Until quite recently studies have been reported which tend to play down the role of inflicted injury in subdural haemorrhage in young children. A study in Seattle (

has confirmed the importance of child abuse.

The study included all children under the age of 3 years with subdural haemorrhage or effusion presenting to two centres in Seattle between March 1995 and December 1998 apart from those with a previously known bleeding disorder, previous neurosurgery, perinatal brain injury, meningitis, renal dialysis, or severe dehydration. Medical, radiological, ophthalmoscopic, and social work data were collected prospectively. Thirty-nine children (mean age 8.7 months) had a diagnosis of child abuse (18 definite, 17 highly likely, 4 likely) and 15 (mean age 19 months) of unintentional injury (6 definite, 7 highly likely, 2 likely). All of the 15 had suffered major trauma (road traffic accident (passenger) 6, road traffic accident (pedestrian) 3, fall from more than 10 feet 3, kicked by horse 1, furniture fell on child 1). For 33 of the 39 children with a diagnosis of abuse the presenting history was of either a minor fall or no explanation. Twelve children had injuries classed as indeterminate as regards the presence or absence of abuse. Chronic subdural haemorrhage was found in 17 children in the abused group and 8 in the indeterminate group but in none of the unintentional injury group, and long bone or rib fractures in 20, 1, and 1 in the three groups. Twenty-eight of the children with a diagnosis of abuse had retinal haemorrhages.

In this series 76% of children with subdural haemorrhage but without an obvious history of severe accidental injury were thought to have been abused. Younger age, chronic subdural haemorrhage, and associated long bone or rib fractures were features associated with a diagnosis of abuse.