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Fatal Pediatric Head Injuries Caused by Short Distance Falls
... Seemingly minor head trauma in a child who appears alert (head trauma resulting in a Glasgow Coma Score [GCS] of 14 or 15) accounts for approximately 50% of TBIs in children. 4 Children can sustain significant injuries when falling from lower heights than adults. 5,6 Differences such as their proportionally greater cephalic mass and the lower levels of energy necessary to produce intracranial bleeding in children are 2 factors believed to contribute to their increased susceptibility. 6 Due to their portability, as well as the fact that many childhood injuries are unwitnessed and the mechanism severity may be unknown, children with head trauma often present as walk-in patients and are subject to triage before being seen by a provider. ...
Triage nurses are the "first stop" for patients who present to the emergency department for care. The assessment of pediatric head injuries is especially challenging because signs and symptoms of head trauma in children do not correlate well with the risk of closed head injury (CHI).
A retrospective matched cohort study was conducted to compare 2 groups of patients who presented to a pediatric emergency department for evaluation of a head injury: a CHI-positive cohort and a CHI-negative cohort as identified by computed tomography scan. The purpose of the chart review was to collect specific information from both cohorts which could be used to inform a nurse-driven pediatric head injury assessment tool.
The younger the child, the more likely they were to be asymptomatic. Scalp hematomas in infants <3 months were associated with CHI even if the infants were otherwise asymptomatic. Injuries to the temporal-parietal region were associated with CHI at every age. Frequency of caregiver report of loss of consciousness (LOC) was almost identical in both cohorts. Children in every age category sustained CHIs as the result of minor falls based on standard age-related fall criteria.
The infants and children at highest risk for CHI are often the most difficult to assess. The results of this study reinforce the need for a nurse-driven, evidence-based risk scoring system that could be used to aid with early identification of infants and children who are at high risk for CHI.
Abusive Head Trauma (AHT) is a medical diagnosis which indicates that accidents, diseases, or other medical conditions do not plausibly explain a child’s injuries. While psychologists may be involved in AHT cases, they do not generally evaluate children at the time injuries caused by AHT occur and they do not diagnose those injuries. This article is a commentary on Johnson et al, which advises that psychologists would benefit from understanding the medical aspects of an AHT case. This is a laudable goal. However, in an effort to discuss medical issues regarding AHT and legal exonerations, the article presents flawed data and speculative theories which are unsupported by medical evidence or the extensive range of generally accepted medical literature. We discuss some of these flaws and present a more in-depth medical analysis in the hope that interested psychologists gain more understanding of this very complex area of medical specialty.
Retinal hemorrhage is a cardinal manifestation of abusive head injury characterized by repetitive acceleration-deceleration with or without blunt head impact. Detailed description of the hemorrhages and documentation are critical to diagnosis. Vitreoretinal traction appears to be the major causative factor. Outcome is largely dependent on brain and optic nerve injury.
Shaken baby syndrome is a controversial topic in forensic pathology. Some forensic pathologists state that shaking alone is insufficient to explain death and that an impact must have occurred even if there is no impact site on the head.
To examine a large cohort of fatal, pediatric head injuries for patterns of specific autopsy findings and circumstances that would support or dispute pure shaking as the cause of death.
We retrospectively reviewed 59 deaths due to head injuries in children younger than 2 years certified in our office during a 9 year period (1998-2006). The review included autopsy, toxicology, microscopy, neuropathology, and police and investigators' reports.
There were 46 homicides, 8 accidents, and 1 undetermined death from blunt-impact injury of the head. In 10 (22%) of the homicides, there was no impact injury to the head, and the cause of death was certified as whiplash shaking. In 4 (40%) of these 10 deaths, there was a history of shaking. In 5 (83%) of the other 6, there was no history of any purported accidental or homicidal injury. All 8 accidental deaths had impact sites. Of the 59 deaths, 4 (6.7%) had only remote injuries (chronic subdural hematomas, remote long bone fractures) that were certified as undetermined cause and manner. These 4 deaths were excluded from the study.
We describe a subset of fatal, nonaccidental head-injury deaths in infants without an impact to the head. The autopsy findings and circumstances are diagnostic of a nonimpact, shaking mechanism as the cause of death. Fatal, accidental head injuries in children younger than 2 years are rare.
Child abuse experts use diagnostic findings of subdural hematoma and retinal hemorrhages as near-pathognomonic findings to diagnose shaken baby syndrome. This article reviews the origin of this link and casts serious doubt on the specificity of the pathophysiologic connection. The forces required to cause brain injury were derived from an experiment of high velocity impacts on monkeys, that generated forces far above those which might occur with a shaking mechanism. These forces, if present, would invariably cause neck trauma, which is conspicuously absent in most babies allegedly injured by shaking. Subdural hematoma may also be the result of common birth trauma, complicated by prenatal vitamin D deficiency, which also contributes to the appearance of long bone fractures commonly associated with child abuse. Retinal hemorrhage is a non-specific finding that occurs with many causes of increased intracranial pressure, including infection and hypoxic brain injury. The evidence challenging these connections should prompt emergency physicians and others who care for children to consider a broad differential diagnosis before settling on occult shaking as the de-facto cause. While childhood non-accidental trauma is certainly a serious problem, the wide exposure of this information may have the potential to exonerate some innocent care-givers who have been convicted, or may be accused, of child abuse.
Context.—Shaken baby syndrome is a controversial topic in forensic pathology. Some forensic pathologists state that shaking alone is insufficient to explain death and that an impact must have occurred even if there is no impact site on the head.
Objective.—To examine a large cohort of fatal, pediatric head injuries for patterns of specific autopsy findings and circumstances that would support or dispute pure shaking as the cause of death.
Design.—We retrospectively reviewed 59 deaths due to head injuries in children younger than 2 years certified in our office during a 9 year period (1998–2006). The review included autopsy, toxicology, microscopy, neuropathology, and police and investigators' reports.
Results.—There were 46 homicides, 8 accidents, and 1 undetermined death from blunt-impact injury of the head. In 10 (22%) of the homicides, there was no impact injury to the head, and the cause of death was certified as whiplash shaking. In 4 (40%) of these 10 deaths, there was a history of shaking. In 5 (83%) of the other 6, there was no history of any purported accidental or homicidal injury. All 8 accidental deaths had impact sites. Of the 59 deaths, 4 (6.7%) had only remote injuries (chronic subdural hematomas, remote long bone fractures) that were certified as undetermined cause and manner. These 4 deaths were excluded from the study.
Conclusions.—We describe a subset of fatal, nonaccidental head-injury deaths in infants without an impact to the head. The autopsy findings and circumstances are diagnostic of a nonimpact, shaking mechanism as the cause of death. Fatal, accidental head injuries in children younger than 2 years are rare.
The national campaign against child abuse has changed the face of American evidence law during the past 30 years. The campaign has led to the relaxation of witness competency standards for alleged child victims, the recognition of new procedures for presenting child testimony such as the use of support persons, the creation of new hearsay exceptions, and the development of novel species of expert testimony. One of the most controversial new types of expert testimony is shaken baby syndrome. The proponents of the syndrome claim that the violent shaking of an infant by an adult can generate enough force to inflict fatal brain injuries on the infant even without impact. Many pediatricians and pathologists subscribe to this theory. However, many biolmechanical experts dispute the theory. To date, the vast majority of courts have admitted testimony based on the syndrome. The purpose of this article is to critically evaluate the available empirical data relevant to the question of the validity of the syndrome. The article concludes that this is one of the rare situations in which both sides' expert claims pass muster under Federal Rule of Evidence 702 and the Supreme Court's leading decisions, Daubert and Kumho. Once a decision-maker posits the validation standard enunciated in Daubert, it is possible to have genuine battles of the experts. In this case, the syndrome opponents can point to relatively well designed experiments finding that even violent shaking by an adult cannot generate enough force to cause fatal injuries to the infant brain. However, syndrome opponents note that in a large number of cases in which infants suffered such fatal brain injuries, the infant's custodian admitted shaking without impact. It may be tempting to conclude that classical experimentation should always trump more anecdotal expert reasoning. However, that conclusion is indefensible as a matter of both statutory construction and epistemology.
Determining the cause of death in children and young adults can pose considerable challenges. Professor Byard provides for the first time a complete overview of pathological aspects of sudden death in the young, from before birth to middle adult life. Highly illustrated with more than 800 colour figures, this third edition contains new sections on sexual abuse, pregnancy-related deaths and rare natural diseases, as well as expanded coverage of unexpected death in young adults up to the age of 30 years. Chapters are organised by systems and cover all aspects of natural death, as well as accidents, suicides and homicides. Supported by extensive referencing and numerous tables, the book can also be used as a practical autopsy manual. An encyclopaedic overview and analysis of sudden death in the young, this is a key text for pediatric and forensic pathologists, pediatricians, and lawyers and physicians involved in medicolegal cases.
We hypothesized that young children uncommonly acquire significant injuries due to household falls that necessitate medical attention. Data on recalled fall experiences were collected from parents of children younger than two years visiting the University Pediatrics Clinic. Statistical analysis was performed using Student's t test and chi square test. Of 573 children, 36% experienced no falls, while 64% experienced 782 falls. Eleven percent of falls occurred from a distance of three to five feet (approximately 90-150 cm). In 6% of all falls, medical care was sought. In 40% of this subcategory, examination was normal; in 33%, medical work-up revealed normal results; in 23%, injuries necessitated subsequent intervention. No fall led to neurological findings. This study supports that it is uncommon for household falls to cause injuries significant enough to require professional medical care. Even falls from a distance of greater than three feet result in only mild injury with no neurological findings.
To determine the normal clinical progression of fatal head injuries in children. Such information can then be used to estimate the time of injury in cases with obscure histories and will thus aid investigations of nonaccidental trauma.
A retrospective chart review design was used. One hundred and thirty eight accidental fatalities involving head injury were identified and 95 of these were used as the study group. Details of the cases were reviewed and cases in which a child either had a Glasgow Coma Scale (GCS) of 14-15 or was described as having a "lucid interval" or as being "conscious" were further studied.
One "lucid interval" case was identified. This case involved an epidural hematoma. Three other cases that partially met the criteria for a lucid interval were also identified; one of these cases did not meet the criteria for inclusion in the study group. Review of head CTs revealed that brain swelling could be detected as early as 1 hour and 17 minutes post injury.
The children studied were in obvious serious medical condition from the time of injury until death. If a history purports a lucid interval in a fatal head injury case that does not involve an epidural hematoma, that history is likely false and the injury is likely inflicted. The time of most fatal head injury events can be restricted to the time period after the last confirmed period of wellness for the child. In addition, the presence of brain swelling on a head CT scan is not helpful in restricting the time of injury.
Diffuse axonal injury (DAI) as defined by detailed microscopic examination was found in 34 of 80 consecutive cases of head trauma surviving for a sufficient length of time to be clinically assessed by the Royal Adelaide Hospital Neurosurgery Unit. The findings indicate that there is a spectrum of axonal injury and that one third of cases of DAI recovered sufficiently to talk between the initial head injury producing coma and subsequent death. The macroscopic "marker" lesions in the corpus callosum and dorsolateral quadrants of the brainstem were present in only 15/34 of the cases and represented the most severe end of the spectrum of DAI.
Because a history of shaking is often lacking in the so-called “shaken baby syndrome,” diagnosis is usually based on a constellation of clinical and radiographic findings. Forty-eight cases of infants and young children with this diagnosis seen between 1978 and 1985 at the Children's Hospital of Philadelphia were reviewed. All patients had a presenting history thought to be suspicious for child abuse, and either retinal hemorrhages with subdural or subarachnoid hemorrhages or a computerized tomography scan showing subdural or subarachnoid hemorrhages with interhemispheric blood. The physical examination and presence of associated trauma were analyzed; autopsy findings for the 13 fatalities were reviewed. All fatal cases had signs of blunt impact to the head, although in more than half of them these findings were noted only at autopsy. All deaths were associated with uncontrollably increased intracranial pressure.
Models of 1-month-old infants with various neck and skull parameters were instrumented with accelerometers and shaken and impacted against padded or unpadded surfaces. Angular accelerations for shakes were smaller than those for impacts by a factor of 50. All shakes fell below injury thresholds established for subhuman primates scaled for the same brain mass, while impacts spanned concussion, subdural hematoma, and diffuse axonal injury ranges. It was concluded that severe head injuries commonly diagnosed as shaking injuries require impact to occur and that shaking alone in an otherwise normal baby is unlikely to cause the shaken baby syndrome.
CT scan findings, clinical features and intracranial pressure were studied in patients with severe diffuse head injury. Compression of the 3rd ventricle and basal cisterns closely correlated with an intracranial pressure greater than 20 mmHg, with clinical signs of midbrain dysfunctions and worse prognosis. These CT scan findings can indicate whether intracranial pressure monitoring is appropriate.
List of contributors. 1: W. Goldsmith: Biomechanics of solids. 2: L. Talbot: Fundamentals of fluid mechanics. 3: S.A. Berger: Physiological fluid mechanics. 4: M.C. Williams: Mass transfer. 5: T.K. Eto and B. Rubinsky: Bioheat transfer. 6: E.L. Keller: The modeling approach to the study of physiological systems. 7: E.R. Lewis: A brief introduction to network theory. 8: R.B. Martin: Biomaterials. 9: H.B. Skinner: The interaction of biomatrials and biomechanics. 10: S.L. Lehman, R. Kram and C.T. Farley: Locomotion and muscle biomechanics. 11: P.D. Grossman and D.S. Soane: Principles of electrophoretic separations. 12: T.F. Budinger: Medical imaging. 13: S. Kaplan and H. Maccabee: Biological applications of ionizing radiation. 14: C. Susskind: Bioeffects of nonionizing electromagnetic fields. Appendix A: Linear transforms. Index
This book provides a description for all the known radiological alterations occurring in child abuse. This allows for precise interpretation of findings by radiologists. It also helps eliminate the confusion among both clinicians and non-medical personnel involved in the diagnosis, management, and legal issues related to child abuse. CONTENTS: Introduction; Skeletal trauma: general considerations; Extremity trauma; Bony thoracic trauma; Spinal trauma; Dating fractures; Visceral trauma; Head trauma; Miscellaneous forms of abuse and neglect; The postmortem examination; Differential diagnosis of child abuse; Legal considerations; Psychosocial considerations; Technical considerations and dosimetry.
Individual chapters cover the following areas: Reticulospinal influences and postural regulation; Reticular influences upon central afferent transmission; Reticulo-hypothalamic influences and neuroendocrine regulation; Reticulo-diencephalic and rhinencephalic systems and emotion; Reticulo-cortical influences for wakefulness and attention; Non-specific brain mechanisms and neuropharmacology; and Reticular influences and cortical activity. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
We hypothesize that apnea induced by shaking or by shaking combined with impact plays a major role in the pathophysiology of nonaccidental head trauma and accounts for the poor outcome in this subgroup of patients. In a retrospective study of 28 children who suffered significant nonaccidental head injury, 57% had a history of apnea prior to hospitalization, 82% were intubated upon admission, and 71% had early seizures. For further evidence of ischemia and hypoxia, the first recorded blood pressure was <80 in 50% and the arterial pH <7.3 in 54%. Seventy-one percent had diffuse brain swelling which is characteristic of cerebral hypoxia and/or ischemia on the first CT scan. None of the children who had clinical evidence of cerebral hypoxia or ischemia had a good outcome. We conclude that trauma-induced apnea causes cerebral hypoxia and/or ischemia which is more fundamental to outcome than the mechanism of injury (shaken vs. shaken with impact), subdural hemorrhage, subarachnoid hemorrhage, diffuse axonal injury, parenchymal shear, or brain contusion.
Unlabelled:
According to pediatric statements, falls from a standing position may cause skull fractures in infants without specific symptoms. Nearly every infant has at some time fallen from the changing table or the baby carriage, etc. From the forensic aspect it is the duty of experts to discuss the "battered child syndrome." Evidence given by the defendants concerning the height of the fall are unreliable. Experimental test series concerned with the stumbling height (82 cm in free fall) and three various types of floor-stone, carpet, and foam-backed linoleum -were carried out. In each case skull fractures were seen. In three cases the fractures crossed the sutures.
Conclusions:
(1) Each fall of an infant from the height of a table may cause a skull fracture, which may lead to death; (2) when child mishandling is suspected, all circumstances must be taken into consideration.
Thesis (M.S.)--Univ. of Minnesota, 1956. Bibliography: leaves 22-23.
The presence of retinal hemorrhage in head-injured children under 3 years of age is believed to be pathognomonic of battering. When a group of battered children was compared to head-injured children due to other causes, the high incidence of retinal hemorrhage in the battered children was contrasted with the absence of retinal hemorrhage produced by other causes of head injury.
Computed tomography (CT) was performed in 26 infants and children with craniocerebral trauma related to abuse during a 41-month period. The pattern of brain injury differed from that seen in the nonabused traumatized infant or child. Parieto-occipital acute interhemispheric subdural hematoma (AIHSH) with associated parenchymal injury was the most frequent finding (58%). Follow-up by CT in patients with AIHSH demonstrated infarction in half and cerebral atrophy in all.
The problem of evaluating injury in childhood as to causation--accidental, inflicted or other--is compounded by conflicting literature. The child presenting with head injury following a short distance fall should be a source of alarm. Some of the key thoughts in the literature are evaluated with presentation of some additional observations, in an attempt to sort out some apparent conflicts.
Head injury in the youngest age group is distinct from that occurring in older children or adults because of differences in mechanisms, injury thresholds, and the frequency with which the question of child abuse is encountered. To analyze some of these characteristics in very young children, the authors prospectively studied 100 consecutively admitted head-injured patients 24 months of age or younger who were drawn from three institutions. Mechanism of injury, injury type, and associated injuries were recorded. All patients underwent ophthalmologic examination to document the presence of retinal hemorrhages. An algorithm incorporating injury type, best history, and associated findings was used to classify each injury as inflicted or accidental. The results confirmed that most head injuries in children younger than 2 years of age occurred from falls, and while different fall heights were associated with different injury types, most household falls were neurologically benign. Using strict criteria, 24% of injuries were presumed inflicted, and an additional 32% were suspicious for abuse, neglect, or social or family problems. Intradural hemorrhage was much more likely to occur from motor vehicle accidents and inflicted injury than from any other mechanism, with the latter being the most common cause of mortality. Retinal hemorrhages were seen in serious accidental head injury but were most commonly encountered in inflicted injury. The presence of more serious injuries associated with particular mechanisms may be related to a predominance of rotational rather than translational forces acting on the head.
The outcome of injury was determined in 317 children who were brought to a children's trauma center with a history from the caretaker that the child had fallen. Cases in which the clinicians' judgment was that an incorrect history had been given were included along with cases in which the history was not questioned. Seven deaths occurred in 100 children who fell 4 feet or less. One death occurred in 117 children who fell 10 feet to 45 feet. The 7 children who died in short falls all had other factors in their cases which suggested false histories. When children incur fatal injuries in falls of less than 4 feet, the history is incorrect. Long falls with an outdoor component are likely to be reliable data points for studies of children's injuribility.
The height of a free fall necessary to cause injury to infants and small children is a confusing and controversial issue among health care, law enforcement, and legal professionals responsible for evaluating cases of possible child abuse. To resolve this confusion, the circumstances of falls were recorded prospectively for 398 consecutive victims of falls seen at Children's Hospital, Oakland, California. From these cases, 106 were selected for further analysis where the falls were witnessed by a second person other than the caretaker and the circumstances of the fall were documented. No injuries occurred in 15 patients, including seven falling more than 10 feet. Mild bruises, abrasions, or simple fractures occurred in 77 patients, including 43 falling more than 10 feet. Severe injuries, including intracranial hemorrhages, cerebral edema, depressed skull fractures, and compound or comminuted fractures occurred in 14 patients falling between 5 and 40 feet. However, no life-threatening injuries occurred in the 3 patients who fell less than 10 feet. These three had small, depressed skull fractures without loss of consciousness, from falling against an edged surface. Only one death occurred in this series, resulting from a fall of 70 feet. In conclusion, infants and small children are relatively resistant to injuries from free falls, and falls of less than 10 feet are unlikely to produce serious or life-threatening injury.
Nonpenetrating or blunt ocular trauma, orbital trauma and systemic trauma may cause a variety of posterior segment abnormalities. Blunt ocular trauma may cause damage to the retina (commotio retinae), retinal pigment epithelium (retinal pigment epithelial edema), choroid (choroidal rupture) and optic nerve (optic nerve evulsion) alone or in combination. Traumatic macular holes and retinal detachment or dialysis may also occur after blunt ocular trauma. Trauma to the orbital tissues adjacent to the globe can cause concussive forces with damage to multiple structures within the eye (chorioretinitis sclopetaria). Systemic trauma may result in diffuse retinopathy (Purtscher's retinopathy, shaken baby syndrome) or localized retinal abnormalities (whiplash retinopathy, fat embolism syndrome). Alterations in intravascular (Valsalva retinopathy) or intracranial pressure (Terson's syndrome) due to a variety of causes may result in preretinal or vitreous hemorrhage and associated visual loss. The purpose of this report is to review each of these entities of traumatic posterior segment abnormalities.
Within a population-based register of childhood injuries, 641 home accidents to children aged under 2 years were recorded in six hospitals. The annual rate was higher in children over 1 year (6.6 per 100) than in infants (2.7 per 100). A male predominance was observed only after the first birthday. Most injuries were related to physical trauma (mainly falls), but burns and poisonings were frequent in the second year. Most lesions were benign, except in the case of falls from a height (from a window or baby furniture). Nineteen per cent of the children were admitted to hospital. There were 15 skull fractures, two fatal cases and two severe sequelae. Child abuse was seldom suspected and the reasons for this are discussed. The study of the circumstances in which accidents occur leads to the conclusion that the main aspect of prevention should be passive protection ensured by the creation of a safe environment (compulsory safety standards for baby furniture, child resistant packaging), but that parents' information and education should also be developed, with emphasis on knowledge of children's normal psychological and motor development and abilities.
Unexplained retinal hemorrhages in infants are usually indicative of child abuse. We present the case of an infant with retinal hemorrhages following cardiopulmonary resuscitation, who had not been abused. Cardiopulmonary resuscitation should be added to the list of causes of retinal hemorrhages in infants and children.
We reviewed complete ocular and systemic necropsy findings of 10 consecutive children who died of suspected child abuse. All 10 children had evidence at necropsy of blunt head trauma, although external signs of blunt trauma occasionally were covert. Ocular injuries were observed in 7 of the 10 cases and when present always included retinal, vitreous, and subdural optic nerve hemorrhages. In 5 cases, intrascleral hemorrhage from the circle of Zinn occurred at the sclera-optic nerve junction. In 4 cases, traumatic retinoschisis or tractional retinal folds were present. Anterior segment findings were uniformly consistent with blunt trauma. Hemosiderin, indicating old hemorrhage, was present in 3 cases. Intracranial hemorrhage, present in all cases with abnormal ocular findings, was always accompanied by signs of direct head trauma, such as subgaleal hemorrhage, skull fracture, cerebral contusion, or external contusions, which are sometimes subtle or hidden beneath the hair.
Falls accounted for 5.9% of the childhood deaths due to trauma in a review of the medical examiner's files in a large urban county. Falls represented the seventh leading cause of traumatic death in all children 15 years of age or younger, but the third leading cause of death in children 1 to 4 years old. The mean age of those with accidental falls was 2.3 years, which is markedly younger than that seen in hospital admission series, suggesting that infants are much more likely to die from a fall than older children. Forty-one per cent of the deaths occurred from "minor" falls such as falls from furniture or while playing; 50% were falls from a height of one story or greater; the remainder were falls down stairs. Of children falling from less than five stories, death was due to a lethal head injury in 86%. Additionally, 61.3% of the children with head injuries had mass lesions which would have required acute neurosurgical intervention. The need for an organized pediatric trauma system is demonstrated as more than one third of the children were transferred to another hospital, with more than half of these deteriorating during the delay. Of the patients with "minor" falls, 38% had parental delay in seeking medical attention, with deterioration of all. The trauma system must also incorporate the education of parents and medical personnel to the potential lethality of "minor" falls in infants and must legislate injury prevention programs.
We describe five patients with blunt traumatic carotid dissection with delayed clinical presentation that varied from 2 weeks to 6 months. Four patients had severe head injury, and one patient had direct blunt trauma to the neck. Cerebrovascular symptoms developed in four patients. The fifth patient suffered loss of vision as a result of a concurrent giant intracranial dissecting aneurysm. Arteriography demonstrated a "string sign" in two cases and a cervical carotid aneurysm in three; two of the latter also had siphon occlusion, and one of these had a superimposed supraclinoid dissecting aneurysm. One patient was treated by thromboendarterectomy, one by aneurysmorraphy, another by carotid ligation, and the other two patients were treated medically. Mechanisms of injury, forensic problems, and therapeutic options are discussed.
The eyes of fourteen fatally abused children and sixteen control cases were examined histopathologically. Ten of the abused children showed intraocular change. The most common ocular changes were subdural hemorrhage of the optic nerve and retinal hemorrhage which involved all the layers of the retina, but most commonly the nerve fiber layer, ganglion cell layer and inner nuclear layer. The presence of blood cavities within the retina partially supported the hypothesis of traumatic retinoschisis. The control cases of non-abused children rarely showed intraocular hemorrhage.
Of 215 patients with severe head injuries, 33 (15%) closed head injury patients who talked before their conditions deteriorated to a Glasgow coma scale score of 8 or less were identified. Of this select group, 15 died (45%), but none of the remaining were left in a vegetative state and 14 patients had a "favorable" outcome (42%). Twenty-five patients (76%) underwent surgical decompression. In these 25 patients, 14 subdural hematomas, 4 epidural hematomas, and 7 intracerebral contusions and hematomas were the initial surgical lesions. Twenty of the 25 patients were operated on within 4 hours (16 within 2 hours) of their neurological deterioration. Eleven of the 25 surgically treated died, for a mortality rate of 44%. All 15 deaths were studied further. Autopsies with examination of the brain were performed in 13 patients. Five patients died with severe brain injuries not complicated by iatrogenic factors, and 4 patients died of severe associated injuries. Iatrogenic factors significantly complicated the deaths of 6 patients (40%). It is concluded that most patients who "talk and deteriorate" have sustained very serious life-threatening injuries. Intracranial hematomas are the most frequent cause of this situation, and rapid diagnosis and decompression is the most important factor in salvaging these patients.
Twenty-six cases of infantile acute subdural hematoma treated between 1972 and 1983 were reviewed. The series was limited to infants with acute subdural hematoma apparently due to minor head trauma without loss of consciousness, and not associated with cerebral contusion. Twenty-three of the patients were boys, and three were girls, showing a clear male predominance. The patients ranged in age between 3 and 13 months, with an average age of 8.1 months, the majority of patients being between 7 and 10 months old. Most of the patients were brought to the hospital because of generalized tonic convulsion which developed soon after minor head trauma, and all patients had retinal and preretinal hemorrhage. The cases were graded into mild, intermediate, and fulminant types, mainly on the basis of the level of consciousness and motor weakness. Treatment for fulminant cases was emergency craniotomy, and that for mild cases was subdural tapping alone. For intermediate cases, craniotomy or subdural tapping was selected according to the contents of the hematoma. The follow-up results included death in two cases, mild physical retardation in one case, and epilepsy in one case. The remaining 23 patients showed normal development.
The relationship between computerized tomography (CT) findings and clinical grading was analyzed. Because some mild and intermediate cases could be missed on CT, the importance of noting the characteristic clinical course and of funduscopic examination is stressed.
Five infants who were victims of physical abuse had extensive bilateral retinal hemorrhages on initial evaluation and subsequently developed signs of permanent retinal damage. None showed external evidence of trauma to the eyes. Vitreous hemorrhage developed after a delay of several days or more in three cases that were followed closely from the time of the traumatic incident. In several eyes, apparent intraretinal blood-filled cavities were seen acutely in the macular region and elsewhere. Late scarring of the macula typically had a cystic or crater-like configuration. Electroretinography showed loss or reduction of the positive B-wave with preservation of the negative A-wave in every case. We propose that splitting of the retina resulting from the direct mechanical effects of violent shaking was responsible for all of these findings.
Following previous experiments on postmortem skull fractures of infants, falls from 82-cm heights onto stone (A), carpet (B) and foam-backed linoleum (C), 35 further falling tests were carried out onto softly cushioned ground. In 10 cases a 2-cm thick foam rubber mat (D) was chosen and in 25 further cases a double-folded (8-cm-thick) camel hair blanket (E). Hence the results of altogether 50 tests could be evaluated. In test groups A-C on a relatively hard surface, skull fractures of the parietale were observed in every case; in test group D this fracture was seen in one case and in test group E in four cases. Measurements along the fracture fissures showed bone thickness of 0.1-0.4 mm. The fracture injuries originated in paper-thin single-layer bone areas without diploe, which can also be considered the preferred regions for skull fractures of older infants following falls from low heights. These results indicate that it is no longer possible to assume that the skull of infants is not damaged after falls from table height.
• The suspected diagnosis of child abuse may prove to be unfounded. Reports in the literature have focused on unusual diseases and folk medicine practices that may mimic abuse. We report ten cases where allegations of abuse were lodged against parents because the treating physicians in the emergency room mistook life-threatening Illness or postmortem artifacts for Inflicted injury. In all cases the families were from the inner city, and with two exceptions the involved institutions were small hospitals without pediatric personnel present in the emergency department. Although the histories related by the parents were in all cases truthful and consistent with the results of physical examinations of the child, the involved physicians failed to make a correct diagnosis. Not only a lack of experience with severe childhood illness and death but also an attitude of suspicion and/or hostility probably contributed to these misdiagnoses.
(AJDC 1985;139:873-875)
The case-histories of two patients with subdural hæmatomas apparently caused by whiplash injury alone are presented. One patient survived uneventfully after surgical relief but the other died before the clot could be evacuated. The impact data from one of these cases was used to derive the approximate level of rotational acceleration produced in the patient's head during the whiplash. This value (1636 radians per second per second) was slightly lower than that predicted for cerebral concussion by head rotation in man.
✓ Intracranial pressure was elevated acutely by inflation of an epidural balloon inside one side of the skull of monkeys. In most of the animals, intraocular pressure rose, beginning only after intracranial pressure had been elevated well above normal and continuing until the pressure in the expanding epidural balloon approached the level of the blood pressure. Thereafter intraocular pressure stabilized until it fell as vasomotor collapse ensued. The role of systemic arterial pressure elevations in the rising phase of intraocular pressure is thought to be less important than increases of ophthalmic venous pressure.
Six cases of bilateral hemorrhage into the vitreous body related to intracranial hypertension are presented. Four were associated with ruptured cerebral aneurysms, and the others followed head injury. The onset of vitreous hemorrhage was delayed in all cases, and in 5 patients subhyaloid hemorrhages were present from 2 to 27 days prior to their extension into the vitreous. Visual acuity was greatly reduced. The ophthalmoscopic and slit lamp appearance of the vitreous are described. The hemorrhages usually cleared spontaneously within 24 mth and vision returned to normal. Surgical treatment to remove residual vitreous blood in selected cases is outlined.
Forty examples (27 from the literature and 13 new cases) of a syndrome of hypomegakaryocytic thrombocytopenia with bilateral absence of the radius have been analyzed. This syndrome is designated in this paper as "thrombocytopenia with absent radius (TAR)". The onset of hematologic complications usually occurs at birth or during early infancy. Thrombocytopenia may be episodic and sometimes is accompanied by leukemoid reactions and eosinophilia. Bone marrow examination reveals decreased and/or abnormal megakaryocytes, with normal myeloid and erythroid precursors. Congenital skeletal deformities include bilateral absence of radius, shortening and deformity of the ulnae, and occasionally absence of all the long bones in the arm. The fingers and thumbs are always present. Other skeletal anomalies are frequent. Cardiac anomalies, particularly the tetralogy of Fallot and atrial septal defects, may be present. Other non-skeletal congenital abnormalities are rare. The prognosis is good if the patient survives to one year of age. The syndrome has been compared to Fanconi's anemia, thalidomide embryopathy, limb-cardiovascular syndrome, and a syndrome of multiple congenital malformations, from which it can be distinguished.
✓ The distribution of coup and contre-coup contusions and subdural hematomas after frontal and occipital impacts has been studied in the rhesus monkey. The effect of skull fracture on these lesions is noted, and the data compared to known postmortem observations in man. The translation/cavitation theory for brain injury as presently conceived is not supported by these data. The skull distortion and head rotation hypothesis offers opportunities for developing a better theory for brain injury by direct as well as indirect impact. The significance of these observations for design of protective devices is briefly discussed.
Experience with craniocerebral trauma in 712 physically abused children is reviewed. Ninety-three (13%) had evidence of head trauma (cranial and/or intracranial). Seventy-seven of these patients had computed tomography (CT) of the head, and 47 had CT evidence of intracranial injury. Extracerebral fluid collections, predominantly convexity subdural hemorrhage, were the most common acute intracranial lesions. Concurrent intracranial and skeletal trauma (cranial and/or extracranial) was present in 33 of the 47 patients (70%) with intracranial injury. A high incidence of skull fractures (45%) in those children with intracranial lesions suggest a significant role for impact head injuries ("battering") in the pathogenesis of craniocerebral trauma in the child abuse syndrome. Greater emphasis on CT examination in evaluation of the abuse infant and child is recommended.
Craniocerebral trauma, and more specifically intracranial injury, is the most devastating consequence of child abuse. Cranial computed tomography provides a sensitive method for evaluation of the abused child for craniocerebral injury. CT may be particularly useful for demonstrating intracranial lesions that might not be immediately evident from clinical examination. The CT findings may also clarify the nature of the trauma, both cranial and intracranial, with detail not otherwise possible. It is therefore surprising that an expanded role for CT in evaluation of child abuse has not received wider general consideration or acceptance. Discussions of child abuse either fail to note CT in evaluation of the abused child or give the subject only cursory attention. Caffey's initial admonition that the presence of unexplained fractures in the long bones warrants investigation for subdural hematoma has gone largely unheeded. A high index of suspicion for abuse, especially in the young infant, should be sufficient reason to request cranial CT. In some cases of abuse without acute neurologic abnormality chronic sequelae, otherwise unsuspected, may be demonstrated by follow-up CT.
A series of 42 children is described who, following a seemingly minor or trivial head injury, developed neurological signs after a lucid or symptom-free period. This group constitutes 4.34 per cent of 967 consecutive patients aged 2 months to 17 years who were seen by members of the neurological staff during the years 1978–1981.
Only one patient had an intracranial haematoma. The majority of patients showed a benign transient syndrome consisting of either convulsive or nonconvulsive signs with a spontaneous and full recovery. There were, however, 3 deaths in this series, apparently due to severe and uncontrollable unilateral or diffuse brain swelling, demonstrating the malignant counterpart of this benign syndrome.
The theories seeking to explain these phenomena are reviewed. Special reference is made to the hypotheses of Bruce and his associates regarding brain swelling as a causative factor. It is considered that an adequate theory to explain the pathogenesis is still lacking.
It is concluded that the juvenile brain responds to cranial trauma in a manner different from the adult brain. This implies a different approach in policy to hospital admission.
Twenty-six cases of infantile acute subdural hematoma treated between 1972 and 1983 were reviewed. The series was limited to infants with acute subdural hematoma apparently due to minor head trauma without loss of consciousness, and not associated with cerebral contusion. Twenty-three of the patients were boys, and three were girls, showing a clear male predominance. The patients ranged in age between 3 and 13 months, with an average age of 8.1 months, the majority of patients being between 7 and 10 months old. Most of the patients were brought to the hospital because of generalized tonic convulsion which developed soon after minor head trauma, and all patients had retinal and preretinal hemorrhage. The cases were graded into mild, intermediate, and fulminant types, mainly on the basis of the level of consciousness and motor weakness. Treatment for fulminant cases was emergency craniotomy, and that for mild cases was subdural tapping alone. For intermediate cases, craniotomy or subdural tapping was selected according to the contents of the hematoma. The follow-up results included death in two cases, mild physical retardation in one case, and epilepsy in one case. The remaining 23 patients showed normal development. The relationship between computerized tomography (CT) findings and clinical grading was analyzed. Because some mild and intermediate cases could be missed on CT, the importance of noting the characteristic clinical course and of funduscopic examination is stressed.