Skull fractures in abusive head trauma: a single centre experience and review of the literature

International Consensus Statement on the Radiological Screening of Contact Children in the Context of Suspected Child Physical Abuse

Importance

Physical abuse is a common but preventable cause of long-term childhood morbidity and mortality. Despite the strong association between abuse in an index child and abuse in contact children, there is no guidance outlining how to screen the latter, significantly more vulnerable group, for abusive injuries. Consequently, the radiological assessment of contact children is often omitted, or variably performed, allowing occult injuries to go undetected and increasing the risk of further abuse.

Objective

To report an evidence-based and consensus-derived set of best practices for the radiological screening of contact children in the context of suspected child physical abuse.

Evidence Review

This consensus statement is supported by a systematic review of the literature and the clinical opinion of an internationally recognized group of 26 experts. The modified Delphi consensus process comprised 3 meetings of the International Consensus Group on Contact Screening in Suspected Child Physical Abuse held between February and June 2021.

Findings

Contacts are defined as the asymptomatic siblings, cohabiting children, or children under the same care as an index child with suspected child physical abuse. All contact children should undergo a thorough physical examination and a history elicited prior to imaging. Contact children younger than 12 months should have neuroimaging, the preferred modality for which is magnetic resonance imaging, and skeletal survey. Contact children aged 12 to 24 months should undergo skeletal survey. No routine imaging is indicated in asymptomatic children older than 24 months. Follow-up skeletal survey with limited views should be performed if abnormal or equivocal at presentation. Contacts with positive findings should be investigated as an index child.

Conclusions and Relevance

This Special Communication reports consensus recommendations for the radiological screening of contact children in the context of suspected child physical abuse, establishing a recognized baseline for the stringent evaluation of these at-risk children and providing clinicians with a more resilient platform from which to advocate for them.

Skeletal survey yields in low vs. high risk pediatric patients with skull fractures

BACKGROUND

To assess for occult fractures, physicians often opt to obtain skeletal surveys (SS) in young, acutely head-injured patients who present with skull fractures. Data informing optimal decision management are lacking.

OBJECTIVE

To determine the positive yields of radiologic SS in young patients with skull fractures presumed to be at low vs. high risk for abuse.

PARTICIPANTS AND SETTING

476 acutely head injured, skull-fractured patients <3 years hospitalized for intensive care across 18 sites between February 2011 and March 2021.

METHODS

We conducted a retrospective, secondary analysis of the combined, prospective Pediatric Brain Injury Research Network (PediBIRN) data set.

RESULTS

204 (43 %) of 476 patients had simple, linear, parietal skull fractures. 272 (57 %) had more complex skull fracture(s). Only 315 (66 %) of 476 patients underwent SS, including 102 (32 %) patients presumed to be at low risk for abuse (patients who presented with a consistent history of accidental trauma; intracranial injuries no deeper than the cortical brain; and no respiratory compromise, alteration or loss of consciousness, seizures, or skin injuries suspicious for abuse). Only one of 102 low risk patients revealed findings indicative of abuse. In two other low risk patients, SS helped to confirm metabolic bone disease.

CONCLUSIONS

Less than 1 % of low risk patients under three years of age who presented with simple or complex skull fracture(s) revealed other abusive fractures. Our results could inform efforts to reduce unnecessary skeletal surveys.

Pediatric skull fractures: could suture contact be a sign of abuse?

PURPOSE

Skull fractures in infants and young children can occur as a result of both accidental trauma and abuse. 1/3 of children with abuse-related head trauma and 1/5 of children with abuse-related fractures were overlooked during the initial evaluation. In this study, we aim to investigate the prevalence of skull fractures that come into contact with the suture in head traumas caused by accidents and abuse, and also to see if contact of the fracture line with the suture could be used as a sign for abuse in the pediatric population.

METHODS

Forry-four patients with head trauma were retrospectively assessed between January 2010 and June 2020 and were confirmed to have fractures on a brain CT. Patient age, gender, and head injury type were recorded. The fracture site, location and number, the contact of the fracture line with the suture, the name, and number of the suture it came into contact with were determined.

RESULTS

Twenty-eight skull fractures in 22 children with a diagnosis of child abuse and 25 skull fractures in 22 children due to accidental trauma were evaluated in the same age and gender range. Eighteen (64%) of 28 abuse-related skull fractures were in contact with two or more sutures. Two (8%) of 25 accident-related fractures were related to two or more sutures. Abuse-related fractures had a significantly higher suture contact rate than accident-related fractures (p = 0.007).

CONCLUSION

Contact with two or more sutures of a skull fracture is a finding related to abuse rather than accident.

Abusive head trauma: neuroimaging mimics and diagnostic complexities

Traumatic brain injury is responsible for approximately half of all childhood deaths from infancy to puberty, the majority of which are attributable to abusive head trauma (AHT). Due to the broad way patients present and the lack of a clear mechanism of injury in some cases, neuroimaging plays an integral role in the diagnostic pathway of these children. However, this nonspecific nature also presages the existence of numerous conditions that mimic both the clinical and neuroimaging findings seen in AHT. This propensity for misdiagnosis is compounded by the lack of pathognomonic patterns and clear diagnostic criteria. The repercussions of this are severe and have a profound stigmatic effect. The authors present an exhaustive review of the literature complemented by illustrative cases from their institutions with the aim of providing a framework with which to approach the neuroimaging and diagnosis of AHT.

Pediatric Abusive Head Trauma: A Systematic Review

Abusive head trauma (AHT) represents a commonly misdiagnosed condition. In fact, there is no pathognomonic sign that allows the diagnosis in children. Therefore, it is such an important medico-legal challenge to evaluate reliable diagnostic tools. The aim of this review is to evaluate the current scientific evidence to assess what the best practice is in order to diagnose AHT. We have focused particularly on evaluating the importance of circumstantial evidence, clinical history, the use of postmortem radiological examinations (such as CT and MRI), and the performance of the autopsy. After autopsy, histological examination of the eye and brain play an important role, with attention paid to correlation with symptoms found in vivo.