Brief CommunicationDepressed skull fractures: a pattern of abusive head injury in three older children
Introduction
Head injury is the leading cause of death in child abuse, especially in young children (Levitt, Smith, & Alexander, 1994). In young infants and toddlers, shaking with or without impact results in severe brain injury with acute subdural hemorrhage, cerebral hypoxia and diffuse axonal injury (Duhaime, Christian, Rorke, & Zimmerman, 1998). The condition is called shaken-impact syndrome and occurs globally including Hong Kong (Lee, So, Fong, & Luk, 1999). Severe abusive head injury in the older child is much less frequent, and no specific pattern has been described. We report three cases from two families, involving similar injuries and scenarios.
Section snippets
Methods
Tuen Mun Hospital provides general and emergency medical services, including pediatric intensive care and neurosurgery, to a population of 800,000. All attending children suspected to be victims of child abuse or neglect are referred to either one of the two authors (ACWL and YO) for further evaluation and notification. A retrospective chart review was carried out looking at abused children who were hospitalized between 1999 and 2001 with the finding of skull fracture and/or intracranial
Results
From the 293 cases of suspected child abuse and neglect evaluated over the 3-year period, there were 7 children suffering from severe head injury. Four cases under the age of 2 were excluded, of which one has been reported (Lee, Hau, & Fong, 2001), because of a diagnosis of shaken-impact syndrome. Three children, an 11-year-old girl and two brothers at ages 7 and 9 years, were included. Their clinical features, the abusive incidents, and subsequent management are described below.
Discussion
Inflicted head injury in children usually affects the young infant or toddler and is commonly referred to as the shaken-impact syndrome (Duhaime et al., 1998). Rapid acceleration–deceleration forces are believed to be the underlying mechanical factor which produces the characteristic constellation of acute subdural hematoma, retinal hemorrhages and axonal damage. The case mortality rate is high, and survivors are frequently left with serious neurodevelopmental handicaps. Why the affected
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2022, Paediatrics and Child Health (United Kingdom)Citation Excerpt :Complex skull fractures are more commonly associated with abusive head trauma, especially fractures that cause widening of the sutures, bilateral fractures, fractures crossing sutures or fractures with a branching fracture line pattern (Figure 6).57–59 Depressed skull fractures can be related to inflicted injury and result from a direct impact.60 Soft tissue swelling over a skull fracture may be absent even in acute fractures and therefore absence of soft tissue swelling does not imply the fracture is subacute.61
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2020, Orthopaedics and TraumaCitation Excerpt :Complex skull fractures are more commonly associated with abusive head trauma, especially fractures that cause widening of the sutures, bilateral fractures, fractures crossing sutures or fractures with a branching fracture line pattern (Figure 6).57–59 Depressed skull fractures can be related to inflicted injury and result from a direct impact.60 Soft tissue swelling over a skull fracture may be absent even in acute fractures and therefore absence of soft tissue swelling does not imply the fracture is subacute.61
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2017, Clinical RadiologyCitation Excerpt :Domestic incidents and falls from heights less than 1 metre are very unlikely to cause fracture.35 Conversely, complex skull fractures (bilateral, widened, branching or crossing suture lines) are more commonly abusive than accidental,32,36–38 most likely because of exposure to greater forces than are commonly found in accidental domestic events, as supported by a recent animal study.39 “Alice band” skull fractures result from an injury to the vertex (a direct impact to the infant/child on the top of the head) to produce fractures through the left and right parietal bones, which usually meet at the sagittal suture (roughly within 1–2 cm of each other) radiating from ear-to-ear giving the appearance of a girl's hair band (“Alice band”).
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