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DOI: 10.1542/peds.100.2.e2
1997;100;e2 Pediatrics
Shari L. Platt, Jeffrey S. Fine and George L. Foltin
Escalator-related Injuries in Children
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Village, Illinois, 60007. Copyright © 1997 by the American Academy of Pediatrics. All rights
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Escalator-related Injuries in Children
Shari L. Platt, MD, FAAP; Jeffrey S. Fine, MD, FAAP, ABMT; and George L. Foltin, MD, FAAP, FACEP
ABSTRACT. Objective. Escalator-related trauma is
uncommon but can cause significant injury. This study
reviewed escalator-related injuries in children to deter-
mine risk factors, types of injuries, medical interven-
tions, and long-term outcomes.
Design and Setting. Retrospective clinical patient se-
ries, Municipal Hospital Pediatric Emergency Service.
Participants. All children less than 18 years of age
who presented to the Pediatric Emergency Service with
an escalator-related injury from August 1990 through
February 1995.
Methods. We reviewed the chart and interviewed the
parent of each child by telephone. We collected the fol-
lowing information: age, gender, child’s supervision and
activity while on the escalator, escalator location, direc-
tion of motion, presence of escalator defects, nature and
extent of injury, medical interventions, and outcome.
Results. Twenty-six children had escalator-related in-
juries. The average age was 6 years (range, 2–16). Thirteen
children (50%) were 2 to 4 years old. There were 15 (57%)
boys. Eighteen children (69%) were accompanied by an
adult. All children 7 years and younger were accompa-
nied by an adult; however, 50% were not holding the
hand of their guardian. Eight children (31%) were injured
while riding improperly, ie, walking, running, playing,
or sitting on the escalator, and among these, all who were
standing fell down before the injury. Six (23%) children
were injured while stepping off the escalator. Of 9 chil-
dren less than 4 years old, 7 (78%) were riding the esca-
lator properly. Of 9 children 4 years or older, only 3 (33%)
were riding properly. Circumstances of injury included
falling down with subsequent blunt trauma, falling
down with subsequent entrapment of an extremity, and
entrapment of an extremity not related to falling down.
Locations of entrapment were between two steps, be-
tween a step and the side-rail, and between the last step
and the comb plate. Twenty-one (81%) injuries occurred
in rail or subway stations. Eight escalators were reported
to have functional or structural problems.
Seventeen (65%) children sustained lower extremity
injuries and 8 (31%) sustained upper extremity injuries.
Injuries included lacerations, avulsions and degloving
injuries of the extremities, tendon and nerve lacerations,
and digit fractures and amputations. Thirteen (50%) chil-
dren were admitted to the hospital for operative manage-
ment; the average length of hospitalization was 13 days
(range 1–29). Four children (15%) suffered significant
functional loss, and 12 (46%) sustained permanent cos-
metic deformities.
Conclusion. Children are at risk for sustaining severe
injuries on escalators. Young age, inadequate adult su-
pervision, improper activity while riding on the escala-
tor, and escalator-related mechanical problems all in-
crease the risk of injury. Public and parent education
directed toward escalator safety issues may help to re-
duce escalator-related injuries in children. Pediatrics
1997;100(2). URL: http://www.pediatrics.org/cgi/content/
full/100/2/e2; escalator, injury, child.
ABBREVIATIONS. PES, Pediatric Emergency Service; CPSC, Con-
sumer Product Safety Commission.
E
scalator-related trauma is uncommon but can
cause significant injury. After evaluating sev-
eral children with escalator-related injuries in
our pediatric emergency service, we became inter-
ested in investigating this unusual mechanism of
injury.
There are a number of case reports of escalator
injuries in children,
1–7
and one large series that in-
cludes three children.
8
In addition, a small number of
cases have been reported to the National Pediatric
Trauma Registry.
9
These reports suggest that
younger children are more frequently injured than
older children, that injuries occur when the child is
riding the escalator improperly, and that injuries
generally involve the hand, foot, or head.
We studied escalator-related injuries in children
with respect to mechanisms and extent of injury,
medical interventions required, and long-term out-
come. Our goal is to use this information to inform
and educate both health care personnel and parents
about escalator-related trauma to prevent further
injuries.
STUDY DESIGN
Bellevue Hospital is a municipal hospital serving a predomi-
nantly inner-city population in New York City and is a Level I
Trauma Center. The Pediatric Emergency Service (PES) sees 25 000
children annually. We reviewed the logs of visits to the PES from
August 1990 through February 1995. Children under the age of 18
years who sustained an escalator-related injury were included in
this study. We reviewed the medical chart for each patient and
abstracted the following historical information: age, gender,
child’s supervision and activity while on the escalator, escalator
location, direction of escalator motion, presence of escalator de-
fects, nature and extent of injury, medical interventions, and out-
come. In addition, we interviewed each child’s parent by tele-
phone to review the events surrounding the injury and to collect
additional information. Although all parents were contacted,
some information was unavailable either because the parent could
From the Department of Pediatrics, New York University School of Medi-
cine and the Pediatric Emergency Service, Bellevue Hospital Center, New
York, New York.
Poster presentation at the 35th Annual Meeting of the Ambulatory Pediatric
Association, San Diego, California, May 11, 1995.
Abstract published in Archives of Pediatric Adolescent Medicine (1995;149:92).
Received for publication Sep 16, 1996; accepted Feb 13, 1997.
Reprint requests to (S.L.P.) Bellevue Hospital Center, Department of Pedi-
atrics, New Bellevue, Room 1-South-6, First Ave and 27th St, New York, NY
10016.
PEDIATRICS (ISSN 0031 4005). Copyright © 1997 by the American Acad-
emy of Pediatrics.
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not remember certain details of the event or because the parent
was not actually with the child at the time of the event.
RESULTS
Epidemiology
Twenty-six children with escalator-related injuries
were identified. The average age was 6 years (range,
2–16; median 4.0 years). Thirteen children (50%)
were 2 to 4 years old, 4 (15%) were 4 to 7 years old,
4 (15%) were 7 to 11 years old, and 5 (20%) were 11
to 16 years old. There were 15 (57%) boys. There was
no difference in age between boys and girls.
Eighteen children (69%) were accompanied by
adults, 3 teenagers (11%) were accompanied by
friends, 1 5-year-old (4%) was accompanied by his
13-year-old sibling and 1 13-year-old (4%) was alone.
Information regarding accompaniment of three chil-
dren (12%) was unavailable. Of 12 children 7 years
old or younger for whom information is available, 6
(50%) were not holding the hand of their guardian
while on the escalator. Four of these children (67%)
fell before their injury.
Ten (38%) children were injured while riding
properly (standing and facing forward) on the es-
calator. Six of these children (60%) fell before their
injury. Eight children (31%) were injured while
riding the escalator improperly, ie, walking, run-
ning, playing, sitting, kneeling to tie a shoelace or
facing backwards, and all fell down before the
injury except for the 2 children already sitting or
kneeling. Six children (23%) were injured while
stepping off the escalator. The activity of 2 children
(8%) is unknown. Of the 18 children who were
injured while riding on the escalator, ie, not step-
ping off, and whose activity was known, 9 were
younger than 4 years and 9 were 4 years of age or
older. Among the younger age group, 7 (78%) were
riding properly, while among the children 4 years
and older, only 3 (33%) were riding properly. The
age varied for the 6 children injured while step-
ping off the escalator.
There were three types of injury events: 1) falling
down with subsequent blunt trauma, seen in 5 chil-
dren (19%), 2) falling down with subsequent entrap-
ment of an extremity, seen in 2 children (8%) and 3)
entrapment of an extremity not related to falling
down, seen in 11 children (42%). For 8 children (31%)
this information is incomplete. Of the 13 children
who suffered injury due to entrapment of an extrem-
ity, locations of entrapment were between two steps
in 2 children (15%), between a step and the side-rail
in 3 children (23%), and between the last step and the
comb plate (the metal plate at the end where the last
step slides in) in 8 children (62%).
Twenty-one injuries (80%) occurred in rail, bus, or
subway stations, 3 (12%) occurred in department
stores, 1 (4%) occurred in an office building, and 1
(4%) occurred at school. The escalator was going up
in 11 (42%) cases.
Structural escalator defects or malfunctions were
reported in 8 cases (31%) including step malfunction,
missing parts, or sudden stops. These 8 children had
a mean age of 9.1 years and 6 (75%) were riding
properly or stepping off.
Medical Data
The mechanism of injury was generally cutting,
tearing, or crushing. Seventeen children (65%) sus-
tained lower extremity injuries and 8 (31%) sustained
upper extremity injuries. Thirteen (50%) children
were admitted to the hospital for operative manage-
ment. The average length of hospitalization was 13
days (range, 1–29). Twelve hospitalized children
(92%) sustained severe lacerations, avulsions or de-
gloving injuries of the extremities, 3 (23%) sustained
tendon lacerations, and 2 (15%) sustained nerve lac-
erations. Five hospitalized children (38%) sustained
digit dislocations or fractures, and 2 (15%) had mul-
tiple digit amputations. Children who were dis-
charged from the emergency department sustained
minor lacerations, contusions or abrasions. One child
fell and fractured a tooth and 1 had a fingertip avul-
sion and fracture.
At the time of follow-up, 4 children (15%) had
significant functional loss, such as persistent abnor-
mal hand function or limp. Twelve (46%) sustained
permanent cosmetic deformities.
CASE REPORTS
Case A
A2
1
⁄
2
year old boy, was accompanied by his par-
ents and 1-year-old sibling. After stepping onto a
down-escalator located in a municipal office build-
ing, his father released the child’s hand and the child
fell. His leg was caught between the escalator step
and the side-rail.
The child sustained a 15-cm degloving injury to
the left calf (Fig 1). There were no fractures and
vascular function remained intact. Operative man-
agement included irrigation and debridement, su-
perficial peroneal nerve repair, and wound closure.
Although he was discharged after 2 days in the hos-
pital, he was readmitted for wound infection and
necrosis. A skin graft was performed and he was
discharged after 14 days. At follow-up the child had
a viable skin graft and was ambulating normally.
Case B
A 9-year-old boy, accompanied by his father, was
riding an up-escalator located in a subway station.
The escalator was reported to be missing a piece of
the comb plate creating a large gap. The patient’s
foot became entrapped in the escalator just before
stepping off. The escalator was stopped and required
disassembly to extricate the foot.
The child sustained an extensive plantar avulsion
of the left foot with open fractures of the first and
second metatarsal shafts, dislocation of the fifth
metatarsal-phalangeal joint, and crush injury of the
third metatarsal head. Open reduction and internal
fixation and skin grafting were performed (Fig 2 and
Fig 3). The child was hospitalized for 26 days, and
convalesced at home for more than 1 month after
discharge. At follow-up, the foot remained deformed
with abnormal function.
DISCUSSION
There is little information in the medical literature
about escalator-related injuries in children. Over the
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26 years covered by the on-line Index Medicus, there
are 25 case reports of children injured on escala-
tors.
1–8
Of 32 754 injuries recorded by the National
Pediatric Trauma Registry between 1988 and 1992,
only 18 were escalator-related.
9
The Consumer Prod-
uct Safety Commission (CPSC) reported that 7300
escalator-related injuries were treated in emergency
departments in 1994.
10
It is apparent that, although uncommon, signifi-
cant injuries can occur to children while riding on
escalators. The most serious escalator-related injuries
we observed were degloving injuries of an extremity
with extensive soft tissue damage. There were also
many neurovascular, tendon, and digit injuries.
These injuries frequently required operative man-
agement and many resulted in functional or cosmetic
deformity. Head and facial trauma may also occur
after falling while riding an escalator.
Murphy and Moore
8
reviewed 50 patients who
sustained escalator-related trauma. Their conclu-
sions about a primarily adult population were that
escalator-related injuries were associated with alco-
hol consumption, age over 70 years, and walking on
a moving escalator.
In our review we tried to gain further insight into
the epidemiology of escalator-related injuries in chil-
dren and the behavioral factors that may play a role.
There was no apparent relationship of gender to
injury. Younger children were more likely to be in-
jured while riding escalators properly, usually after
falling down. Lack of supervision and hand-holding
may have been causative factors for the initial fall.
Older children were more frequently injured when
riding the escalator improperly, ie, while playing,
running, or walking, because these activities led to
falls. According to the CPSC, 75% of reported esca-
lator-related injuries are attributable to falls.
10
Stairs
are a common site for fall-related injuries in tod-
dlers.
11,12
It is not surprising, then, that young chil-
dren should have difficulty with moving stairs.
Fig 1. Case A. Degloving injury to the
calf in a 2
1
⁄
2
-year-old boy, due to entrap-
ment between the escalator step and the
side-rail.
Fig 2. Case B. Plantar avulsion of the
foot with metatarsal fracture and dislo-
cation in a 9-year-old boy, due to en-
trapment between the escalator step
and the comb plate while stepping off
the escalator. Intraoperative view.
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In our series, the action of stepping off the escala-
tor was also associated with an increased risk of
injury. Young children may remain standing on the
escalator and allow their feet to slide off at the end,
instead of actually stepping off. The small size of a
child’s foot might increase the risk of it slipping into
the gap where the last step slides into the comb plate.
While stepping off an escalator may seem like a
simple and natural task to an adult, the developmen-
tal level of young children limits their ability to both
anticipate and coordinate this action. In addition to
feet becoming entrapped during the process of step-
ping off, children’s small extremities may become
lodged between two steps or between a step and the
side-rail. According to the CPSC, 20% of recorded
injuries occur when hands, feet, or shoes become
entrapped.
10
Structural or mechanical escalator defects may also
contribute to injuries, especially in older children
who are riding properly. Escalator direction was not
related to the injury. Escalators in rail and subway
stations were most frequently associated with injury
in our sample. Contributing factors may be high
volume, poor lighting, or an insufficient number of
caution signs located on subway station escalators.
Seven of eight escalators that were reported to have
structural defects were located in rail and subway
stations.
There are several limitations to this retrospective
review. Some cases may have been missed. Parents
were interviewed to obtain additional details and
their recall may have been inaccurate or biased.
Some parents did not actually witness the exact
mechanism of injury, since it “all happened so fast.”
There may have been some ascertainment bias in this
series because Bellevue Hospital is a regional Micro-
vascular Surgery and Limb Reimplantation referral
center and it is possible that we had an inordinate
number of serious injuries triaged here from the
field. Minor injuries may have been triaged to other
institutions or may not have led to any medical eval-
uation whatsoever. Nonetheless, most of the patients
were transported by prehospital providers from
within our usual geographic catchment area. An-
other limitation is that the true injury risk cannot be
calculated because the total number of children
riding escalators (the denominator) is unknown. Ad-
ditionally, we do not know the frequency with which
children ride particular escalators. Although rail and
subway stations were identified as the most common
site for injury, it may be that escalators in these
locations were more frequently utilized by children.
Finally, the small sample size may limit our ability to
generalize our conclusions; however, this is the larg-
est single series of pediatric escalator injuries re-
ported to date.
In conclusion, children are at risk for sustaining
severe injuries while riding on escalators. Until
health care personnel and parents become aware of
these injuries, we cannot hope to prevent them. Pre-
vention of escalator-related injuries should be a pri-
mary goal and efforts should be focused in two di-
rections. Anticipatory guidance regarding injury
prevention should include information about riding
on escalators. Primary care providers can encourage
increased parental supervision, such as hand-hold-
ing or even carrying of young children while riding
on and especially while stepping off escalators. Chil-
dren should be taught not to run, play, or sit while
riding on an escalator. Children should face forward
and hold the handrails. In addition, education can
take place in other venues. The New York City Tran-
sit Authority promotes escalator safety through an
educational campaign that includes elementary
school programs, improved escalator safety caution
signs and posters, and distribution of safety litera-
ture. One organization, The Elevator Escalator Safety
Foundation, has developed a school-based education
program to promote escalator and elevator safety.
13
The CPSC has issued a “Safety Alert” regarding es-
calators (Fig 4).
10
Passive preventive efforts may have greater bene-
Fig 3. Case B. The same foot as in
Fig 2, after repair and skin graft pro-
cedure.
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fit than behavioral recommendations. Improved de-
sign and maintenance may reduce escalator-related
injuries. Regulations must ensure frequent inspec-
tion and appropriate escalator function. Improved
lighting and warning signs, painted borders on steps
and easily accessible emergency shut-off buttons
may also aid in injury prevention. The American
Society of Mechanical Engineers/American National
Standards Institute Escalator Committee have issued
voluntary standards for safe escalator function and
maintenance.
14
Central reporting of escalator injuries
may serve to better delineate risk factors for injury
and identify problem escalators.
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Fig 4. Recommendations adapted from CPSC Escalator Safety
Alert.
10
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DOI: 10.1542/peds.100.2.e2
1997;100;e2 Pediatrics
Shari L. Platt, Jeffrey S. Fine and George L. Foltin
Escalator-related Injuries in Children
& Services
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