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Extra-axial haemorrhages in young children with skull fractures: abuse or accident?
  1. Jordan Wallace1,
  2. James Benson Metz2,
  3. Jeffrey Otjen3,
  4. Francisco A Perez3,
  5. Stephen Done3,
  6. Emily C B Brown4,
  7. Rebecca T Wiester4,
  8. Stephen C Boos5,
  9. Sheila Ganti4,
  10. Kenneth W Feldman1
  1. 1 Pediatrics, Seattle Children's Hospital, Seattle, Washington, USA
  2. 2 Pediatrics, University of Vermont Children's Hospital, Burlington, Vermont, USA
  3. 3 Radiology, Seattle Children's Hospital, Seattle, Washington, USA
  4. 4 Research Clinical Core, Seattle Children's Hospital, Seattle, Washington, USA
  5. 5 Pediatrics, Baystate Medical Center, Springfield, Massachusetts, USA
  1. Correspondence to Dr James Benson Metz, Pediatrics, University of Vermont Children's Hospital, Burlington, Vermont, USA; James.Metz{at}


Objective Infant and toddler subdural haemorrhages (SDH) are often considered indicative of abuse or major trauma. However, accidental impact events, such as falls, cause contact extra-axial haemorrhages (EAHs). The current study sought to determine frequency and clinical behaviour of EAHs with infant and toddler accidental and abusive skull fractures.

Patients and methods Children aged <4 years with accidental skull fractures and abusive fractures identified by CT at two paediatric tertiary care centres. Clinical data were abstracted by child abuse paediatricians and images were reviewed by paediatric radiologists. Data were analysed using univariate and multivariate logistic regression as well as descriptive statistics.

Results Among 227 subjects, 86 (37.9%) had EAHs. EAH was present in 73 (34.8%) accidental and 13 (76.5%) of the abusive injuries. Intracranial haemorrhage rates were not different for children with major or minor accidents but were fewer than abused. EAH was equally common with falls <4 and >4 ft. EAH depths did not differ by mechanism, but 69% of accidental EAHs were localised solely at fracture sites vs 38% abuse. Widespread and multifocal EAHs were more common with abuse. Children with abuse or major accidental injuries presented with lower initial Glasgow Coma Scales than those with minor accidents. Abused children had initial loss of consciousness more often than those with either minor or major accidents.

Conclusions Simple contact EAHs were common among children with minor and major accidental skull fractures. Accidental EAHs were more localised with less neurological dysfunction than abusive.

  • child abuse
  • neurosurgery

Data availability statement

Data are available upon request.

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Data availability statement

Data are available upon request.

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  • Contributors JW: abstracted and analysed data, composed the initial manuscript draft. JBM: developed the parent study and database, assisted with data analysis, edited the paper. JO: assisted with development of the database, conducted radiology review, edited the paper. FAP: conducted radiology review and edited the paper. SD: conducted radiology review. ECBB: conducted clinical review and data abstraction, edited the paper. RTW: conducted clinical review and data abstraction. SCB: conceived the study purpose and analysis. SG: provided data analysis and manuscript review. KWF: conceived of and assisted with development of the parent study and the current subanalysis, had access to the data, participated in data analysis and study editing and is the guarantor for the study and controlled the decision to publish this manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests JBM, JO, SD, ECBB, RTW, SCB and KWF have provided medical legal consultation and testimony.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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