ABSTRACT
A 10-month-old baby boy presented to the emergency department due to swelling of his head noticed by his mother. She noticed the swelling when she was getting the baby dressed in the morning. She denied any history of trauma. The mother’s boyfriend then stated that the previous evening the baby fell and hit his head on the barbell in the living room. The baby was reaching to play with a dangling cord (Image 47a). The baby attempted to stand on the barbell’s bar and hold the cord but lost his balance and hit his head on the barbell. He cried immediately. The boyfriend stated the mother was in the shower when that happened. The mother said she did recall him crying when she left him in the living room with her boyfriend, however she was not aware he fell. His physical examination was significant for extensive subgaleal haematoma on both sides of his head. Otherwise his examination did not show any further signs of trauma. His skull x-rays are shown in Images 47b, 47c and 47d. https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig47a.jpg"/> 108 https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig47b.jpg"/> https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig47c.jpg"/> https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig47d.jpg"/>
What injury do you see in the radiology images?
Is the injury consistent with an accidental injury?
110The skull x-rays of this child show a depressed, comminuted fracture of the left frontal-parietal calvarium. A skull fracture is considered depressed when the skull has an inward displacement of the bone and the normal curvature is disrupted as in this child. It is also a comminuted fracture because the skull bone is broken into fragments.
When assessing a fracture in a child, we need to consider the site and type of fracture as well as the development of the child. 1 No fracture on its own can distinguish abuse from non-abuse even in those with a lower probability for abuse. 1 In children under 2 years old with a skull fracture and a history of minor trauma, certain features raise the suspicion for abuse. These features include multiple or complex fracture, diastatic fracture (maximum fracture width more than 3 mm), depressed fracture, growing fracture, non-parietal fracture, involvement of more than one cranial bone and associated intracranial injury. 2 In a study on children less than 18 months of age presenting with isolated skull fractures, the skeletal survey revealed additional fractures in 6% of patients. 3 This child is developmentally able to reach to the cord shown in Image 47a and cruise on the furniture when holding with one hand. Falling on the bar of the barbell may have concentrated the impact to his left parietal area resulting in a depressed skull fracture. However we were concerned due to the short distance of fall and the severity of the fracture. A head CT scan was performed that re-demonstrated the fracture; however there was no intracranial bleeding. A skeletal survey was done which did not show any additional fractures. We suspected abuse due to the severity of the fracture as compared to the history of a short fall and a report was made to Child Protective Services.
