Simple Isolated Skull Fractures in Young Children: Findings From a Hospital-Based Child Protection Team

Isolated skull fractures (ISFs) in young children are a common reason for referral to hospital-based child protection teams for forensic medical assessment. The purpose of this study was to describe the injury opinion of simple ISFs determined by a child protection team, and to assess the utility of skeletal survey and ophthalmology examination in forming the injury opinion.

A retrospective study was performed for children under 2 years referred to the child protection team at a tertiary children's hospital with a simple ISF between July 2015 and December 2024. The primary outcome was the injury opinion determined by the child protection team: accidental, indeterminate or inflicted. Secondary outcomes included the rate and positive yield of skeletal survey and ophthalmology examination.

Of the 81 children referred with a simple ISF, 4 (5%) were considered inflicted, 30 (37%) indeterminate and 47 (58%) accidental. History with statutory child protection services (p-value 0.042) and additional suspicious cutaneous injuries (p-value < 0.001) were significantly associated with inflicted injury. A skeletal survey was obtained for 43 children (53%). Four skeletal surveys identified additional injuries, giving a positive yield of 9%. Ophthalmology examination was performed for 38 children (47%), and none had retinal haemorrhages.

ISFs in young children are rarely determined to be inflicted injuries. In cases of inflicted ISF, there are additional clinical factors prompting concern (age under 6 months, history with child protection services, or additional suspicious cutaneous injuries). Skeletal survey rarely adds additional information, and ophthalmology examination never adds additional information.