Complex Skull Fractures Research Articles

802 The Predictive Role of Initial Brain Imaging on Seizure Development in Pediatric Traumatic Brain Injury

INTRODUCTION: Pediatric traumatic brain injury (TBI) poses risk for early post-traumatic seizures (EPTS). Antiepileptic drugs are often prescribed prophylactically, though limited evidence exists regarding their effectiveness in pediatric TBI. Neuroimaging has been predictive of EPTS in adult TBI, but this is not well studied in children. Given the heterogeneous nature of TBIs, injury type and location may serve as predictors of seizure development. METHODS: This is a single-center retrospective analysis of 348 pediatric patients with TBI from January 2011 to June 2021 treated with levetiracetam. Factors analyzed include age, sex, GCS, dosage and date of levetiracetam administration, presence of seizures, medical and surgical management, and findings on CT imaging. The primary outcome was the prevalence of seizures within 7 days of injury. RESULTS: On multivariate analysis, the risk of having seizures any time within 7 days of injury was decreased in children with contusions (OR .425 [.205-.880], p = 0.021), simple skull fractures (OR .226 [.079-.648], p = 0.006), and complex skull fractures (OR .370 [.175-.784], p = 0.009). Findings of SDH, traumatic SAH, and pneumocephalus did not significantly increase the risk of EPTS. On univariate analysis of patients who developed seizures after levetiracetam, the only significant imaging factor for EPTS was SDH (OR 4.398 [1.447-13.370], p = 0.009). On multivariate analysis, no imaging characteristics were predictive of EPTS, but older children had a decreased risk of EPTS (1-2 yo OR .095 [.016-.560], p = 0.009; 3-18 yo; OR .006 [0-.132], p = 0.001) despite levetiracetam prophylaxis. CONCLUSIONS: This study demonstrates that regardless of initial neuroimaging, younger age is associated with an increased risk of seizures despite prophylaxis. Further studies are needed to determine the predictive value of imaging characteristics in developing EPTS in pediatric TBI patients.

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

BackgroundTo 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. ObjectiveTo 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 setting476 acutely head injured, skull-fractured patients <3 years hospitalized for intensive care across 18 sites between February 2011 and March 2021. MethodsWe conducted a retrospective, secondary analysis of the combined, prospective Pediatric Brain Injury Research Network (PediBIRN) data set. Results204 (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. ConclusionsLess 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.

Delayed Bilateral, Post-Traumatic Extra-Subdural Hematomas in a Patient with Meningioma

Concomitant acute epidural hematoma (EDH) and subdural hematoma (SDH) is a rare finding, and its bilateral onset has not yet been reported in literature. We present the first report of a patient affected by post-traumatic concomitant EDH and SDH, with the contralateral, delayed onset of another, associated with meningioma previously treated with gamma knife. A 60-year-old female patient with a history of simple focal seizures with motor symptoms and well-controlled by drugs since childhood, arterial hypertension, and incidental diagnosis of multiple meningiomas was referred to our department after falling down the stairs. Initially, the patient was prescribed gamma knife treatment of the right frontal convexity meningioma. The patient was admitted to our emergency department with Glasgow Coma Scale (GCS) score of 7/15 and isochoric, myotic pupils. An immediate head CT scan revealed a small acute SDH in the right hemisphere and an acute blood collection in the left hemisphere, which exerted mass effect; furthermore, we discovered complex skull fractures across the superior sagittal sinus, and dislocated bone fragments. A left decompressive craniectomy was performed, and intraoperatively we observed a concomitant EDH/SDH. Due to the patient’s anisocoria, an urgent postoperative CT scan was performed, revealing a massive blood collection in the right hemisphere, which was discovered to be another concomitant EDH/SDH, during right trauma flap. Through this approach, we also removed the right frontal convexity meningioma. After 5 days in the intensive care unit (ICU), the patient died because she presented an acute heart failure. The development of a contralateral, delayed EDH/SDH must be considered in severe traumatic patients, especially if associated fractures across major dural sinuses are present. Intraoperative CT scan, if available, or immediate postoperative CT scan, is mandatory for adequate management of complex neurotrauma cases.

Complex Skull Fracture in a Toddler.

Complex Skull Fracture in a Toddler.

Evaluation of Panfacial Fractures in a German Supraregional Trauma Center between 2015 and 2017 - A Retrospective Study.

Introduction:Panfacial fractures represent the most severe injuries to the face. The combination of these fractures determines the treatment strategy. This study aims to retrospectively review the data of adult patients treated for complex facial skull fractures in a hospital in Dortmund, Germany from 2015-2017.Materials and Methods:We extracted related patient data from the hospital electronic repository and reviewed the patient files and radiological images. The fractures were classified based on the AO-Classification. The statistical analysis was performed by descriptive statistical methods. The main goal was to determine the most common fracture combinations.Results:A total of 188 patients with panfacial fractures were identified (181 adults, 7 children and adolescents). The gender and age distribution corresponded to the international literature (male-to-female ratio: 3.1:1, most common injuries among young men). 2–9 fracture sites were identified per patient, resulting in a fracture frequency of 3.13 per patient. 69 different fracture combinations have been identified. The most common ones were combinations of lateral and central mid-face fractures, and combinations of nasal bone fractures with lateral midface fractures or nasal bone fractures combined with mandibular fractures. Between 1 and 13 osteosynthesis implants per patient were used for osteosynthesis; the most commonly used plates were 2.0 mm and 1.5 mm straight plates. The average inpatient stay was 3 days (standard deviation [SD] = 3.0 days), and the average operation time (incision to suture) was 39.5 min (SD = 53.5 min).Discussion:Panfacial fractures are the most complex maxillofacial injuries. The complication rate in this study (4.5%) is below the international data. The treatment of panfacial fractures requires designated centers with experienced teams and good interdisciplinary cooperation.

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

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. 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. 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%. 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.

Complicated Mild Traumatic Brain Injury at a Level I Pediatric Trauma Center: Burden of Care and Imaging Findings

OBJECTIVE: The aims of this study were: (1) to characterize mild traumatic brain injury (mTBI), mTBI with skull fracture, and complicated mTBI in school-aged children seen at a Level I pediatric trauma center and (2) to examine the nature of imaging findings seen in children with mTBI with skull fracture and those with complicated mTBI.METHODS: A total of 1777 pediatric patients (male: 1193 or 67.1%; age = 11.1 ± 3.5 years) sustaining mTBI who presented to the Emergency Department or directly to the trauma service in the years 2010 to 2013 were identified and classified into mTBI (n = 1,319 or 74.2%), mTBI with skull fracture (n = 127 or 7.2%), and complicated mTBI (n = 331 or 18.6%). Patient characteristics and imaging findings were analyzed using descriptive statistics, Pearson's χ2 test, Fisher's exact test, and logistic regression analysis.RESULTS: In children with complicated mTBI, subdural hematoma (36.9%) was the most common finding. Of the 331 children with complicated mTBI, 241 (72.8%) had multiple findings compared with one (0.8%) of 127 children having mTBI with skull fracture (Fisher's exact P < 0.001), with logistic regression analysis revealing younger age as a potential risk factor (P < 0.01). Children sustaining a depressed or complex skull fracture were nearly twice as likely as those with simple, linear skull fracture to have intracranial abnormality.CONCLUSIONS: Multiple radiographic findings in children sustaining mTBI with skull fracture or complicated mTBI are prevalent (72.8%), with younger age as a potential risk factor.

Skeletal Manifestations of Child Maltreatment

Musculoskeletal manifestations of child maltreatment represent common presentations to the emergency department. The recognition of child maltreatment is an essential role for the practicing emergency physician, as it can directly prevent further serious injury. Orthopedic trauma in children presents very differently than that in adults. Understanding of the unique properties of pediatric bone as well as the developmental capabilities of children in relation to injury mechanism is essential in the interpretation of these injuries. Children younger than 3 years are most vulnerable to bony injury from child maltreatment. Common presenting findings include complex skull fractures, rib fractures, long bone fractures, and metaphyseal corner fractures. Skeletal survey remains the mainstay of detection for injuries, but recent work has also elucidated a role for other modalities in fracture detection. Management should include proper orthopedic interventions, along with mandatory reporting of possible maltreatment to the local child protective services or other equivalent agency.

Expanded screening criteria for blunt cerebrovascular injury: a bigger impact than anticipated

BackgroundWe implemented expanded screening criteria for blunt cerebrovascular injuries (BCVIs) in an attempt to capture the remaining 20% of patients not historically identified with earlier protocols. We hypothesized that these expanded criteria would capture the additional 20% of BCVI patients not previously identified. MethodsScreening criteria for BCVI were expanded in 2011 after identifying new injury patterns. The study population included 4 years prior (2007 to 2010; classic) and following (2011 to 2014; expanded) implementation of expanded criteria. ResultsBCVIs were identified in 386 patients: 150 during the classic period (2.36% incidence) and 236 in the expanded period (2.99% incidence). In the expanded period, 155 patients were imaged based on classic screening criteria, 62 on expanded criteria (21 complex skull fractures, 20 upper rib fractures, 6 mandible fractures, 2 scalp degloving, 1 great vessel injury, and 12 combination), and 19 for other injuries and symptoms. ConclusionsThere was a significant increase in the identification of BCVI following the adoption of expanded screening criteria, resulting in a substantial reduction of missed injuries. Expanded criteria should be adopted when screening for BCVI.

Abusive head trauma and accidental head injury: a 20-year comparative study of referrals to a hospital child protection team

AimTo describe children referred for suspected abusive head trauma (AHT) to a hospital child protection team in Auckland, New Zealand.MethodsComparative review of demographics, histories, injuries, investigations and diagnostic outcomes for...

PP08.9 – 2594: Glycine receptor antibody mediated progressive encephalomyelitis with rigidity and myoclonus (PERM) presenting as an abnormal startle response in an adolescent girl

Objective To describe a young girl in whom stimulus sensitive spasms were a diagnostic clue to the underlying glycine receptor antibody mediated progressive encephalomyelitis with rigidity and myoclonus (PERM) which has been described mainly in adults. Methods We illustrate the clinical data from the case-notes with a video recording of stimulus-sensitive spasms. Results A previously well 15-year-old girl presented with a traumatic head injury after falling down the stairs. The noise from a doorbell had triggered a severe muscle spasm causing the fall. She sustained a complex skull fracture with coup-contrecoup brain injury. She had previously been evaluated over five months for stimulus-sensitive whole body spasms with axial hyperextension without impairment of consciousness. She also had daily stimulus-sensitive myoclonic jerks, headaches and subtle cognitive impairment over the preceding year. Whilst on the paediatric intensive care unit, she was noted to have spontaneous and stimulus-sensitive muscle spasms (EMG duration 360–680 ms with no EEG correlate). She also developed generalised tonic clonic seizures, which were treated with Levetiracetam. A diagnosis of PERM was considered and glycine receptor antibodies were found to be strongly positive in serum and CSF. VGKC-complex antibodies were also weakly positive but GAD and NMDAR antibodies were negative. Oligoclonal bands were positive in CSF but negative in serum. Paraneoplastic antibodies were negative. Brain MRI showed contusions in the right hemisphere. Body imaging did not identify any tumours. Glycine receptor gene analysis is awaited. Her spasms have improved with a residual mild startle response to touch or loud auditory stimuli. She has a residual left hemiparesis. She was not treated with immunomodulation but will be followed up, and immunotherapy considered if she does not continue to improve and antibodies persist. Conclusion Glycine receptor antibody-mediated progressive encephalomyelitis with rigidity and myoclonus can present in children as stimulus-sensitive muscle spasms.

The yield of high-detail radiographic skeletal surveys in suspected infant abuse.

Skeletal surveys are routinely performed in cases of suspected child abuse, but there are limited data regarding the yield of high-detail skeletal surveys in infants. To determine the diagnostic yield of high-detail radiographic skeletal surveys in suspected infant abuse. We reviewed the high-detail American College of Radiology standardized skeletal surveys performed for suspected abuse in 567 infants (median: 4.4 months, SD 3.47; range: 4 days-12 months) at a large urban children's hospital between 2005 and 2013. Skeletal survey images, radiology reports and medical records were reviewed. A skeletal survey was considered positive when it showed at least one unsuspected fracture. In 313 of 567 infants (55%), 1,029 definite fractures were found. Twenty-one percent (119/567) of the patients had a positive skeletal survey with a total of 789 (77%) unsuspected fractures. Long-bone fractures were the most common injuries, present in 145 children (26%). The skull was the site of fracture in 138 infants (24%); rib cage in 77 (14%), clavicle in 24 (4.2%) and uncommon fractures (including spine, scapula, hands and feet and pelvis) were noted in 26 infants (4.6%). Of the 425 infants with neuroimaging, 154 (36%) had intracranial injury. No significant correlation between positive skeletal survey and associated intracranial injury was found. Scapular fractures and complex skull fractures showed a statistically significant correlation with intracranial injury (P = 0.029, P = 0.007, respectively). Previously unsuspected fractures are noted on skeletal surveys in 20% of cases of suspected infant abuse. These data may be helpful in the design and optimization of global skeletal imaging in this vulnerable population.

Dedicated Retinal Examination in Children Evaluated for Physical Abuse without Radiographically Identified Traumatic Brain Injury

To determine the rate of retinal hemorrhages in children evaluated for physical abuse without traumatic brain injury (TBI) by diagnostic imaging. This study was a prospectively planned, secondary analysis of the Examining Siblings to Recognize Abuse (ExSTRA) research network, and included only index children who presented with concerns for abuse. Subjects were eligible for the parent study if they were less than 10 years old and evaluated by a Child Abuse Physician for concerns of physical abuse. Child Abuse Physicians recorded results of all screening testing and determination of the likelihood of abuse in each case. For this analysis, we examined the results of dedicated retinal examinations for children with neuroimaging that showed no TBI. Isolated skull fractures were not considered to be TBI. The original ExSTRA sample included 2890 index children evaluated for physical abuse. Of this group, 1692 underwent neuroimaging and 1122 had no TBI. Of these 1122 children, 352 had a dedicated retinal examination. Retinal hemorrhages were identified in 2 (0.6%) children. In both cases, there were few (defined as 3-10) hemorrhages isolated to the posterior poles; neither was diagnosed with physical abuse. The presence of facial bruising, altered mental status, or complex skull fractures was neither sensitive nor specific for retinal hemorrhage identification. Forensically significant retinal hemorrhages are unlikely to be found in children evaluated for physical abuse without TBI on neuroimaging, and such children may not require routine dedicated retinal examination.

Blunt cerebrovascular injuries

Screening for blunt cerebrovascular injuries (BCVIs) and early treatment has virtually eliminated injury-related strokes. Screening protocols developed in the 1990s captured ∼80% of ultimately identified BCVI. With the availability of noninvasive diagnosis with computed tomographic angiography, broader indications for screening seem warranted. The purpose of this study was to identify injury patterns of patients with BCVI that are not currently recommended screening criteria. Our prospective BCVI database, initiated in 1997, was queried through December 2010. Indications for screening, injury mechanism, and outcomes were analyzed. Patients younger than 18 years were excluded. During the 14-year study period, 585 BCVIs were identified in 418 patients (66% men; age, 40 years ± 0.7 years). Eighty-three (20%) patients with BCVI did not have standard screening criteria; 66% were asymptomatic at diagnosis. Injury patterns in these patients included mandible fracture (27 patients), complex skull fractures (21 patients), traumatic brain injury with thoracic trauma (6 patients), scalp degloving (6 patients), and great vessel or cardiac injuries (4 patients). Other injuries (11 patients) and no injuries (8 patients) were identified in the remainder. Of the 307 asymptomatic patients who received antithrombotic treatment, one patient suffered stroke (0.3%) and one patient a transient ischemic attack (0.3%). A significant number of patients suffering BCVI are not captured by current screening guidelines. Screening for BCVI should be considered in patients with mandible fractures, complex skull fractures, traumatic brain injury with thoracic injuries, scalp degloving, and thoracic vascular injuries. II, prognostic study.

CT and MR imaging of primary cerebrovascular complications in pediatric head trauma

The incidence of severe traumatic head injury in children has constantly increased over the last years. Diagnostic imaging has become an unrenounceable tool for the documentation and follow-up of intracranial lesions. The use of magnetic resonance imaging (MRI) in the early posttraumatic phase has led to a more thorough understanding of intracranial injuries. We retrospectively analyzed the cranial computed tomography (CCT) and magnetic resonance (MR)-studies of patients with traumatic head injuries for primary cerebrovascular complications. In 64 children (45 male, 19 female) with traumatic head injuries, CCT and MR examinations were available for analysis. The children's age ranged from 3 months to 15 years with a median age of 7 years. All patients had initial CCT on admission to the hospital with follow-up examinations depending on clinical state and initial imaging findings. All patients had at least one MR examination between 0 to 120 days after the trauma with a median time interval of 17 days. In five of 64 (7.8%) patients, cerebrovascular complications were found on imaging studies. Initial imaging within the first 24 h after the trauma detected a complete middle cerebral artery infarction in one patient and extensive sinus thrombosis after a complex skull fracture in another. In two patients, thrombosis of the transverse sinus appeared on MRI 4 to 6 days after the trauma. In another patient with open-skull injury, a posttraumatic aneurysm of the pericallosal artery was diagnosed on MRI 30 days after the trauma. Our study shows that, although primary cerebrovascular lesions after traumatic head injuries in children are rare, the radiologist should be aware of the characteristic injury patterns and the time appearance of imaging findings on CT and MRI.

Orthopaedic aspects of paediatric non-accidental injury

Non-accidental injury (NAI) in children includes orthopaedic trauma throughout the skeleton. Fractures with soft-tissue injuries constitute the majority of manifestations of physical abuse in children. Fracture and injury patterns vary with age and development, and NAI is intrinsically related to the mobility of the child. No fracture in isolation is pathognomonic of NAI, but specific abuse-related injuries include multiple fractures, particularly at various stages of healing, metaphyseal corner and bucket-handle fractures and fractures of ribs. Isolated or multiple rib fractures, irrespective of location, have the highest specificity for NAI. Other fractures with a high specificity for abuse include those of the scapula, lateral end of the clavicle, vertebrae and complex skull fractures. Injuries caused by NAI constitute a relatively small proportion of childhood fractures. They may be associated with significant physical and psychological morbidity, with wide- ranging effects from deviations in normal developmental progression to death. Orthopaedic surgeons must systematically assess, recognise and act on the indicators for NAI in conjunction with the paediatric multidisciplinary team.

Skeletal surveys in infants with isolated skull fractures

. Wood J. N., Christian C. W., Adams C. M. &amp; Rubin D. M. ( 2009 ) , 123 , e247 – e252 . DOI: 10.1542/peds.2008‐2467 . Objective The goal was to describe the utility of skeletal surveys and factors associated with both skeletal survey use and referral to child protective services for infants with skull fractures in the absence of significant intracranial injury. Methods A retrospective chart review was performed for infants who were evaluated at a tertiary children's hospital because of an isolated, non‐motor vehicle‐related, skull fracture between 1997 and 2006. Logistic regression analyses were used to test for associations of demographic factors, clinical findings that raised suspicion for abuse (absence of trauma history, changing history, delay in care, previous child protective services involvement and other cutaneous injuries), and fracture type (simple vs. complex) with the primary outcomes of skeletal survey use and reports to child protective services. Results Among the 341 infants in the study, 31% had clinical findings that raised suspicion for abuse and 42% had complex skull fractures. Skeletal surveys were obtained for 141 infants (41%) and detected additional fractures for only two (1.4%) of those 141 infants. Child protective services reports were made for 52 (15%) of the 341 children. Both infants with positive skeletal survey findings had other clinical findings that raised suspicion for abuse, and they were among those reported. With controlling for race and age, Medicaid‐eligible/uninsured infants were more likely than privately insured infants to receive skeletal surveys and child protective services reports in the presence of a complex skull fracture or clinical findings that raised suspicion for abuse. Conclusion Skeletal surveys were ordered frequently for infants with isolated skull fractures, but they rarely added additional information, beyond the history and physical findings, to support a report to child protective services.

Skeletal Surveys in Infants With Isolated Skull Fractures

The goal was to describe the utility of skeletal surveys and factors associated with both skeletal survey use and referral to child protective services for infants with skull fractures in the absence of significant intracranial injury. A retrospective chart review was performed for infants who were evaluated at a tertiary children's hospital because of an isolated, non-motor vehicle-related, skull fracture between 1997 and 2006. Logistic regression analyses were used to test for associations of demographic factors, clinical findings that raised suspicion for abuse (absence of trauma history, changing history, delay in care, previous child protective services involvement, and other cutaneous injuries), and fracture type (simple versus complex) with the primary outcomes of skeletal survey use and reports to child protective services. Among the 341 infants in the study, 31% had clinical findings that raised suspicion for abuse and 42% had complex skull fractures. Skeletal surveys were obtained for 141 infants (41%) and detected additional fractures for only 2 (1.4%) of those 141 infants. Child protective services reports were made for 52 (15%) of the 341 children. Both infants with positive skeletal survey findings had other clinical findings that raised suspicion for abuse, and they were among those reported. With controlling for race and age, Medicaid-eligible/uninsured infants were more likely than privately insured infants to receive skeletal surveys and child protective services reports in the presence of a complex skull fracture or clinical findings that raised suspicion for abuse. Skeletal surveys were ordered frequently for infants with isolated skull fractures, but they rarely added additional information, beyond the history and physical findings, to support a report to child protective services.

Fall or Shaken: Traumatic Brain Injury in Children Caused by Falls or Abuse at Home - A Review on Biomechanics and Diagnosis

In cases of traumatic brain injuries in children it may be difficult to differentiate between physical abuse and accidental occurrence. This review will shed light on discriminating epidemiological as well as biomechanical data, morphological findings, and clinical features. As a basic principle, simple injuries are caused by simple mechanisms like falls whereas life-threatening injuries should be attributed to abuse until proven otherwise. Implausibilities between reported events and mechanisms by caregivers as well as more than one explanation of injury indicate suspicion of child abuse. From reviewing the literature, it can be stated that falls from less than 1.5 m lead only in few cases to severe brain injuries. Children who experienced a fall at home seldom exhibit fractures of the skull but just minor intracranial injuries without neurological deficits. Regarding biomechanical aspects, multiple or complex skull fractures, depression fractures, additional fractures of the body, and intracranial hemorrhages as a consequence of an impact are the most important findings in child abuse. Moreover, additional specific morphological criteria give evidence of clinical and/or post-mortem diagnosis of the shaken baby syndrome. These include subdural hemorrhage and laceration of the brain and retinal bleeding, epidural hemorrhage of the cervical cord, gripping marks (bruises) on chest and/or shoulders, and tearing injuries of the throat and neck muscles. Post-mortem signs of recurrent shaken baby syndrome are indicated by iron-positive cells or microglial cells in neuronal or retinal tissue. A clinical diagnosis will be dependent on the one hand on the exclusion of coagulation diseases, on the other hand on the demonstration of a subdural hemorrhage by means of neuroimaging techniques, i.e., CT and MRI, as well as retinal hemorrhage. The shaken baby syndrome will usually be observed within the first year of life. The doctor has to manifest his diagnosis to the caregivers and - before informing the caregivers - he must be sure of his diagnosis.

Child abuse

Child abuse is most often diagnosed by an emergency doctor on call who sometimes "feels" more than knows what he is confronted with. He should nevertheless always take a medical history and make a physical and radiological examination. X-ray imaging and an ophthalmologic retinal examination are the most important diagnostic steps. Typical findings are multiple and/or dorsal rib fractures, complex skull fractures, physeal fractures, all fractures within the first 12 months, multiple fractures in different localisations and stages of healing, all injuries with uncommon distributions, all patterned bruises, immersion burns, intramural hematoma and every unexplained loss of consciousness. The first step towards victim protection is always the removal of the abused child from its caregivers by admitting it to hospital, as 95% of all cases of reported child abuse take place within the child's family.