We report five cases of serious isolated head injury inflicted on children by rear view mirrors mounted on vehicles (table 1). All the injuries occurred between 1996 and 2001 and were admitted to our unit. So far there has been scant reporting of this particular type of injury. The risk of injury from rear view mirrors to pedestrians can potentially be prevented by modification of vehicle design and use of new technology.

In our series of five patients, all had serious head injuries requiring admission to the intensive care unit and three needed neurosurgical intervention. At follow up, two of the patients had persisting neurological problems. The cause of these head injuries was a very high pressure resulting from a force applied to a small area, in this instance a rear view mirror.

The relatively small surface area of a rear view mirror can transmit a large force carried by the vehicle. Even when a relatively small impact is applied over a small area, it is converted to a large force with the potential to cause substantial tissue damage. Ahmed, in discussing “stiletto heel” penetrating fractures of the skull, gave a good example of this by estimating that the force exerted per square centimetre by the heel of a woman’s stiletto shoe is greater than that of an elephant’s foot on the ground on which it treads.¹

There have been three case reports in the literature of fatal cyclist and motorcyclist injuries from rear view mirrors.^2,3 The deaths were all caused as a result of head injury. Additionally there have been published case reports of perforating eye injuries from extended rear vision mirrors because of shattering of the mirror in motor vehicle accidents.^4,5

Head injury prevention must be the primary goal in management for all care providers. Clearly children of any age should be supervised while crossing the road, but thousands of young lives are lost every year as a result of accidents, and trauma remains the number one cause of paediatric death. There is a pattern and regularity to children’s injury: the pedestrian child has usually been the victim of a road traffic accident and in 75% of these cases has suffered head injury.^6,7

Over the years there have been significant steps taken to make roads safer. Roadway design improvement, such as removal of fixed objects from roadsides, widening roadside recovery zones, and installing dividers between opposing lanes of traffic, has been effective in reducing crashes and injuries. Speed restrictions in urban areas and the use of traffic cameras have probably caused a reduction in the number of lethal crashes.

There have been significant improvements in the last 30 years in all aspects of vehicle design to make them safer for occupants in the event of a collision with research conducted to help minimise forces exerted to the occupant’s head.⁸ These improvements include lap and shoulder belts for car occupants, the use of automatic air bags for front and side impacts, head restraints, and even the use of automatic roll bars for vehicles that overturn in a collision.

Less attention has been directed at making vehicles safer for pedestrians in the event of a collision. The Department for Transport sets out the requirements for mirrors on motor vehicles in the Road Vehicles Regulations act 1986.⁹ Where the bottom edge of an exterior rear view mirror is less than 2 m above the ground, the mirror should not project more than 0.2 m beyond the overall width of the vehicle.

New technologies have been introduced to vehicles in order to minimise pedestrian injuries. These include modifying vehicle exterior structures, such as wing mirrors, including size reduction and fold down designs. The authors agree that there is a clear benefit in the use of rear view mirrors in accident prevention; however, a significant number of manufacturers still build large or extended mirrors on all types of vehicles, including trucks, vans, and buses. We believe this area needs to be given greater focus and that wing mirror injuries are potentially preventable if technology allows.