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Occult abusive injuries in infants with apparently isolated skull fractures
Katherine P Deye1, Rachel P Berger, Daniel M Lindberg
1Freddie Mac Foundation Child and Adolescent Protection Center (K.P.D.),Children's National Medical Center, George Washington University School ofMedicine and Health Sciences, Washington, District of Columbia, USA.
Insights
Screening infants with isolated skull fractures for abusive injuries is crucial. Skeletal surveys identify additional fractures in a small subset, highlighting the need for thorough evaluation in suspected child abuse cases.
Area of Science:
- Pediatric Traumatology
- Child Abuse Pediatrics
- Forensic Pediatrics
Background:
- Consensus is lacking on optimal screening for abusive injuries in infants with isolated skull fractures.
- Infants with apparently isolated skull fractures represent a significant proportion of physical abuse consultations.
- Subspecialty evaluation is critical for identifying abusive injuries in this vulnerable population.
Purpose of the Study:
- To determine screening rates for abusive injuries in infants with isolated skull fractures.
- To assess the rates of injury identification through various screening methods.
- To evaluate the frequency of reporting to child protective services.
Main Methods:
- Retrospective analysis of infants (<12 months) presenting with skull fractures and concerns for abuse.
- Inclusion of data on skeletal surveys, ophthalmologic examinations, and abdominal injury screening.
- Analysis of injury identification rates and child protective services reporting.
Main Results:
- Skeletal surveys were performed in 93.4% of infants, identifying additional fractures in 5.6%.
- Ophthalmologic examination (46.5%) revealed retinal hemorrhages in one child; abdominal screening (62.7%) identified no injuries.
- Additional fractures on skeletal surveys were not reliably predicted by age, trauma history, or fracture type.
Conclusions:
- Infants with isolated skull fractures warrant thorough evaluation for physical abuse.
- While skeletal surveys detect additional fractures in a minority of cases, they remain an important diagnostic tool.
- Comprehensive screening protocols are essential for accurate diagnosis and intervention in suspected child abuse.
Background:
There is currently no consensus about which screening studies should be undertaken to identify abusive injuries in infants with apparently isolated skull fractures. Our objective was to determine rates of screening, rates of injury identification, and rates of reporting to child protective services among infants who underwent subspecialty evaluation for abuse after presenting with an apparently isolated skull fracture.
Methods:
This was a retrospectively planned, secondary analysis of index children enrolled in a large network of children with concerns for physical abuse. For this analysis, we included infants (<12 months) who presented with signs and symptoms attributable to a skull fracture. We determined rates of skeletal survey, dedicated ophthalmologic examination and abdominal injury screening, rates of injury identification by testing and reports to child protective services.
Results:
A total of 215 infants underwent abuse consultation for apparently isolated skull fractures. Skeletal surveys were performed in 201 subjects (93.4%) and identified additional fractures in 12 (5.6%; 95% confidence interval, 2.9-9.6%). Patient age, trauma history, and fracture type (simple/complex) were not sensitive predictors of finding additional fractures on skeletal survey. Only one additional fracture was associated with clinical signs or symptoms. Dedicated ophthalmologic examination was undertaken in 100 subjects (46.5%); one child had retinal hemorrhages. Hepatic transaminases were obtained in 135 subjects (62.7%), and 5 subjects (2.3%) had abdominal computed tomography. No abdominal injuries were identified. A total of 146 subjects (67.9%) were reported to child protective services.
Conclusion:
Infants with apparently isolated skull fractures are an important fraction of consultations for physical abuse. Additional fractures are identified in a small subset of the skeletal surveys completed in these children.
Level Of Evidence:
Epidemiological study, level IV.
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