having two documented cases requiring neurosurgery in the current study, these cases highlight the potential for ceiling fan head injuries to result in significant morbidity.One case involved a metal fan, which caused significant internal injury not obvious on initial exam.Reports from additional institutions might help determine the importance of fan type to injury severity, but a more cautious clinical approach may be warranted when a metal fan is involved.
The study also found that nearly half of the injuries involved bunk or loft beds, with a predilection for kids aged 5 to 7 years.This finding corroborates prior research, which finds that bunk-bed-related injuries tend to occur most often in children under age 6 [8].These findings support the recommendation that bunk beds should not be placed too close to ceiling fans [9].Opportunities should be explored for increased national guidance and warning labels on ceiling fans and/or bunk beds.Additionally, clinicians and public health professionals may need to better inform parents of risks to patient safety.
Younger children, including infants as young as 3 months of age, were more frequently injured by being lifted into the fan's path.A similar study found that 14% of ceiling fan injuries were from this mechanism, with no analysis of age [6].The study from Iraq analyzing metal ceiling fans found that children were significantly more likely to be injured as a result of being lifted up in the first year of life [7].Our finding supports the literature that children under the age of 2 are at particular risk for liftrelated injuries with ceiling fans.
Overall, the findings of this study will help to inform public health efforts aimed at reducing the risk of ceiling fan-related head injuries in children.Injury prevention efforts may include warning labels on ceiling fans, improved design features that prevent accidental contact with the blades, and educational materials for parents and caregivers about common mechanisms of injury and how to avoid them.In addition, healthcare providers, particularly in pediatric emergency departments, should be aware of the potential for ceiling fan head injuries that can be severe and  help educate parents on injury prevention strategies.While counseling families, it is important to recognize there may be disproportionate challenges to mitigating risks from ceiling fans, especially for families with lower incomes.For instance, people who rent their homes may not have the option to change or remove a ceiling fan, and families with many household members living in smaller quarters may rely on bunk beds for needed space.
Our study has several limitations.It is a retrospective study, which means that it is subject to missing data or inaccurate documentation.We may not have been able to identify all relevant cases using our search of the data warehouse, although we think this represents a novel use of hospital administrative data in a situation where cases cannot be identified using existing coding schemes.It was also encouraging that this method correctly identified the two known neurosurgical cases.This study also likely underestimates the incidence of ceiling fan injuries because only injuries that were presented in a pediatric emergency department were included, excluding children that may have presented at adult hospitals, urgent cares, or foregone medical examinations.
The study was also conducted in a single center, which may limit the generalizability of the findings.Specifically, our center is in an area with a hot, humid climate where ceiling fan use is very common, so other centers may see fewer cases.Interestingly, we expected to find more cases in the summer months, but this was not reflected in our data.However, an unpublished analysis using an existing National Electronic Injury Surveillance System dataset shows the more expected trend of a peak during the summer months.More than half of the patients in this study had Medicaid, which is consistent with our patient population overall.We recognize that disparities exist in childhood injury, including by socioeconomic status [10], and this study may not have been robust enough to reflect such differences.

Conclusion
This study highlights the potential for ceiling fans to cause traumatic head injuries in children.Although ceiling fan-induced traumatic head injuries were predominantly minor, such as lacerations requiring closure in the emergency department, there were two documented cases requiring neurosurgical intervention.Injury prevention efforts for parents may prove beneficial, particularly warning against lifting-related accidents in younger children and loft or bunk bed-related injuries in older children.Further research is needed to evaluate the effectiveness of preventive measures and interventions to reduce the incidence of ceiling fan-related injuries in children.

Fig. 1 .
Fig. 1.Contributing factors to the mechanism of ceiling fan injuries.

Fig. 2 .
Fig. 2. CT scan of epidural hematoma and image of laceration in bone flap in a child hit by a ceiling fan.

Fig. 3 .
Fig. 3. CT scan of subarachnoid hemorrhage in a child hit by a ceiling fan.