Fractures and skin lesions in pediatric abusive head trauma: a forensic multi-center study

Katharina Feld,Sibylle Banaschak,Sebastian Schenkl,Dustin Feld,Tim Ricken,Heidi Pfeiffer,Holger Muggenthaler,Janine Helmus,Daniel Wittschieber,Bernd Karger,Maria Hahnemann

doi:10.1007/s00414-021-02751-4

Abstract

Abusive head trauma (AHT) and its most common variant, the shaken baby syndrome (SBS), are predominantly characterized by central nervous system-associated lesions. Relatively little data are available on the value of skeletal and skin injuries for the diagnosis of SBS or AHT. Thus, the present study retrospectively investigated 72 cases of living children diagnosed with the explicit diagnosis of SBS during medico-legal examinations at three German university institutes of legal medicine. The risk of circular reasoning was reduced by the presence of 15 cases with confession by perpetrators. Accordingly, the comparison with the 57 non-confession cases yielded no significant differences. Skeletal survey by conventional projection radiography, often incomplete, was found to be performed in 78% of the cases only. Fractures were found in 32% of the cases. The skull (43%) and ribs (48%) were affected most frequently; only 8% of the cases showed classic metaphyseal lesions. In 48% of the cases, healing fractures were present. Skin lesions (hematomas and abrasions) were found in 53% of the cases with the face (76%), scalp (26%), and trunk (50%) being the major sites. In 48% of the cases, healing skin lesions were observed. Nearly 80% of the cases with fractures also showed skin lesions. The data prove that SBS is frequently accompanied by other forms of physical abuse. Therefore, skeletal survey is indispensable and should always be done completely and according to existing imaging guidelines if child abuse is suspected.

Highlights

Head trauma is a crucial factor for mortality in both adults [1,2,3] and young children [4,5,6]
Throughout the entire recent body of literature on that topic, abusive head trauma (AHT) is generally understood as an umbrella term comprising different types of violence against a child’s head such as violent shaking of the child, mere blunt force or impact trauma, or combinations of both
International Journal of Legal Medicine on fractures and skin lesions in cases of AHT are relatively sparse. Another problem in AHT studies relates to circular reasoning: If the inclusion criterion for the diagnosis of AHT is solely based on generally accepted medical findings, it is likely that these findings are found to be characteristic features of AHT

Summary

Introduction

Head trauma is a crucial factor for mortality in both adults [1,2,3] and young children [4,5,6]. International Journal of Legal Medicine on fractures and skin lesions in cases of AHT are relatively sparse. Another problem in AHT studies relates to circular reasoning: If the inclusion criterion for the diagnosis of AHT is solely based on generally accepted medical findings (e.g., subdural hematoma), it is likely that these findings are found to be characteristic features of AHT. The present study aims at investigating the presence of fractures and skin lesions and their value for the diagnosis of SBS and AHT, respectively. To this issue, a study cohort of 72 SBS cases was compiled using a multicenter approach and a retrospective 10-year period. Concordant results independent of a confession would strongly support a correct diagnosis of SBS/AHT in the non-confession cases

Compliance with ethical standards

Results

Discussion

Conclusions