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Are Complex Skull Fractures Indicative of Either Child Abuse or Major Trauma in the Era of 3-Dimensional Computed
James B Metz1, Jeffrey P Otjen2, Francisco A Perez2
1Department of Pediatrics, University of Vermont Children's Hospital, Burlington, VT.
Insights
Complex skull fractures are common in accidental injuries, not solely indicative of child abuse. Medical professionals should not rely on complex fractures alone when assessing potential abuse cases.
Area of Science:
- Pediatric Traumatology
- Child Abuse Forensics
- Radiology
Background:
- Skull fractures in children can be challenging to differentiate between abuse and accidental trauma.
- Complex skull fractures, defined by specific characteristics, warrant further investigation into their etiology.
Purpose of the Study:
- To investigate the association between complex skull fractures and their correlation with child abuse versus major accidental trauma.
- To evaluate the diagnostic utility of complex skull fractures in identifying non-accidental injuries in young children.
Main Methods:
- Retrospective review of medical records and 3D-rendered head CT scans for children under 4 years old with skull fractures.
- Classification of skull fractures as simple or complex based on predefined criteria.
- Correlation of fracture type with confirmed findings of abuse or accidental mechanisms of injury.
Main Results:
- Of 147 subjects, 50.3% had complex skull fractures and 49.7% had simple fractures.
- While 80% of abused children had complex fractures, 48.5% of accidentally injured children also presented with complex fractures.
- The positive predictive value of complex skull fractures for abuse was low (7%).
Conclusions:
- Complex skull fractures are frequently associated with accidental injuries in children.
- The presence of complex skull fractures alone is insufficient for determining child abuse.
Objective:
The aim of the study was to determine whether complex skull fractures are more indicative of child abuse or major trauma than simple skull fractures.
Design:
This is a retrospective chart and imaging review of children diagnosed with a skull fracture. Subjects were from 2 pediatric tertiary care centers. Children younger than 4 years who underwent a head computed tomography with 3-dimensional rendering were included. We reviewed the medical records and imaging for type of skull fracture, abuse findings, and reported mechanism of injury. A complex skull fracture was defined as multiple fractures of a single skull bone, fractures of more than 1 skull bone, a nonlinear fracture, or diastasis of greater than 3 mm. Abuse versus accident was determined at the time of the initial evaluation with child abuse physician team confirmation.
Results:
From 2011 to 2012, 287 subjects were identified by International Classification of Diseases, Ninth Revision, code. The 147 subjects with a cranial vault fracture and available 3-dimensional computed tomography composed this study's subjects. The average age was 12.3 months. Seventy four (50.3%) had complex and 73 (49.7%) had simple fractures. Abuse was determined in 6 subjects (4.1%), and a determination could not be made for 5 subjects. Adding abused children from 2013 to 2014 yielded 15 abused subjects. Twelve of the abused children (80%) had complex fractures; more than the 66 (48.5%) of 136 accidentally injured children (P = 0.001; relative risk = 1.65 [1.21-2.24]). However, among children with a complex fracture, the positive predictive value for abuse was only 7%.
Conclusions:
Complex skull fractures frequently occur from accidental injuries. This study suggests that the presence of complex skull fractures should not be used alone when making a determination of abuse.
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