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1 Q1 Vacuum cleaner friction injuries in paediatrics. A 10 year review

2 looking at national trends
3 Q2 Karl Walsh * , Mohamed Osman-Elabd, Zeeshan Sheikh, Ali Soueid
4 Paediatric Burns Centre, Royal Manchester Children’s Hospital, Manchester University Foundation Trust, Oxford Road,
5 Q3
Q4 Manchester, M13 9WL, United Kingdom
Q5

article info abstract

Article history: Our regional burns service has gained experience in managing paediatric hand friction burns due to vacuum
Accepted 1 September 2021 cleaners (VC).
Available online xxx We aimed to evaluate our 10 year experience managing these injuries as well as reviewing national data trends in
order to identify those at risk of injury.
Materials and Methods: A International Burns Injury Database (IBID) request was made to review the number of
6 Keywords:
burn injuries recorded due to Vacuum cleaner injuries (VCIs). In addition, a local IBID request was made to
7 Friction burns
identify the number of burn injuries managed within our regional burns service.
8 Burns
Results: We identified 288 VCIs which have increasingly occurred in England and Wales between 1996
9 Paediatrics
2020 and 32 children who sustained these injuries within our regional burns service. A general theme from
10 Vacuum cleaner
both national and local data highlighted that these injuries occurred in males (78%, n=25) with a mean age of
11 Hands
20 months (9 months 4.5 years) affecting children’s hands (94%). In 25 cases (78%) these injuries involved an
interphalangeal joint. 85% (n = 27) of injuries were deep dermal/full thickness with eleven children (34%)
requiring surgical excision and skin grafts.
Q7 Discussion: Significant paediatric burn injuries can be sustained from VCs. Greater awareness is required of these
injuries and legislation is necessary in order to improve the safety of vacuum cleaners. International burn societies
are urged to collect data of these injuries in order to co-ordinate improved prevention strategies and change within
the VC industry.
© 2021 Published by Elsevier Ltd.

Our regional burns service has encountered a number of full thickness 21

12 1. Introduction paediatric hand friction burns in recent years due to vacuum cleaners. As 22

reported by Joshi et al., hand friction injuries can result in poor functional and 23
13 Over 5 million vacuum cleaners are annually sold in the United Kingdom aesthetic outcomes [6]. In 2017, the European Union introduced legislation 24
14 [1,2]. Dust removal traditionally was performed by beating fabric without to improve the energy efficiency of vacuum cleaners and limit the noise 25
15 the use of machinery. Within a century, electrical vacuum cleaners have emitted from vacuum cleaners to 80 decibels [7]. Unfortunately, the 26
16 evolved resulting in lighter and more powerful devices, weighing as little as legislation did not address improving child safety which likely represents a 27
17 3 kg (compared to 43 kg a century ago) with greater airflow [3]. Within the lack of awareness of vacuum cleaner injuries amongst the public and those 28
18 recent two decades vacuum cleaners have more elaborate features with within the manufacturing industry. 29
19 greater adjustability in the size and shape of devices. The description of how Friction is the force generated when two surfaces slide against each other. 30
20 vacuum cleaners operate is demonstrated in Fig. 1 [4,5]. The friction force is determined by two factors; the force perpendicular to the 31

* Corresponding author.
E-mail addresses: drkcwalsh@gmail.com (K. Walsh), Mohamed.Osman-Elabd@mft.nhs.uk (M. Osman-Elabd), edplasticsteaching@gmail.com (Z. Sheikh),
alisoueid@hotmail.com (A. Soueid).
https://doi.org/10.1016/j.burns.2021.09.001
0305-4179/© 2021 Published by Elsevier Ltd.

Please cite this article in press as: K. Walsh, M. Osman-Elabd, Z. Sheikh et al. Vacuum cleaner friction injuries in paediatrics. A 10 year review looking at national
trends. Burns (2021), https://doi.org/10.1016/j.burns.2021.09.001
 JBUR 6530 1 6

2 burns xxx (2021) xxx xxx

Fig. 1 – The electrical vacuum cleaner. An electrical current powers the motor to spin the fan (left) as well as turning the brush bar (right) spinning. The brush bar
beats the dust from the carpet. Meanwhile air is pushed through the fan creating a pressure gradient from the front and back of the fan and thus a vacuum for dust
particles to be suctioned into the device [4].

32 contact surface and the friction coefficient (the ratio of force determined by In addition, an IBID request was made using the terms ‘vacuum cleaner’ 53
33 the material properties of the two surfaces coming into contact) [8]. Deep to identify the number of registered friction burns sustained in England and 54
34 dermal/ full thickness injuries are sustained as a result of a thermal and Wales between 1996 2020. Within our request we aimed to identify patient 55
35 mechanical insult [8]. This is due to thermal energy produced as a result of demographics, the size, depth and location of the injury as well as the 56
36 friction as well as the mechanical disruption of the structural and vascular management. 57
37 integrity of the skin. Vacuum cleaner injuries occur as the bristles of the
38 brush bar move up to 90 rotations/second against the surface of the child’s
39 skin [9]. 3. Results 58
40 To our knowledge we are unaware of any large case series or any national
41 statistics reporting hand friction injuries due to vacuum cleaners. We 3.1. Manchester centre results 59
42 therefore aimed to evaluate our experience of these injuries and review
43 national data to identify those most risk of injury, raise public awareness and 32 children presented with friction injuries by vacuum cleaners over a 60
44 determine the need for greater legislation for the manufacturing industry on 10 year period from 2010 to 2020. 30 children presented with hand injuries 61
45 improving safety. (94%). One child presented with a toe injury (3%) and another child 62

sustained a thigh injury (3%) (Fig. 2). 63

The mean age of the children was 20 months of age (range: 9 months 64
46 2. Methods and materials 4.5 years of age) (Fig. 3). This injury was most prevalent in males 65

(n = 25, 78%) with the injury predominantly occurring in the living room 66
47 A 10 year retrospective study (October 2010 January 2020) was undertaken (n = 19, 59%) (Table 1). 67
48 at Royal Manchester Children’s Hospital (RMCH) using our regional The left hand was most commonly injured (n = 18, 60%), typically 68
49 International Burns Injury Database (IBID). This identified 32 patients who affecting the volar surface (n = 25, 83%). In total 43 fingers were injured (due 69
50 sustained vacuum cleaner friction burns between October 2010 and January to injury of more than one digit). Eleven children injured just one digit, eight 70
51 2020. Case notes were reviewed identifying patient demographics, details of children injured two digits, 4 children injured three digits and 1 child 71
52 their injuries and their treatment. sustained injury to 4 digits. Of the thirty injured hands, five children (17%) 72

sustained injury to the hand without sustaining an injury to their digit. The 73

Fig. 2 – Incidence of VCI/year attending the Royal Manchester Children’s Hospital. N.B, 2020 results included results in January 2020.

Please cite this article in press as: K. Walsh, M. Osman-Elabd, Z. Sheikh et al. Vacuum cleaner friction injuries in paediatrics. A 10 year review looking at national
trends. Burns (2021), https://doi.org/10.1016/j.burns.2021.09.001
 JBUR 6530 1 6

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74 mean estimated total body surface area (%TBSA) was 0.2% (range 0.1 Table 1 – Location in the house where injuries occurred.
75 0.5%) and typically involved the joint of the child’s hands (n = 24, 80%).
76
Location Incidence %
Fig. 4 demonstrates the preponderance for injury to interphalangeal joints
77 and digital injury. Dorsal hand injuries occurred in 7 patients (23%). Injuries Living room 63% (n = 20)
78 sustained to both upper and lower limbs were deep dermal / full thickness
Kitchen 13% (n = 4)
79 Hallway 9% (n = 3)
injuries in twenty seven cases (85%). No fracture, tendon or neurovascular
Stairs 3% (n = 1)
80 injury was reported in the case series. Dining room 3% (n = 1)
81 All injuries occurred whilst using an upright vacuum cleaner with a Bedroom 3% (n = 1)
82 rolling brush bar. Except in one case, all children sustained injury whilst sat Unknown 6% (n = 2)
83 or crawling in front of the vacuum cleaner and placed their limb under the
84 device whilst a parent was operating it with the base on the floor. One injury
85 occurred when a parent left the vacuum cleaner on the sofa with the base
86 exposed in which the child climbed onto the sofa and placed his hand onto the
87 spinning brush bar. In 10 cases, the parent did not see the actual injury happen
88 but saw the child cry after moving their limb away from the vacuum cleaner.
89 In the remaining cases, the parents witnessed the injury.
90 Fig. 5 demonstrates the method of management for these types of
91 injuries, including the which dressings were used. All patients who sustained
92 deep dermal/full thickness dorsal injuries were managed with split thickness
93 skin grafts (STSGs) (n = 6) whilst those with volar injuries were managed
94 with dressings (n = 21) or full thickness skin grafts (n = 4). All patients with
95 deep burns were initially dressed with flamazine prior to surgical
96 debridement. One patient underwent surgical debridement and subsequently 117
97 managed with dressings only. Flamazine was used to dress these injuries in 118
98 the majority of cases (16 patients), whilst Betadine (n = 4) and honey based 119
99 dressing (n = 2) were used less frequently. The choice of dressing was based 120
100 upon senior clinical preference with no standardised protocol. 121
101 The mean length of time to wound healing with a skin graft compared to 122
102 Fig. 4 – Incidence of the site of injury to the hand. 123
dressing management was 22 days and 18 days respectively. Scarring was
103 the main complication (n = 27, 84%) in which scar management was offered 124
104 (n = 23, 72%). There was no difference in children requiring scar 125
105 management therapy in surgical and dressing groups (n = 9, 82%) managed 126
106 surgically vs eighteen children (86%) managed with dressings. 127
107 Mean length of stay was 1.5 days (range 1 3 days). Children were 3.2. National data 128
137
136
135
134
133
132
131
130
129
108 typically admitted if the child were prescribed opiates/sedation for
109 debridement, if the child underwent surgery or if the child arrived in the As demonstrated in Fig. 6, 288 cases (273 hand injuries (95%), 15 foot 138
110 department during unsociable hours from a distant referring hospital and injuries (5%)) of vacuum cleaner friction injuries have been identified in 139
111 awaiting consultant review the following morning or if there was a change in England and Wales based on free text recording of vacuum cleaner injuries. 140
112 the child’s observations or if there was a query in relation to the mechanism Similar to our local study there was a similar mean age was 1.9 years of age 141
113 of injury. Twenty-seven patients were followed up on an outpatient basis, (Fig. 3), (range 0.45 15 years of age), affecting males in 211 cases (78%) 142
114 3 months following injury. Excluding four children requiring compression and 77 female cases (22%) with a mean TBSA% of 0.4% (0.1 1.25%). Forty 143
115 scar therapy, all children had a full range of movement and subsequently two patients underwent surgical intervention in which forty patients 144
116 discharged from the service. underwent burns excision with autografting. 145

Fig. 3 – Ages of children sustaining friction injuries due to vacuum cleaners.

Please cite this article in press as: K. Walsh, M. Osman-Elabd, Z. Sheikh et al. Vacuum cleaner friction injuries in paediatrics. A 10 year review looking at national
trends. Burns (2021), https://doi.org/10.1016/j.burns.2021.09.001
 JBUR 6530 1 6

4 burns xxx (2021) xxx xxx

the United Kingdom and the United States have reported these injuries to our 203

knowledge. 204

Comparing surgical and conservative management, there was minimal 205

difference in wound healing time. The preference within our institution is that 206

small digital deep wounds are managed conservatively, whilst larger deep 207

digital wounds are managed surgically. All children who were reviewed post- 208

operatively in our outpatient clinics were managed with scar therapy. In all 209

cases, this involved basic management e.g. moisturisation however four 210

children used pressure garments. 211

Comparisons between scarring outcome between conservative and 212

146 surgical groups cannot be made due to a lack of objective scar assessments 213
147 whilst being followed up during this time period. However, despite this 214
148 limitation in our data set, vacuum cleaner injuries are evidently significant 215
149 Fig. 6 – National IBID data of VCIs occurring between 1996 2020. due to the requirement for children to undergo surgery and scar therapy. 216
150 There are 450,000 injuries requiring emergency department attendance 217
151 in the UK per annum for children under 5 years of age with majority of 218
152 injuries occurring in the living room [14]. This is in accordance with our data 219
153 trend. The factors associated with paediatric injury is due to the 220
154 inquisitiveness of the child as well as a lack of parental supervision [15]. 221
155 Children between the ages of 12 18 months of age can walk without support 222
156 and have developed fine motor skills to self-select toys that were once out of 223
157 their reach [16]. Males are more likely to engage in risk-taking behaviour 224
158 than girls resulting in a higher number of accidents, similarly identified with 225
159 vacuum cleaners [17]. 226
160 Various vacuum brands advise that either the vacuum cleaner is kept out 227
161 of reach of children or to be used by children over the age of eight years of age 228
Fig. 5 – The modality of the management of VCIs (N.B ‘other’ refers to
162 following instruction or supervision by an adult [19 22]. Although these 229
surgical debridement and dressings).
163 injuries occurred whilst being supervised, these injuries nevertheless did 230
164 occur showing a potential lack of awareness of possible injury. In our 231
165 experience, parents describe lacking awareness of injury from vacuum 232
166 cleaners and do not understand how their child could have sustained their 233
167
176
175
174
173
172
171
170
169
168 4. Discussion injury. Greater public awareness is necessary and will require greater health 234

promotion by national organisations (e.g. British Burns Association (BBA), 235

177 Our report identifies a total of 288 children who have sustained friction burn British Association of Plastic and Reconstructive Surgeons (BAPRAS), 236
178 injuries to their hands and feet due to vacuum cleaners. To our knowledge British Society for Surgery of the Hand (BSSH) and Royal Society for the 237
179 this is the largest data series on vacuum cleaner injuries. Eighteen injuries Prevention of Accidents (ROSPA)) as well as manufacturers of vacuum 238
180 have been reported in the literature. The largest case series was reported by cleaners. 239
181 Grob et al. with 7 cases [10 13]. In comparison to the literature we have It is useful if vacuum cleaner injuries are coded appropriately and 240
182 identified a male predominance typically affecting children aged less than recorded on IBID in order to accurately assess trends of these injuries. 241
183 2 years of age [10 13]. Currently vacuum cleaner injuries are recorded as free text and it is possible 242
184 Although not described in the national data, our local data identified that that there is under reporting of these injuries as they could be coded as a 243
185 the left hand was most routinely injured. In our regional service, all injuries “friction injury”. Greater reporting will determine whether injuries are as a 244
186 occurred in vacuum cleaners that had a rolling brush bar. Most children result from a particular type of vacuum cleaners or modification / appliance 245
187 sustained their injuries whilst sitting/crawling in front of the vacuum cleaner or whether they have reduced due to changes in safety features. Monitoring 246
188 and placing their hand underneath the base of the vacuum cleaner. A possible trends will identify the effectiveness of any injury prevention activity. 247
189 theory as to why the left hand was most commonly injured was perhaps the Collecting postal code information is relevant as we can identify 248
190 child stabilising / supporting themselves with their stronger dominant upper geographical hotspots where injuries occur and specifically target these 249
191 limb whilst they trapped their non dominant limb under the vacuum cleaner. areas to improve health promotion. 250
192 The index finger was more commonly injured as this digit is typically used by Injuries could also be prevented by improved safety features. A possible 251
193 the child in their coordinated efforts to explore their environment. Grob et al. safety feature would be for the brush bar spinning once the vacuum cleaner is 252
194 similarly identified the index finger most routinely injured [10]. The width of pulled up away from the floor or alternatively an automatic guard to cover the 253
195 most brush bars is approximately the size of an infant’s digit. This likely brush bar once the base of the vacuum cleaner no longer makes contact with 254
196 explains why the MCPJs and PIPJs were routinely injured as the child likely the floor. 255
197 inserts their full finger into the base of the vacuum against the brush bar.
198 Injuries which did not involve a finger, injured just the dorsal surface of the
199 hand. This may also occur due to the child crawling and their hand passing 5. Conclusion 256
200 beneath the base of the vacuum cleaners for the brush bar to make contact with
201 the dorsal surface. It is unclear what proportion of vacuum cleaners have Vacuum cleaner injuries predominantly affect males under the age of 2 years 257
202 rotating bristles and what type of vacuum cleaners are used worldwide. Only of age. The depth of burn injuries sustained tend to be deep dermal to full 258

thickness and typically affect the child’s digit and involves an 259

Please cite this article in press as: K. Walsh, M. Osman-Elabd, Z. Sheikh et al. Vacuum cleaner friction injuries in paediatrics. A 10 year review looking at national
trends. Burns (2021), https://doi.org/10.1016/j.burns.2021.09.001
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Please cite this article in press as: K. Walsh, M. Osman-Elabd, Z. Sheikh et al. Vacuum cleaner friction injuries in paediatrics. A 10 year review looking at national
trends. Burns (2021), https://doi.org/10.1016/j.burns.2021.09.001
JBUR 6530 1 6

6 burns xxx (2021) xxx xxx

Please cite this article in press as: K. Walsh, M. Osman-Elabd, Z. Sheikh et al. Vacuum cleaner friction injuries in paediatrics. A 10 year review looking at national
trends. Burns (2021), https://doi.org/10.1016/j.burns.2021.09.001