An otherwise healthy 21-month-old girl, who had been born at 32 weeks’ gestation, is brought to the emergency department by her mother due to concern regarding scalp swelling. The mother states that the child sustained a fall off a couch. The fall was not witnessed by the mother but was conveyed to her by two of her other school-age children. The mother reports that they told her about the fall immediately but did not provide additional details. Therefore, the mother does not know whether the child made contact with the coffee table that is in the middle of the room or any other objects. The mother notes that the child has remained at her active baseline without any known loss of consciousness, vomiting, or visible signs of injury aside from the scalp swelling.On physical examination a nontender, boggy hematoma is appreciated spanning almost the entire right aspect of the head without crossing the midline. The remainder of the examination findings are largely normal, without evidence of focal deficits or unexplained cutaneous injuries.Computed tomography (CT) of the head demonstrates a prominent right-sided hematoma involving the frontal, parietal, temporal, and occipital scalp. Deep to the swelling at the level of the right parietal bone is noted to be a depressed, comminuted skull fracture with inward angulation of the fracture apex and a small epidural hematoma (Figs 1 and 2). A skeletal survey is ordered and confirms the depressed right parietal skull fracture and overlying scalp hematoma without identification of additional injuries. An ophthalmologic examination does not reveal retinal hemorrhages. Laboratory screening for underlying coagulopathy and abdominal trauma is reassuring. A hospital social worker completes a psychosocial assessment. The neurosurgery, trauma surgery, ophthalmology, and child protection teams are consulted, and the child is admitted to the PICU for further evaluation and monitoring. The physical examination and patient history confirm the diagnosis.The patient’s head examination is notable for the presence of multiple plastic beads braided into the hair (Fig 3). The mother confirms that the hair beads were in place at the time of the suspected fall. Based on the findings and literature review, a plausible accidental mechanism of injury is suspected in which a fall onto the hair bead caused the fracture.The differential diagnosis for skull fractures includes both accidental and nonaccidental trauma, and a core consideration in the evaluation of pediatric head trauma is evaluating whether the identified injury is consistent with the reported mechanism and developmental level of the child. This clinical distinction is especially important considering the relative commonality of skull fractures and the psychosocial ramifications of either false-positive or false-negative diagnosis. (1) Skull fractures can broadly be classified into simple and complex categories. (2) Simple, or linear, fractures denote a single fracture line, whereas complex fractures consist of more than 1 fracture line. (2) Further characterization may include description of the inward displacement (depression) or outward displacement (elevation) of the skull bone. (2) Pediatricians should consider skull fracture features when assessing causality. Although skull fracture type alone does not rule out or confirm a diagnosis of nonaccidental trauma, considerable research has demonstrated that simple parietal fractures have low specificity for abuse and can be caused by routine household accidents, including short falls. (2) Comparatively, complex nature and depression are examples of features less commonly seen in uncomplicated short falls, and this should be taken into account when evaluating whether there is a plausible, corresponding mechanism of injury. (3)A thorough history and physical examination are key components of the assessment and guide the remainder of the medical evaluation. As described in an American Academy of Pediatrics clinical report, the age-appropriate evaluation for a young child when there is concern for nonaccidental trauma can include neuroimaging, ophthalmologic evaluation when intracranial bleeding is present, skeletal survey, and laboratory testing. (4) CT of the head is preferred over magnetic resonance imaging in the identification of acute hemorrhage and skull fractures, whereas magnetic resonance imaging provides optimal assessment of intracranial injury. (4) When available, CT three-dimensional reconstruction of the images can further aid in enhancing the sensitivity and specificity of accurately diagnosing skull fracture morphology. (5) In children with unexplained intracranial bleeding, indirect ophthalmoscopy with detailed description of findings is warranted. (4) Patterns of retinal hemorrhages with high specificity for nonaccidental trauma include those too numerous to count, multilayered, and extending to the periphery. (4) A skeletal survey to screen for occult injury is also recommended as part of the evaluation for physical abuse concerns in children younger than 2 years. (4) In addition, laboratory testing can be used to evaluate for underlying predispositions for fracture or bleeding, as well as occult abdominal trauma.In an otherwise healthy child, the fracture morphology observed in our patient suggests impact with a focal blunt force leading to a depressed skull fracture. (6) A growing literature base has revealed that significant head injury can result from falls sustained while wearing embedded hair beads. Geller et al (7) seem to have first raised this issue with their radiologic case series detailing the findings associated with multiple children who sustained a fall and experienced suspected exacerbation of the injury due to a plastic hair bead becoming the contact point. Avotri (8) furthered this concern after caring for a 7-year-old girl who fell onto a hair ball and sustained a depressed comminuted skull fracture requiring emergency craniectomy. Jarrar et al (9) noted a similar phenomenon in an 8-year-old girl. Furthermore, although there is no pathognomonic bleeding distribution to clearly delineate between accidental and nonaccidental trauma, research suggests that epidural hematomas can reasonably collect in the potential space underlying skull fractures after short falls. (10) The associated pathophysiology involves shearing of the adherent arteries and veins subjacent to the impact site. (10)In summary, the skull fracture features in this case, including depression, complex nature, and underlying epidural hemorrhage, prompted a thorough evaluation to determine whether there was a plausible accidental mechanism to explain the findings. A detailed history was obtained. There were no other injuries identified on physical examination, skeletal survey, or ophthalmologic evaluation. As detailed previously herein, the reported history of an accidental fall while wearing plastic hair beads in an active toddler is consistent with the child’s developmental level and could have reasonably generated the necessary force and direction to result in the complex nature of the skull fracture.Our patient was monitored in the PICU overnight and was maintained on frequent neurologic assessments. She remained at her baseline without signs of clinical deterioration. Because it was determined that the sustained injury was consistent with an accidental mechanism, a report to child protective services was not filed, and the patient was discharged home with her mother. The family was offered surgical intervention for cosmetic purposes but declined. Routine follow-up with outpatient neurosurgery was recommended to monitor fracture healing and gradual resolution of the hematoma.