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Extra-axial haemorrhages in young children with skull fractures: abuse or accident?
Jordan Wallace1, James Benson Metz2, Jeffrey Otjen3
1Pediatrics, Seattle Children's Hospital, Seattle, Washington, USA.
Insights
Extra-axial haemorrhages (EAHs) are common in infant and toddler skull fractures from accidental falls. Accidental EAHs are typically localized and cause less neurological dysfunction compared to abusive injuries.
Area of Science:
- Pediatric Radiology
- Child Abuse Pediatrics
- Trauma Imaging
Background:
- Subdural haemorrhages (SDH) in infants and toddlers are often linked to abuse or major trauma.
- Accidental impact events, like falls, can result in contact extra-axial haemorrhages (EAHs).
Purpose of the Study:
- To determine the frequency and clinical characteristics of EAHs in infant and toddler skull fractures.
- To differentiate EAH patterns in accidental versus abusive injuries.
Main Methods:
- Retrospective analysis of CT scans from children under 4 years with accidental and abusive skull fractures.
- Clinical data abstraction by child abuse pediatricians and image review by pediatric radiologists.
- Statistical analysis including univariate and multivariate logistic regression.
Main Results:
- 86 out of 227 subjects (37.9%) had EAHs.
- EAHs were present in 34.8% of accidental and 76.5% of abusive fractures.
- Accidental EAHs were more localized to fracture sites (69%) compared to abusive injuries (38%), with less neurological dysfunction.
Conclusions:
- Simple contact EAHs are frequent in both minor and major accidental skull fractures.
- Accidental EAHs present as more localized injuries with less associated neurological impairment than those seen in abusive injuries.
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.
