Biomechanical characteristics of head injuries from falls in children younger than 48 months

Retinodural haemorrhage of infancy, abusive head trauma, shaken baby syndrome: The continuing quest for evidence

The shaken baby syndrome was originally proposed in the 1970s without any formal scientific basis. Once data generated by scientific research was available, the hypothesis became controversial. There developed essentially two sides in the debate. One side claimed that the clinical triad of subdural haemorrhage, retinal haemorrhage, and encephalopathy, or its components, is evidence that an infant has been shaken. The other side stated this is not a scientifically valid proposal and that alternative causes, such as low falls and natural diseases, should be considered. The controversy continues, but the contours have shifted. During the last 15 years, research has shown that the triad is not sufficient to infer shaking or abuse and the shaking hypothesis does not meet the standards of evidence-based medicine. This raises the issue of whether it is fit for either clinical practice or for the courtroom; evidence presented to the courts must be unassailable. WHAT THIS PAPER ADDS: There is insufficient scientific evidence to assume that an infant with the triad of subdural haemorrhage (SDH), retinal haemorrhage, and encephalopathy must have been shaken. Biomechanical and animal studies have failed to support the hypothesis that shaking can cause SDH and retinal haemorrhage. Patterns of retinal haemorrhage cannot distinguish abuse. Retinal haemorrhages are commonly associated with extracerebral fluid collections (including SDH) but not with shaking. Infants can develop SDH, retinal haemorrhage, and encephalopathy from natural diseases and falls as low as 1 foot. The shaking hypothesis and the literature on which it depends do not meet the standards of evidence-based medicine.

Short Falls in Childhood Occasionally Cause Major Brain Injuries Because of Unusual Circumstances

METHODS

Records and imaging were reviewed for children younger than 6 years, hospitalized between 2015 and 2020 for major closed head injuries following less than 4-ft falls. Major injury was defined as intensive care admission more than 2 days, neurosurgical intervention, death, or disability at hospital discharge. Subjects were identified through Seattle and Spokane, Washington abuse consultations. Harborview Medical Center's trauma registry and Seattle Children's Hospital's Hemophilia Treatment Program and Radiology were searched for subjects.

RESULTS

We identified 12 young children who sustained major closed head injury due to short falls. Seven developed major space-occupying epidural hemorrhages. One child developed internal hydrocephalus after intraventricular hemorrhage. One child with prior meningomyelocele, Chiari 2 malformation, and ventriculoperitoneal shunt developed shunt decompensation after an acute-on-chronic subdural hemorrhage. One child developed an internal capsule stroke because of a previously undiagnosed calcifying angiopathy. Another child developed space-occupying subdural hemorrhage associated with previously unrecognized platelet pool disorder. Only this child had abuse concerns, which were resolved with his coagulopathy diagnosis. One child had a diastatic skull fracture leading to pseudomeningocele.At Harborview Medical Center, 140 children were seen for short falls in the emergency department or inpatient service. Among the 40 needing intensive care, 4 (12.5%) had major injuries after short falls. Our hemophilia treatment program did not see any children who had sustained major injury following a short fall in a 5½ year period.

CONCLUSIONS

Although young children rarely sustain major head injury following short falls, serious head injuries do occasionally occur because of unusual injury mechanisms or preexisting conditions. It is important to fully evaluate these patients to differentiate these unintentional falls from abusive head injury.

Understanding Bilateral Skull Fractures in Infancy: A Retrospective Multicenter Case Review

BACKGROUND

Bilateral skull fractures in infancy often raise suspicion for abuse. Nevertheless, literature suggests that they may occur accidentally. However, empiric data are lacking.

OBJECTIVE

This multicenter retrospective review aimed to characterize bilateral skull fractures in a large sample.

PARTICIPANTS AND SETTING

Medical records for infants younger than 24 months with bilateral skull fractures involving hospital consultation with a child abuse pediatrician (CAP) were reviewed from 2005 to 2020 at 13 nationally represented institutions.

METHODS

Standardized data collection across institutions included historical features, fracture characteristics, and additional injuries, as well as the CAP's determination of accident versus abuse. Pooled data were analyzed for descriptive and bivariate analyses.

RESULTS

For 235 cases, 141 were accidental, and 94 abuse. The majority occurred in young infants, and a history of a fall was common in 70% of cases. More than 80% involved both parietal bones. Bilateral simple linear fractures were more common in accidental cases, 79% versus 35%, whereas a complex fracture was more frequent in abuse cases, 55% versus 21% ( P < 0.001). Almost two thirds of accidental cases showed approximation of the fractures at the sagittal suture, compared with one third of abuse cases ( P < 0.001). Whereas focal intracranial hemorrhage was seen in 43% of all cases, diffuse intracranial hemorrhage was seen more in abuse cases (45%) than accidents (11%). Skin trauma was more common in abusive than accidental injury (67% vs 17%, P < 0.001), as were additional fractures on skeletal survey (49% vs 3%, P < 0.001).

CONCLUSIONS

A fall history was common in bilateral skull fractures deemed accidental by a CAP. Most accidental cases involved young infants with biparietal simple linear fractures, without skin trauma or additional fractures. A skeletal survey may aid in the determination of accidental or abusive injury for unwitnessed events resulting in bilateral skull fractures in infants.

Falls of newborn infants in a New Zealand hospital: A case series

AIM

The fall of a newborn baby to the hospital floor is a devastating experience for the family and staff caring for the mother and baby. The aim of this study was to report our experience in an ethnically diverse and socioeconomically disadvantaged community.

METHODS

The study was a retrospective case series of all baby falls in the Counties Manukau Health (New Zealand) post-natal care wards, birthing suites and birthing units from 2015 to 2018. Information from the incident reporting system was used to identify the circumstances surrounding the fall. In addition, medical records of the mother and the baby were examined for the admission during which the fall occurred.

RESULTS

There were 32 cases (rate 12.1/10 000 live births). Mothers of babies who fell were more likely to present late for antenatal care, to smoke and be obese. They were more likely to have delivered by caesarean. Falls were more likely to occur at night and around weekends. In most instances (84%) the mother fell asleep with baby on the bed while breastfeeding. There were no major injuries.

CONCLUSIONS

The rate of baby falls is considerably greater than previous reports. Recommendations are made to reduce this occurrence. These can be incorporated into safe sleep education.

Head biomechanics of video recorded falls involving children in a childcare setting

The objective of this study was to characterize head biomechanics of video-recorded falls involving young children in a licensed childcare setting. Children 12 to < 36 months of age were observed using video monitoring during daily activities in a childcare setting (in classrooms and outdoor playground) to capture fall events. Sensors (SIM G) incorporated into headbands worn by the children were used to obtain head accelerations and velocities during falls. The SIM G device was activated when linear acceleration was ≥ 12 g. 174 video-recorded falls activated the SIM G device; these falls involved 31 children (mean age = 21.6 months ± 5.6 SD). Fall heights ranged from 0.1 to 1.2 m. Across falls, max linear head acceleration was 50.2 g, max rotational head acceleration was 5388 rad/s², max linear head velocity was 3.8 m/s and max rotational head velocity was 21.6 rad/s. Falls with head impact had significantly higher biomechanical measures. There was no correlation between head acceleration and fall height. No serious injuries resulted from falls—only 1 child had a minor injury. In conclusion, wearable sensors enabled characterization of head biomechanics during video-recorded falls involving young children in a childcare setting. Falls in this setting did not result in serious injury.

Children With a Soft Scalp Hematoma Presenting to the Emergency Department More Than 24 Hours After a Head Injury

OBJECTIVES

The soft scalp hematoma is one of the clinical markers used as a predictor for the presence of intracranial injury in children with a head trauma. We evaluated the significance of time presentation in the management of these patients.

METHODS

We conducted a retrospective study of children and adolescents aged 0 to <18 years by comparing the clinical, radiological, and epidemiological features in those presenting within 24 hours with those presenting greater than 24 hours after a head injury.

RESULTS

We identified 188 and 98 patients with early presentation and late presentation, respectively. The percentage of children aged 0 to <6 months was lower in those with late presentation (6.12%) than those with early presentation (20.21%) with a significant difference (P < .001). Likewise, the percentage of children aged ≥24 months was lower in children with late presentation (7.14%) than those with early presentation (34.04%) with a significant difference (P < .001). The severe mechanism rate was more elevated in early presentation (38.83%) with a significant difference (-14.34%; 95% confidence interval [CI], -25.34% to -3.34%; P = .015). The symptom rate resulted higher in early presentation (14.36%) with a significant difference (-11.30%; 95% CI, -17.36% to 5.22%; P = .003). The parietal scalp hematoma occurred mostly in children with late presentation (85.71%) with a significant difference (19.76%; 95% CI, 10.07% to 29.45%; P < .001). The occipital scalp hematoma rate was higher in early presentation with a significant difference (-17.50%; 95% CI, -22.99% to -12.12%; P < .001). There was no significant difference in the prevalence of different types of intracranial injury, and the only 5 patients needing a neurosurgical intervention were exclusively children with an early presentation.

CONCLUSION

Although children with soft scalp hematoma presenting to the emergency department greater than 24 hours after a head injury may have pathological findings on computed tomography, all of them had a good short- and long-term outcomes, and no neurological deterioration aroused the medical attention on follow-up. For this subset of patients that does not experience red flags (neurological symptoms, focal signs on examination, or severe injury mechanism), a wait-and-see approach might be more appropriate rather than neuroimaging.

Are Complex Skull Fractures Indicative of Either Child Abuse or Major Trauma in the Era of 3-Dimensional Computed Tomography Imaging?

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.

3 Cases of Inflicted Skull Crush Injuries in Infants

ABSTRACT

We describe 3 infants with skull fractures that involved more than 1 skull bone. On further evaluation, 2 of the 3 infants had additional fractures at other sites of the body and the third infant had concerning bruising of the face. Although an accidental mechanism of injury was initially given as the history in each case, law enforcement investigations led all 3 fathers to confess to crushing their infants' skulls out of frustration. These crushes were caused by their arms or hands. Bilateral skull fractures or those involving more than 1 skull bone can be seen in falls as well as in crush injuries. A crush-like pattern of injury, in the absence of a clear and plausible accidental mechanism, should raise concerns for possible physical abuse especially in nonambulatory infants.

Fracture-Associated Bruising and Soft Tissue Swelling in Young Children With Skull Fractures: How Sensitive Are They to Fracture Presence?

OBJECTIVES

The aim of this study was to determine how reliable scalp bruising and soft tissue swelling/cephalohematomas (STS) are for underlying young child skull fractures.

METHODS

This was a retrospective clinical and imaging review from 2011 to 2012 of children younger than 4 years with skull fractures from 2 tertiary care hospitals. Imaging was reread by 3 pediatric radiologists. Descriptive statistics were utilized. The retrospective review had institutional review board approval.

RESULTS

We identified 218 subjects for review: 210 unintentional and 8 abusive. One hundred forty-three had available 3-dimensional computed tomography reconstructions: 136 unintentional and 7 abused. Two-thirds were younger than 1 year. Twelve subjects had visible scalp bruising, but 73% had clinically and 93% radiologically apparent fracture-associated STS. There was no difference in clinical STS with simple (79%) versus complex (68%) fractures. Nor was there difference in subjects with fractures from minor (77%) versus major (70%) trauma. Unintentionally injured infants did not differ from abused for detectable STS (74% vs 50%). Parietal and frontal bones most frequently sustained fractures and most consistently had associated STS.

CONCLUSIONS

Clinically apparent STS is present in approximately three-fourths of children with skull fractures. It may not be important to consistently identify skull fractures in unintentionally injured children. Point-of-care ultrasound may be adequate. For abuse concerns, it is important to identify skull fractures as evidence of cranial impacts and intracranial hemorrhages. The most sensitive, widely available imaging technique, cranial computed tomography scan with 3-dimensional skull reconstruction, should be utilized. Scalp bruising is present in a minority of young children with skull fractures. Its absence does not exclude cranial impact injury.

Combined Symphyseal and Condylar Fractures: Considerations for Treatment in Growing Pediatric Patients

BACKGROUND

Combined symphyseal-condylar mandible fractures are relatively common but difficult to manage in children. This study investigated the cause and management of symphyseal-condylar fractures in pediatric patients.

METHODS

This study presents a retrospective review and expert opinion of pediatric symphyseal-condylar mandibular fracture management at the authors' institution between 1990 and 2019. National data from the Healthcare Cost and Utilization Project Kids' Inpatient Database (2000 to 2016) were used to determine whether institutional data had national applicability.

RESULTS

Twenty-one patients at the authors' institution met inclusion criteria. Of these patients, 26.7 percent of deciduous dentition patients underwent open reduction and internal fixation, 40 percent underwent closed treatment (maxillomandibular fixation), and 33.3 percent received a soft diet. All mixed dentition patients underwent open reduction and internal fixation or closed treatment; all permanent dentition patients underwent open reduction and internal fixation. The national database (n = 1708) demonstrated similar treatment patterns: most permanent dentition patients (88.7 percent) underwent open reduction and internal fixation, most mixed dentition patients (79.2 percent) underwent closed treatment, and among deciduous dentition patients, 53.5 percent patients received a soft diet; 38 percent received closed treatment. In this study, the overall posttreatment complication rate was 62.5 percent among open reduction and internal fixation patients, 14.3 percent among closed treatment patients, and 16.7 percent among patients treated with a soft diet.

CONCLUSIONS

Symphyseal-condylar mandibular fractures were associated with substantial morbidity in children. The authors created a treatment algorithm to maximize outcomes in children who suffer from this challenging fracture pattern.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Delays in care seeking for young children with accidental skull fractures are common

AIM

We sought to determine the frequency and patterns of delayed medical care seeking for young children with skull fractures.

METHODS

We identified accidental skull fractures <4 years old, 2011-2012. Child abuse paediatricians abstracted retrospective data and paediatric radiologists re-reviewed images. 'Delays' were defined as presentation at ≥6 h. 'Minor accidents' included falls <4 feet and low force trauma, while 'major accidents' included higher height falls and major force events. We studied the frequency and duration of care delays, the signs or symptoms leading to care, and the duration of delays after signs or symptoms developed.

RESULTS

Two hundred and ten children had accidental skull fractures. Delays were less likely with major accidents (4.9%), than with minor accidents (25.8%) (RR = 0.32 [0.15-0.70]). Children came to care for scalp swelling (STS) (39%), the injury event (36.2%), altered consciousness (15.2%) and vomiting (10.5%). Delayed onset of STS (78.6%) caused most delayed care. Early STS was firm, (17.6%) versus delayed (5.0%), as opposed to soft or fluctuant.

CONCLUSION

Delayed care seeking is common for minor, but not major accidental infant and toddler skull fractures. Most followed delayed onset of signs and symptoms. Delayed care seeking alone should not imply child abuse.

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.

Parenchymal brain injuries in abusive head trauma

The consequences of abusive head trauma (AHT) can be devastating for both the individual child and for wider society. Death is undoubtedly a very real possibility, but even for those children who survive, there is often very significant morbidity with the potential for gross motor and cognitive impairment, behavioural problems, blindness and epilepsy, which can greatly affect their quality of life. Caring for such children places a vast financial and infrastructural burden on society that frequently extends well into adulthood. While few struggle to have any sympathy for the perpetrator, frequently the infant's father, it should be noted that a single solitary and momentary loss of complete control can have horrific and unforeseen consequences. A number of papers within this edition describe features of AHT and include descriptions of skull fractures and extra-axial haemorrhage, along with mimics of such phenomena. However, in this review we concentrate our attention on the myriad of parenchymal findings that can occur. Such parenchymal injuries include hypoxic-ischaemic damage, clefts, contusion and focal haemorrhage. We offer our perspectives on current thinking on these entities and put them in the context of the immensely important question - how do we recognise abusive head trauma?

Radiologic Assessment of Skull Fracture Healing in Young Children

BACKGROUND

Skull fractures are commonly seen after both accidental and nonaccidental head injuries in young children. A history of recent trauma may be lacking in either an accidental or nonaccidental head injury event. Furthermore, skull fractures do not offer an indication of the stage of healing on radiologic studies because they do not heal with callus formation as seen with long bone fractures. Thus, a better understanding on the timing of skull fracture resolution may provide guidance on the medical evaluation for accidental or nonaccidental head injury.

OBJECTIVE

The aim of the study was to determine the time required for radiographic skull fracture resolution in children younger than 24 months.

METHODS

This was a retrospective observational analysis of children younger than 24 months referred with skull fractures between January 2008 and December 2012. Analysis included children with accidental head injuries with a known time interval since injury and a negative skeletal survey who underwent serial radiographic studies. Complete healing of a skull fracture was defined as resolution of fracture lucency by radiograph.

RESULTS

Of the 26 children who met inclusion criteria, 11 (42.3%) demonstrated resolution of skull fracture(s) on follow-up imaging. Fracture resolution on radiologic studies ranged from 2 to 18 weeks. Twelve fractures in 10 children demonstrated fracture resolution at 10 or more weeks after injury.

CONCLUSIONS

Healing or resolution of a skull fracture can take months in children younger than 24 months. With the high variability in skull fracture presentation and large window to fracture resolution, unexplained or multiple skull fractures in children younger than 24 months may be the result of a single or multiple events of head trauma.

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

PURPOSE

The authors provide a comprehensive framework with which to approach paediatric calvarial injury sustained as a result of suspected abusive head trauma (AHT). This is achieved through the presentation of a case series set in the context of the unique morphology of the infant skull and the possible diagnostic pitfalls which may arise due to the presence of variant anatomy or other mimicking conditions.

METHODS

A retrospective analysis of sixty-three patients referred to our institution with suspected AHT was carried out. Seventeen patients with skull fractures were identified and their fractures were described in terms of anatomical location, type and course. Our data was then interpreted in the light of known anatomical fracture mimics and the available literature on the subject.

RESULTS

Forty-two skull fractures were identified and described in our cohort, most of which were simple linear fractures of the parietal bones (33%). There were also a substantial number of complex stellate fractures, namely of the parietal (29%) and occipital (10%) bones. Eleven fracture mimics including accessory sutures and wormian bones were also identified in this cohort.

CONCLUSIONS

Our study supports and builds on the existing literature, thereby offering a more complete view of the spectrum of calvarial damage sustained as a result of AHT in the context of its diagnostic pitfalls.

Occurrence of traumatic brain injury due to short falls with or without a witness by a nonrelative in children younger than 2 years

OBJECTIVE

There is disagreement about the occurrence of severe traumatic brain injury, especially subdural hematoma, caused by short falls in very young children. To verify intracranial injury due to these falls and examine its characteristics, the authors compared infants and toddlers with head trauma witnessed by a nonrelative with those whose injuries were not witnessed by a nonrelative.

METHODS

The authors retrospectively reviewed clinical records of children younger than 2 years with head trauma due to a short fall who visited the emergency department of the National Center for Child Health and Development in Japan between April 2015 and March 2018. Patients were classified into two groups: falls that were witnessed by a nonrelative and falls not witnessed by a nonrelative. The authors compared the age in months, sex, mechanism of injury, fall height, prevalence rate of intracranial injury, skull fracture, type of traumatic brain injury, retinal hemorrhage, rib or long-bone fracture, and outcomes between patients whose fall was witnessed by a nonrelative and those whose fall was not witnessed by a nonrelative.

RESULTS

Among 1494 patients included in the present analysis, 392 patients were classified into the group of falls witnessed by a nonrelative, and 1102 patients were classified into the group of falls that were not witnessed by a nonrelative. The prevalence rates of intracranial injury, skull fracture, epidural hematoma, and subarachnoid hemorrhage were equal between the groups. The prevalence rate of subdural hematoma in the group whose falls were witnessed by a nonrelative was significantly lower than that of the other group (p = 0.027). There were no patients with subdural hematoma, retinal hemorrhage, or neurological sequelae in the group whose fall was witnessed by a nonrelative.

CONCLUSIONS

Subdural hematoma, retinal hemorrhage, and neurological sequelae due to short falls were not seen after witnessed falls in the present study.

A secondary analysis to inform a clinical decision rule for predicting skull fracture and intracranial injury in children under age 2

The purpose of this study was to identify factors associated with the risk of closed head injury (CHI) in children under age 2 years with suspected minor head injuries based on age-appropriate, or near age-appropriate, mental status on an exam. The study was a secondary data analysis of a public-use dataset from the largest prospective, multicenter pediatric head injury study found in the current literature. An existing, validated clinical decision rule was examined using a sample of 3,329 children under age 2 to determine whether it, or the individual variables within it, could be utilized alone, or in conjunction with other variables to accurately predict the risk of underlying CHI in this sample. Results indicated that the keys to an accurate triage assessment for children under age 2 with suspected minor head injuries include the ability to identify the specific skull region injured, the ability to assess for the presence and size of any scalp hematoma, the ability to identify signs of altered mental status in this age group, and having access to accurate information regarding the child's age and the details of the injury mechanism. The findings from this study add to the body of knowledge regarding what factors are associated with CHI in children under age 2 with suspected minor head injuries and could be used to inform age-specific recommendations for children under age 2 in triage, educational resources, and national trauma criteria.

Abusive head trauma: evidence, obfuscation, and informed management

Abusive head trauma remains the major cause of serious head injury in infants and young children. A great deal of research has been undertaken to inform the recognition, evaluation, differential diagnosis, management, and legal interventions when children present with findings suggestive of inflicted injury. This paper reviews the evolution of current practices and controversies, both with respect to medical management and to etiological determination of the variable constellations of signs, symptoms, and radiological findings that characterize young injured children presenting for neurosurgical care.

Infant skull fracture risk for low height falls

Skull fractures are common injuries in young children, typically caused by accidental falls and child abuse. The paucity of detailed biomechanical data from real-world trauma in children has hampered development of biomechanical thresholds for skull fracture in infants. The objectives of this study were to identify biomechanical metrics to predict skull fracture, determine threshold values associated with fracture, and develop skull fracture risk curves for low-height falls in infants. To achieve these objectives, we utilized an integrated approach consisting of case evaluation, anthropomorphic reconstruction, and finite element simulation. Four biomechanical candidates for predicting skull fracture were identified (first principal stress, first principal strain, shear stress, and von Mises stress) and evaluated against well-witnessed falls in infants (0-6 months). Among the predictor candidates, first principal stress and strain correlated best with the occurrence of parietal skull fracture. The principal stress and strain thresholds associated with 50 and 95% probability of parietal skull fracture were 25.229 and 36.015 MPa and 0.0464 and 0.0699, respectively. Risk curves using these predictors determined that infant falls from 0.3 m had a low probability (0-54%) to result in parietal skull fracture, particularly with carpet impact (0-1%). Head-first falls from 0.9 m had a high probability of fracture (86-100%) for concrete impact and a moderate probability (34-81%) for carpet impact. Probabilities of fracture in 0.6 m falls were dependent on impact surface. Occipital impacts from 0.9 m onto the concrete also had the potential (27-90% probability) to generate parietal skull fracture. These data represent a multi-faceted biomechanical assessment of infant skull fracture risk and can assist in the differential diagnosis for head trauma in children.

A Novel Approach to Assessing Head Injury Severity in Pediatric Patient Falls

INTRODUCTION

Pediatric patient falls with head-to-floor impact have the greatest potential for injury.

METHODS

An objective measure of head injury severity, the Head Injury Criterion (HIC₁₅), was calculated from anthropometric and biomechanical components of patient falls. A secondary aim was to compare HIC₁₅ levels with the hospital's subjective assignment of level of harm (1-9 scale) used for regulatory reports.

RESULTS

Adverse event reports yielded a sample of 49 falls from heights of 72.5 to 1793.0 cm by children ages 11 months through 17 years. Contact velocity from beginning to end was 2.81 to 6.16 ms. Mean acceleration was 19.5 to 95.3g. HIC₁₅ levels of impact ranged from 26.4 to 1,330.0, and mean force upon contact was 2.0 to 9.8 N/kg body mass. Seven (14.3%) children's HIC₁₅ levels exceeded age-specific thresholds, with no follow-up scheduled. Hospital-assigned levels of harm were not correlated with HIC₁₅ levels (r = .23, R² = .05, p = .12).

DISCUSSION

A point-of-care computerized HIC₁₅ algorithm would be useful for diagnostic and follow-up decisions.

A proclaimed accidental fall of an infant-an experimental case reconstruction study

The differentiation between a non-accidental injury and injuries resulting from accidents, such as falls to the ground or onto various objects, is a challenge not only for forensic experts but also for all clinicians caring for children. The forensic-biomechanical analysis of accidents in infants aims at the assessment of the loading characteristics based on the reconstruction of the particular incident. It includes an evidence-based analytical comparison between the actual injuries presented and the injuries that should be expected as a result of the proclaimed accident. With the help of kinematical and dynamical parameters of the described actions and the resulting loading situations, the forensic-biomechanical analysis can assess the plausibility of the proclaimed course of the event and thus contribute to the differentiation between accidental and non-accidental injuries. The quality of such a forensic-biomechanical expert opinion depends on the accuracy and quantity of available data regarding biomechanical tolerance of tissues, organs, and body parts. Case-specific measurements can contribute significantly to the insight of the kinematics and dynamics of the proclaimed event, its feasibility, etc. The present article demonstrates, based on one case report, the potential as well as the limits of such an analysis of proclaimed accidental fall injuries.

Variation in management of in-hospital newborn falls: a single-center experience

OBJECTIVE There are only 3 small case series in the literature that report on the management of in-hospital newborn falls (NFs), and recommendations are unclear. The authors performed a retrospective review to determine outcome and differences in management and to understand why management of NFs varies at their institution. METHODS All NFs occurring within the authors' institution over a 3.5-year period were reviewed. Post-fall management and outcomes of each incident were compared. RESULTS There were 24 NFs out of 40,349 deliveries (5.9 NFs/10,000 deliveries). The mechanism of injury was nearly identical in 22 of 24 falls (the newborn fell to the floor from a parent in a bed or chair), and physical examination findings were normal or benign in all cases. Unexplained management variation based solely on clinician preference was noted, including observation only (in 13 cases), skull radiograph (in 7), head CT scan (in 6), bone survey (in 4), and head ultrasound examination (in 1), with some babies having more than 1 study. Two babies had nondepressed linear parietal fractures diagnosed by skull radiograph, and 2 babies had small subdural hemorrhages diagnosed by head CT scan. All 24 babies had normal findings on examination at discharge. CONCLUSIONS There is a high incidence of nondepressed linear parietal skull fractures associated with NFs. However, since associated intracranial injury is uncommon, imaging studies may not be routinely performed. Neonatal intensive care unit admission, head CT, and neurosurgical evaluation are reserved for the rare baby with abnormal physical examination or neurological findings.

Injury from falls in infants under one year

AIM

Falls in infants are a common cause of injury. Compared to older children, infants under age one are likely to have distinctive causation and injury patterns, as they are pre-mobile or have limited independent mobility and falls are more directly the responsibility of the care giver. There is little known about the mechanistic factors, predictors of injury and injury patterns in this age group.

METHODS

We conducted a retrospective review of infants under age one who presented after a fall to a paediatric trauma centre in Sydney, Australia. Circumstances and mechanisms of the fall, injury patterns, burden of investigations and outcomes were analysed.

RESULTS

Over a 3-year period (2011-2013), 916 infants presented following a fall. One hundred and six (11.6%) were admitted and there was one death. Head injury was the most common reason for admission (85%). While there were severe and critical head injuries (Abbreviated Injury Scale 4-5) these were infrequent (2% of presentations). All admitted cases involved a short distance fall. Patients dropped by others were three times more likely to be admitted than infants presenting following other fall types (95% CI 1.9-4.8). Compared to other mechanisms, patients who fell from furniture had significantly longer hospital stays.

CONCLUSIONS

Fall mechanisms involving infants being dropped by adults, and falls from beds or couches carry the highest clinical burden. These mechanisms should be targets for injury prevention and inform the design of safe equipment and environments for babies.