Article Text
PDF
Statistics from Altmetric.com
‘Did he fall, or has he suffered inflicted injury?’ is a question faced frequently by clinicians caring for infants and toddlers with traumatic brain injury. Publicised court cases, with widely divergent medical opinions, illustrate the dilemma of distinguishing between inflicted and accidental causes, especially when there are no other signs of abuse but just an uncorroborated, alleged accident, often a fall. Although there has been resistance to diagnosing abuse there may also be over enthusiasm to do so, and although there is an increasingly prevalent opinion that short falls can never cause serious injury,1 this, too, is still open to debate.
Causes of variability in injury
Determinants of injury severity for a given trauma mechanism such as a fall may include:
-
The distance fallen.
-
The nature of the surface on to which the child falls.
-
Forwards or sideways protective reflexes; there is no backwards protective reflex or righting reflex.
-
Whether a fall is in some way ‘broken’.
-
Whether the child propelled himself.
-
The mass of the body and of the head.
-
What proportion of the total kinetic energy is absorbed in deforming the skull, the brain or the rest of the body, and in compressing the ground; this itself may be influenced by which body part hits the ground first.
-
Whether or not some kinetic energy is dissipated in causing fractures.
-
Whether the contact with the ground is focal or diffuse, that is whether the fall is on to a point or on to a flat surface.
-
Secondary brain injury can confuse the picture, for example hypoxic encephalopathy from an unprotected airway, or ischaemic from cerebral oedema.
Very few of these aspects have been subjected to scientific scrutiny and some of the literature relates to adults rather than children.
Falls: how far is fatal?
Short distance household falls do not normally cause serious brain injury,2 3 but there …