BACKGROUND:In March 2010, New South Wales (NSW), Australia, introduced legislation mandating age-appropriate restraints for child passengers up to 7 years. This study aims to evaluate its impact on child injury rates using linked hospital and death data. METHODS:An interrupted time series using random effects quasi-Poisson regression analysed hospital-admitted injury rates in child passengers (0-14 years) in NSW, Australia, from July 2001 to March 2019. Hospital administration data were divided into prelegislation, legislation and postlegislation periods, with the legislative period spanning November 2007 to December 2011, accounting for a 6-month adaptation and enforcement grace period. RESULTS:Injury rates in children under 14 were reduced postlegislation compared with prelegislation. The average injury rate was 33% lower for children directly affected by the legislation (aged 1-6 years, incidence rate ratio (IRR)=0.67, 95% CI: 0.57 to 0.79), 25% lower for children aged 7-10 years (IRR=0.75, 95% CI: 0.65 to 0.85) and 20% lower for children aged 11-14 years (IRR=0.80, 95% CI: 0.68 to 0.94). Compared with children aged 11-14, the injury rate for other age groups decreased, though with large uncertainty in these estimates. CONCLUSIONS:The findings suggest a decrease in injuries among child passengers following legislation mandating age-appropriate restraints up to 7 years. However, similar reductions among older children and substantial uncertainty in estimates using the oldest children as controls limit attribution of the effect solely to the legislation. Combined with observational studies showing increased restraint use among children under 12 years old, the results indicate an overall postlegislation improvement in child passenger safety in NSW, Australia.

BACKGROUND:Premature graduation to an adult seatbelt is common and detrimental to optimal crash protection. While there is an existing tool (the 5-step test) to support a parent's decision to graduate their child, its effectiveness is unknown. The aim of this study was to evaluate the 5-step test. METHOD:A randomised controlled design was used. Participants were parents of children aged 7-12 years. After exposure to information about the 5-step test or control material, participants assessed belt fit in three seating conditions and 'thought aloud' while making their assessment. Seating conditions provided a good, poor and partially good seatbelt fit based on the child's anthropometry. Participants were also assessed on their knowledge of good seatbelt fit criteria. RESULTS:Participants exposed to the 5-step test (n=18) had significantly improved their knowledge of the criteria required to achieve good seatbelt with, on average, 1.0 higher score in the 6-point assessment (95% CI 0.23 to 1.7, p=0.012) than those in the control group. There was also a greater percentage of participants in this group (44.4% intervention vs 27.8% control) who made accurate decisions about seatbelt fit, but this difference did not reach significance (OR 2.08, 95% CI 0.52 to 8.34). CONCLUSION:The results demonstrate that the 5-step test is effective in improving knowledge but are inconclusive about its effectiveness in promoting accurate decision-making. However, the proportion of participants making accurate decisions in the intervention group remained low. This suggests that parents may require greater assistance than what is currently provided.

OBJECTIVE:Many children with physical disabilities need additional postural support when sitting and supplementary padding is used on standards approved child restraints to achieve this when traveling in a motor vehicle. However, the effect of this padding on crash protection for a child is unknown. This study aimed to investigate the effect of additional padding for postural support on crash protection for child occupants in forward facing child restraints.METHODS:Forty frontal sled tests at 49 km/h were conducted to compare Q1 anthropometric test device (ATD) responses in a forward-facing restraint, with and without additional padding in locations to increase recline of the restraint, and/or support the head, trunk and pelvis. Three padding materials were tested: cloth toweling, soft foam, and expanded polystyrene (EPS). The influence of padding on head excursion, peak 3 ms head acceleration, HIC15, peak 3 ms chest acceleration and chest deflection were analyzed.RESULTS:The influence of padding varied depending on the location of use. Padding used under the restraint to increase the recline angle increased head injury metrics. Toweling in multiple locations which included behind the head increased head excursion and chest injury metrics. There was minimal effect on injury risk measures with additional padding to support the sides of the head or the pelvis position. Rigid EPS foam, as recommended in Australian standards and guidelines, had minimal effect on injury metrics when used inside the restraint, as did tightly rolled or folded toweling secured to the restraint at single locations around the body of the child.CONCLUSIONS:This study does not support the use of postural support padding to increase recline of a forward-facing restraint or padding behind the head. Recommendations in published standards and guidelines to not use foam that is spongy, soft or easily compressed, with preference for secured firm foam or short-term use of tightly rolled or folded toweling under the child restraint cover is supported. This study also highlights the importance of considering the whole context of child occupant protection when using additional padding, particularly the change in the child's seated position when adding padding in relation to the standard safety features of the restraint.

Background Transitioning a child prematurely from a booster seat to the vehicle seat with seatbelt is prevalent worldwide. This type of inappropriate restraint use can worsen the severity of injuries of children in a motor vehicle crash. Despite the availability of the 5-step test (a tool to aid parents in making transition decisions), there is a lack of research on its effectiveness in changing practice. The objective of this study was to evaluate the effectiveness of the 5-step test. Methods To assess the 5-step test, a randomised controlled design was employed. The study compared parents exposed to the 5-step test (intervention group) vs. legal requirements (control group). All resources were provided in written form. After exposure, parents were asked to evaluate the suitability of an adult seatbelt when observing their child (aged 7–12 years) in three distinct belt fit conditions: good, poor, and partially good fit. Parents were prompted to verbalise their thought processes while making the evaluation and were assessed on their knowledge regarding good seatbelt fit criteria. Results Participants exposed to the 5-step test (n=18) showed a statistically significant improvement in their understanding of the criteria for achieving a good seatbelt fit. On average, they scored 1.0 point higher on the 6-point assessment compared to the control group (95% CI 0.23–1.7, p=0.012). Despite this greater knowledge, there was no significant difference between the two groups' decisions about their child's seatbelt fit (OR 2.08, 95% CI 0.52–8.34). Qualitative analysis of the 'think aloud' data indicates that parents possess some understanding of how to accurately determine a safe seatbelt fit for their child, yet also demonstrate supplementary metrics influence their decision beyond information provided in the 5-step test. Conclusion The findings indicate that the 5-step test effectively enhances knowledge but offers inconclusive evidence regarding its ability to promote correct assessments about seatbelt fit. This implies that parents may need more support than is currently available, and merely grasping the essential criteria for safe seatbelt fit may not be sufficient for correct decision making. In future, user input should be incorporated into enhanced resources for parents guiding transition from booster seats.

Background In March 2010, new child restraint legislation was implemented in NSW, Australia which required child passengers up to the age of seven travelling in a motor vehicle to be restrained in an age-appropriate restraint. There is conflicting evidence for the impact of changes in legislation. Studies that fail to find reductions in injury may be limited due to short periods of follow-up, the types of datasets used, and use of methods that assume an abrupt, specified change time-point directly aligned with date of the law change. Objective To examine injury rates in child passengers before and after implementation of new child restraint legislation in NSW, Australia in March 2010, with a legislation time-period and a control group. Methods An interrupted time series (ITS) approach in SAS was used to investigate the trends in hospital admitted injury among children aged 0–14. The data used for this analysis was collected through linked administrative datasets between 1 July 2001 and 31 March 2019. Monthly injury admission number and rate were aggregated and adjusted to the population. The temporal data was split into three time periods: pre-legislation (July 2001 – October 2007), legislation (November 2007 – December 2011), and post-legislation (January 2012 – March 2019). Results Across the study period, there were 2940 injury cases. For each age group, 213 data-points/months over the study period were analysed. When comparing children aged 11–14 years and pre-legislation period, the injury rate for age-group zero, those 1–6 years, and 7–13 years reduced by 49% (IRR= 0.51, 95% CI= 0.12–2.12), 36% (IRR= 0.64, 95% CI= 0.30–1.37), and 37% (IRR= 0.63, 95% CI= 0.27–1.47), respectively, in the post-legislation period. Conclusions The lack of detailed information on the use of child restraints in each injury case, coupled with the small sample size of severe injury cases, may limit the conclusiveness of our findings. Future research analysing media and market reports could offer a more comprehensive understanding of the impact of legislation on child restraint usage at the population level.

All children travelling in motor vehicles must be properly secured in a size-appropriate child restraint. However, for many children with a disability, standard child restraints are not suitable, and health professionals or caregivers modify restraints. There is however little data characterising these modifications. This study examined the modifications used to assist with the restraint of children aged 0-16 years with additional needs in motor vehicles. Two anonymous online surveys, one for caregivers and one for health professionals on child restraint use and modifications to seating for children with disabilities were undertaken. The quantitative and qualitative data were analysed with descriptive statistics. Eighty-six responses were analysed (40 caregivers and 46 health professionals). The majority (95.7%) of health professionals and 22.5 percent of caregivers reported having used modifications. Additional padding for postural support was the most frequently used modification (47.7% health professionals, 10% caregivers). Specialised harnesses were the most frequently used accessory used by health professionals (47.8%), with cross chest straps most frequently used by the surveyed caregivers (10%). Challenges for children with disabilities using compliant child restraints continue to persist, despite the use of modifications. There is also a lack of evidence on the impact of the modifications on restraint performance, potentially placing children at risk.

Background/Aims Off-road motorcycles and quad-bikes are an important cause of paediatric injury and hospitalisation. A small subset of riders have multiple crashes and hospitalisations, which poses a significant burden on the individual and healthcare system. Our aim was to identify characteristics and differences between those injured only once and injury recidivists. Methods A retrospective, cross-sectional study using linked data was performed of children 0–16 years in New South Wales, Australia, from 2001–2018, hospitalised due to injury from an off-road vehicle crash. Cox proportional hazard models were performed to estimate the hazard ratios for the likelihood of repeat hospital admissions. Results Of the total 6624 hospitalisations, there were 202 repeated admissions in 184 patients, the recidivism rate was 3%. This included 24 repeat admissions from quad-bikes (in 23 patients) and 178 repeat admissions from motorcycles (in 161 patients). Males were more likely to be recidivists than females (HR:3.1, p<0.01). Both motorcycles and quad-bikes riders were more likely to be re-injured on the same vehicle type (motorcycle HR:2.4, p=0.003; quad-bike HR:4.2, p=<0.001). Living in remote or very remote areas was associated with increased risk of being admitted for a subsequent quad bike injury (HR:3.5, p=0.02). Other demographic factors, body region of injury, injury severity, or type of injury did not affect the likelihood of recidivism. Conclusions Paediatric off-road riders are frequently re-injured on the same vehicle as their initial crash. A better understanding of the circumstances and contexts of these crashes may help to better target injury prevention counter-measures for recidivist riders.

OBJECTIVE:The aim of this study was to investigate the feasibility of rider-worn pelvis protection for mitigating injury risk when contacting the motorcycle fuel tank in a crash. METHODS:A newly developed test apparatus was designed and constructed to simulate the interaction between a rider's pelvis and the motorcycle fuel tank in a frontal crash. Impacts were performed at a velocity of 18 km/h into four motorcycle fuel tanks. Further testing used a rigid fuel tank surrogate and the pelvis surrogate in an unprotected condition and with a series of impact protector prototypes. A subset of prototype samples was also tested at varying tank angles (30°, 37.5°, 45°) and impact speeds (8.5 km/h, 13 km/h, 18 km/h). Analysis of variance was used to determine whether the protector prototypes reduced pelvis response compared to unprotected. RESULTS:Resultant peak pelvis acceleration was reduced by three pelvis impact protector prototypes compared to an unprotected condition. The reduction in peak acceleration occurred without a significant change in the peak pelvis rotational velocity. The pattern of protector performance was consistent at varying fuel tank angles but only reduced the pelvis response at the highest impact speed tested of 18 km/h. CONCLUSIONS:The results indicate that there may be potential for using pelvis impact protection to mitigate injury risk by absorbing and/or distributing impact energy that would otherwise be transmitted to the rider's pelvis. However, due to the current paucity in understanding of pelvis biomechanics to anteroposterior loading, it is unknown whether the pelvis acceleration reductions achieved would prevent injury.

Objective It is often assumed that a child restraint with a five or six-point internal harness provides greater protection for children in frontal crashes than a booster seat with a lap-sash seat belt. However, most research comparing these restraint types has focused on protection for children aged up to approximately 3-4 years of age. Recently, harnessed child restraints for older children up to approximately 8 years of age have become available, but there is little data on their performance compared to booster seats for children over 4 years of age. This study aimed to compare frontal crash performance of a series of harnessed child restraints for children aged 4-8 years to booster seats. Methods Four large harnessed child restraints (Type G in the Australian Standard, AS/NZS 1754:2013) and six high back booster seats (Type E in AS/NZS 1754:2013) were tested in frontal impact on a deceleration sled. Head and pelvis accelerations were recorded and head excursions were measured from high speed video. Results Head excursion was an average of 92 mm greater in the large harnessed child restraints than the high back booster seats. The initial position of the head in Type G restraints, an average of 58 mm further forward compared to Type E boosters, was the main contributor to the larger head excursion during impact. Conversely, peak head accelerations in the impact phase were, on average, 37.2 g lower in the large harnessed child restraints than the high back booster seats. Conclusions These data suggest that recommendations for harnessed restraints and booster seats for children aged 4-8 years is not as obvious as is sometimes assumed. Harnessed restraints allow greater head excursion in frontal impacts, potentially increasing the chances of head impacts, especially in vehicles with limited clearance between the restraint and the seat in front. The likelihood, and types of, incorrect use that occur in each restraint type, the vehicle occupant space, and the restraint's crash performance under ideal conditions should be considered in recommending restraints for these older children.

Serious cervical spine injuries have been documented from falls into foam pits at trampoline parks. To address the lack of evidence on how foam pits should be designed for mitigating neck injury risk, this study aimed to quantify neck loads during head-first entry into varying foam pit designs. An instrumented Hybrid III anthropomorphic test device was dropped head-first from a height of up to 1.5 m into three differently constructed foam pits, each using a different mechanism to prevent direct contact between the falling person and the floor (foam slab, trampoline or net bed). Measured neck loads were compared to published injury reference values. In the simplest, foam-only pit design, increasing foam depth tended to reduce peak compressive force. At least one injury assessment reference metric was exceeded in all pit conditions tested for 1.5 m falls, most commonly the time-dependent neck compression criterion. The results highlight the importance of adequate foam depth in combination with appropriate pit design in minimizing injury risk. The risk of cervical spine injury may not be reduced sufficiently with current foam pit designs.

Objective To compare how errors in child restraint use influence crash injury risk in rearward and forward-facing restraints for a 1-year old occupant. Methods Three convertible child restraint systems (CRS) were subjected to frontal dynamic sled tests at 56 km/h in rearward-facing and forward-facing modes in a correct use (baseline) condition and in five incorrect use conditions: loose securing belt, loose harness, partial harness use, top tether slack, and three minor errors. Excursion, head, and chest 3 ms resultant acceleration, HIC15, and neck forces and moments of a Q1 anthropomorphic test device (ATD) seated in the restraints were measured. The effect of incorrect use on each outcome and restraint type was analyzed. Results The influence of errors varied across different outcome variables, the three restraints tested and orientation modes. Excursion increased in four of five incorrect use conditions in both rearward and forward-facing orientations. A very loose harness increased four of five outcome variables in at least one forward-facing restraint, whereas only excursion was increased when rearward-facing. Overall, there tended to be a more negative effect of incorrect use (demonstrated through increases in outcome variables compared to the baseline) in the forward-facing orientation. Conclusions Overall, errors in use tended to have a larger negative impact on forward-facing restraints than rearward-facing restraints. Given the widespread nature of errors in use, this adds further weight to arguments to keep children rearward-facing to 12 months of age and older. The results also highlight a variation in response to errors across differently designed restraints, suggesting the influence of errors may be minimized by restraint design that is more resistant to errors.

This study aimed to investigate associations between demographic, anthropometric and vehicle factors and the fit of adult seat belts in children aged 7–12 years in passenger vehicles. Seat belt fit was assessed by inspection of 7–12-year-old children in their own cars. Logistic regressions examined associations between anthropometric and vehicle factors on achieving good seat belt fit. There were 40 participants included in the analysis, with 16 (40%) having good overall belt fit. The odds of achieving good overall seat belt fit increased by 15% (OR 1.15, 95% CI 1.04–1.27) with every centimeter increase in height and increased by 5% with every one-month increase in age (OR 1.045, 95% CI 1.001–1.10). Controlling for vehicle factors, neither age or height was significantly associated with overall good belt fit, and the discriminatory power of models including these metrics to predict good belt fit was 73% (AUC 0.73, 95% CI 0.55–0.91) and 74% (AUC 0.74, 95% CI 0.58–0.91). The results suggest that taller and older children have a better chance of achieving a good seat belt fit. However, with variations in seat geometry between vehicles, no single simple metric clearly defines an appropriate transition to the adult seat belt.

ObjectiveTo characterise and compare off-road motorcycle and quad bike crashes in children in New South Wales (NSW), Australia.MethodsA retrospective, cross-sectional study was performed of children aged 0–16 years, admitted to hospitals in NSW, from 2001 to 2018 following an injury sustained in an off-road motorcycle or quad bike crash, using linked hospital admissions, mortality and census data.Motorcycle and quad bike injuries were compared regarding: demographics; incidence; body region injured and type of injury; injury severity based on the survival risk ratio; length of stay and mortality.ResultsThere were 6624 crashes resulting in hospitalisation; 5156 involving motorcycles (77.8%) and 1468 involving quad bikes (22.2%). There were 10 fatalities (6 from motorcycles and 4 from quad bikes). The rates of injury declined over the study period for motorcycles, but not for quad bikes.Motorcycle riders were more likely than quad bike riders to have lower limb injuries (OR 1.49, p<0.001) but less likely to have head/neck (OR 0.616, p<0.001), abdominal (OR 0.778, p=0.007) and thoracic (OR 0.745, p=0.003) injuries. Quad bike crashes resulted in higher injury severity (mean International Classification Injury Severity Score 0.975 vs 0.977, p=0.03) and longer hospital stay (mean 2.42 days vs 2.09 days, p=0.01).ConclusionsThere are significant differences between quad bike and motorcycle crashes in injury type and affected body region. While quad bike injuries in children were more severe, there were almost four times more hospitalisations from motorcycles overall. The overall larger burden of motorcycle crashes suggests a greater focus of injury prevention countermeasures for two-wheeled riders is needed.

BACKGROUND:CT is considered the best method for vertebral fracture detection clinically, but its efficacy in laboratory studies is unknown. Therefore, our objective was to determine the sensitivity, precision, and specificity of high-resolution CT imaging compared to detailed anatomic dissection in an axial compression and lateral bending cervical spine biomechanical injury model.METHODS:35 three-vertebra human cadaver cervical spine specimens were impacted in dynamic axial compression (0.5 m/s) at one of three lateral eccentricities (low 5% of the spine transverse diameter, middle 50%, high 150%) and two end conditions (19 constrained lateral translation and 16 unconstrained). All specimens were imaged using high resolution CT imaging (246 μm). Two clinicians (spine surgeon and neuroradiologist) diagnosed the vertebral fractures based on 34 discrete anatomical structures using both the CT images and anatomical dissection.FINDINGS:The sensitivity of CT was highest for fractures of the facet joint (59%) and vertebral endplate (57%), and was lowest for pedicle (13%) and lateral mass fractures (23%). The precision of CT was highest for spinous process fractures (83%) and lowest for pedicle (21%), uncinate process and lateral mass (both 23%) fractures. The specificity of CT exceeded 90% for all fractures. The Kappa value between the two reviewers was 0.52, indicating moderate agreement.INTERPRETATION:In this in vitro cervical spine injury model, high resolution CT scanning missed many fractures, notably those of the lateral mass and pedicle. This finding is potentially important clinically, as the integrity of these structures is important to clinical stability and surgical fixation planning.

The cervical spine experiences shear forces during everyday activities and injurious events yet there is a paucity of biomechanical data characterizing the cervical spine under shear loading. This study aimed to (1) characterize load transmission paths and kinematics of the subaxial cervical spine under shear loading, and (2) assess a contemporary finite element cervical spine model using this data. Subaxial functional spinal units (FSUs) were subjected to anterior, posterior, and lateral shear forces (200 N) applied with and without superimposed axial compression preload (200 N) while monitoring spine kinematics. Load transmission paths were identified using strain gauges on the anterior vertebral body and lateral masses and a disc pressure sensor. Experimental conditions were simulated with cervical spine finite element model FSUs (GHBMC M50 version 5.0). The mean kinematics, vertebral strains, and disc pressures were compared to experimental results. The shear force-displacement response typically demonstrated a toe region followed by a linear response, with higher stiffness in anterior shear relative to lateral and posterior shear. Compressive axial preload decreased posterior and lateral shear stiffness and increased initial anterior shear stiffness. Load transmission patterns and kinematics suggest the facet joints play a key role in limiting anterior shear while the disc governs motion in posterior shear. The main cervical spine shear responses and trends are faithfully predicted by the GHBMC cervical spine model. These basic cervical spine biomechanics and the computational model can provide insight into mechanisms for facet dislocation in high severity impacts, and tissue distraction in low severity impacts.

Objective To examine the effect of age on the dynamic performance of child restraint systems in frontal crashes. Methods A sample of used (3-269 months from manufacture) and newly purchased child restraints were subjected to frontal crash simulations of more than 56 km/h and peak deceleration approximately 33 g on a deceleration sled. Restraints were monitored for evidence of damage before and after each impact. Anthropometric test device (ATD) head and chest responses and peak head excursions were recorded for rearward facing restraints using the Q1 ATD and for forward facing restraints and booster seats using the Q6 ATD. The influence of restraint age on peak 3 ms head acceleration, HIC15, head excursion, peak 3 ms chest acceleration and restraint damage were analyzed. Results In all impacts, the ATD remained within the restraint and secured to the test bench demonstrating the crash protection offered by the old and used restraints. There was no apparent relationship between ATD responses and restraint age for any restraint type. Older forward facing restraint systems had a very modest increase in forward head excursion (R-2 = 0.59, p = 0.001) of 0.27 mm for each month of age (95% CI, 0.13 mm - 0.42 mm). This equates to a 0.7% increase in the minimum measured excursion per year of restraint age. There was also a small increased likelihood of critical damage to the restraints in the simulated crashes per month of restraint age (OR 1.031, 95% CI 1.010-1.069). Conclusions Overall, degradation in restraint dynamic performance in older restraints, including some that are much older than the currently recommended 10-year lifetime, is minimal. However newer restraints may provide better protection due to marginal improvements in restraint design over time. Furthermore, the results of this study confirm previous recommendations that restraints should not be re-used after crash involvement.

During axial impact compression of the cervical spine, injury outcome is highly dependent on initial posture of the spine and the orientation, frictional properties and stiffness of the impact surface. These properties influence the "end condition" the spine experiences in real-world impacts. The effect of end condition on compression and sagittal plane bending in laboratory experiments is well-documented. The spine is able to escape injury in an unconstrained flexion-inducing end condition (e.g. against an angled, low friction surface), but when the end condition is constrained (e.g. head pocketing into a deformable surface) the following torso can compress the aligned spine causing injury. The aim of this study was to determine whether this effect exists under combined axial compression and lateral bending. Over two experimental studies, twenty-four human three vertebra functional spinal units were subjected to controlled dynamic axial compression at two levels of laterally eccentric force and in two end conditions. One end condition allowed the superior spine to laterally rotate and translate (T-Free) and the other end condition allowed only lateral rotation (T-Fixed). Spine kinetics, kinematics, injuries and occlusion of the spinal canal were measured during impact and pre- and post-impact flexibility. In contrast to typical spine responses in flexion-compression loading, the cervical spine specimens in this study did not escape injury in lateral bending when allowed to translate laterally. The specimen group that allowed lateral translation during compression had more injuries at high laterally eccentric force, saw greater peak canal occlusions and post-impact flexibility than constrained specimens.

Inappropriate or incorrect use of child restraints can influence crash injury outcome. This study examined the role of restraint factors in child passenger deaths and the effect of legislation requiring appropriate restraint systems up to 7 years old. Data for child (0–12 years) passenger deaths occurring in New South Wales (NSW) from 2007 to 2016 were collected by the child death review team including photographs, reports of in-depth crash investigation, witness reports and medical reports. Restraint use, type of restraint, appropriateness of the restraint for the age of the child and correctness of restraint use were examined. The primary contributor to death was determined in each case. Sixty-four child passengers died in NSW during the data period. Twenty-nine (29/64, 45%) were properly restrained. Thirteen children (13/64, 20%) were unrestrained. In 20 cases (20/64, 31%), children were using a restraint that was either inappropriate for their age (6) or not used correctly (14). Restraint factors were a primary contributor in 22 (22/64, 34%) child deaths. Compared to pre-legislation, appropriate restraint use was more common post-legislation (13/22. 59% vs. 30/42, 71%). However, incorrect use was also greater (3/22, 14% vs. 11/42, 26%). Interventions targeting increasing restraint use and reduction of common ‘use’ errors are needed to prevent further restraint factor-related deaths.

# Presentation CPSS1: Spinal insufficiency fracture in the geriatric pediatric spine {#article-title-2} Regular corticosteroid has become standard for slowing disease progression in Duchenne muscular dystrophy (DMD). However, patients must contend with the insidious side effect of osteopenia and