December 2002 Bulletin

Childhood pedestrian injuries preventable, orthopaedists show

Community interventions result in a 61 percent decrease in pedestrian injuries

By Carolyn Rogers

Pedestrian injury is second only to cancer as the leading cause of death in children between five and nine years of age. According to a recently completed study published in the Journal of Bone and Joint Surgery (May 2002), however, the incidence of childhood pedestrian-motor vehicle trauma can be greatly reduced with the help of environmental and community interventions. 

Thomas S. Renshaw, MD, study co-author and chief of pediatric orthopaedics at Yale University School of Medicine in New Haven, Conn., reported on the study during the AAOS "Orthopaedics Update 2002" Web conference on Oct. 16, 2002. Dr. Renshaw’s co-authors were orthopaedic surgeons Gregory A. Merrell, MD, and Jon C. Driscoll, MD, department of orthopaedic surgery, and Linda C. Degutis, DrPH, department of surgery, Yale University School of Medicine.

"In 1994, we examined the frequency and location of pediatric pedestrian injuries that had occurred over an 18-month period in New Haven—from June 1992 through December 1993," explained Dr. Renshaw. "Over the next several years, five interventions were implemented in the community. Six years later, we reexamined these injury rates and found substantial decreases in pediatric pedestrian injuries."

Collecting the data

The data on pediatric pedestrian injuries were collected from two sources—the New Haven Police Department accident database and the Children’s Hospital at Yale/New Haven Hospital Emergency Department records.

"Both sources were used because some pedestrians struck by a motor vehicle are brought to the emergency room without a police report being filed, and conversely, some cases are reported to the police, but medical attention is not required or sought," Dr. Renshaw explained.

The findings

Pedestrian-motor vehicle collisions had decreased a full 61 percent—from 223 in 1992-1993 to 87 in 1998-1999, the data showed. The five-to-nine year age group showed the greatest decrease in pedestrian injuries, from 78 incidents to 27 incidents—a 65 percent drop. This age group also was found to be most at risk for injury, accounting for more than 30 percent of the incidents in 1998-1999.

Fifty-three percent of incidents occurred between the hours of 3 p.m. and 8 p.m., it was found, and boys were more commonly involved than girls, by a ratio of 2-to-1.

Five interventions

During the six-year span between the two fact-finding periods, New Haven officials implemented five initiatives that may account for the decrease in injuries:

"The factors that traditionally affect the frequency of pediatric pedestrian injuries had not changed meaningfully between 1992 and 1999," Dr. Renshaw pointed out. "These included population, traffic volume, speed limits, laws allowing right turns at red lights, parking regulations, public parks, one-way streets, crosswalks and crossing guards."

The five interventions instituted in New Haven were:

  1. Traffic safety education
    "Traffic safety education was completely transformed in the New Haven Public School System," Dr. Renshaw reported. Prior to 1991, traffic safety education was not a formal part of the curriculum. Beginning in 1991 this education was provided twice a year for every elementary schoolchild who rode a bus to school. In 1995, the education was expanded to include all grade levels.
  2. Expanded school busing
    School busing increased greatly in the 1990s as schools were integrated citywide and magnet schools were created. In 1992, approximately 35 percent of public school children rode a bus to school. By 1999, that number grew to 73 percent.
    Additionally, there was an increase in the number of door-to-door pick-ups rather than the use of bus stops to pick up a large number of children.
    "We speculate that this had two effects on pedestrian safety," Dr. Renshaw said. "First, the risk of children being hit by a motor vehicle is associated with the number of streets they have to cross, and door-to-door pickups substantially decrease that number. Second, when a child who previously had a short walk to school begins to ride the bus instead, he or she may return home 30 to 45 minutes later, decreasing the number of daylight hours of exposure to traffic hazards."
  3. Safe driving campaign
    In 1996, New Haven sponsored an initiative to promote safe driving. This campaign included flyers in public areas, mailings and billboards. A revised version, called "Drive Smart—Do Your Part," was launched in 1999.
  4. Decentralized public housing
    New Haven began decentralizing its public housing in 1990. The largest complex was gradually vacated and was demolished in 1999, the study showed.
    "In the first portion of this study, we found a significant relationship between child population density and pedestrian injuries," Dr. Renshaw said. "However, after New Haven changed from a strategy of concentrated public housing to one of more even distribution of low-income families around the city, the overall incidence of pedestrian injuries has remained low."
  5. Increased traffic tickets, warnings
    Beginning in 1999, police officers, as part of a department-wide initiative, were encouraged to increase the number of traffic tickets and warnings that they issued. Police resources were concentrated at known high-risk areas during times associated with a high frequency of collisions.

"The effect of this campaign may or may not be a causal factor in the decreased number of incidents, since it was started relatively recently," the authors noted.

Other cities follow, see similar decreases

Although additional studies over longer periods of time may be necessary to determine whether the improvements will be permanent, similar results have been reported in other locations. A substantial decrease in pedestrian injuries also has occurred as a result of pedestrian safety programs in four Alabama schools, as well as in Milwaukee, Los Angeles and Columbus, Ohio. 

The authors believe their study can be used as a model for other communities to collect data and effect positive change.

"This study demonstrates that reductions in childhood pedestrian injuries can be achieved without changing some of the intractable problems that correlate with pediatric pedestrian injury, such as poverty," they write. "To the best of our knowledge, this is the first long-term study of citywide initiatives that proposes methods to drastically reduce pediatric pedestrian injuries."

Added Dr. Renshaw: "This work suggests an opportunity for orthopaedic surgeons and others to provide an impetus for change in their communities."

To start the authors say communities should:

  1. Identify the areas where accidents are most frequent.
  2. Look at when accidents happen.
  3. Determine how many children live in the area.
  4. When the facts have been assembled, design a plan.

Additional safety initiatives

The authors also suggest a number of additional initiatives communities might consider when developing a plan to reduce child pedestrian injuries.

According to Dr. Renshaw, most pedestrian-motor vehicle accidents happen due to driver distraction. "Cell phones are a huge factor—there is no way a driver can devote his full attention to the road while he’s on the phone."

In addition to banning the use of cellular phones while driving, the authors suggest:

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