Cranial Suture Evaluation in Pediatric Head Trauma: Importance in Differentiating Abusive From Accidental Injury.

OBJECTIVES: Pediatric skull fracture association with the cranial sutures (crossing, widening, or contacting 2 or more cranial sutures) is suggestive of abusive injury. We studied the efficacy of head computed tomography (CT) versus skull radiographs in identifying pediatric skull fracture association with cranial sutures and reviewed head CT literature recommendations for pediatric head trauma. METHODS: Retrospective review was performed of skull radiographs and head CT at a tertiary care, free-standing children's hospital (2012-2019). Statistical 2-proportion Z test determined efficacy of head CT versus skull radiographs in assessing cranial suture involvement with fractures. RESULTS: Forty-seven children with 56 abusive skull fractures and 47 children with 54 accidental skull fractures were evaluated, ages 1 to 36 months. Of the 110 total skull fractures evaluated, 51 abusive and 41 accidental skull fractures had terminal ends contacting cranial sutures for a total of 92 (84%). Twelve abusive fractures (24%) crossed sutures; no accidental fractures crossed sutures (P < 0.01). Of the 12 abusive cases with skull fractures that crossed sutures, 7 were definitively identified only on CT (P < 0.01). Widened sutures were documented in 4 (8%) of the abusive cases with skull fracture; none in the accidental cases. All 4 of these cases were equally identified on both skull radiography and CT imaging. In 21 of 47 abusive versus 5 of 47 accidental cases, CT identified skull fractures lines that extended to cranial sutures that were not definitive on skull radiography (P = 0.00022). CONCLUSIONS: Cranial suture involvement with pediatric skull fractures is common. Head CT significantly aided in the identification of skull fractures contacting and crossing cranial sutures in abusive cases, supporting eliminating concurrent skull radiographs.

Pediatric Skull Fractures Contacting Sutures: Relevance in Abusive Head Trauma.

OBJECTIVE. The purpose of this study was to assess the incidence of pediatric skull fractures contacting cranial sutures in abusive versus accidental trauma. MATERIALS AND METHODS. A retrospective review was conducted of head CT studies performed for pediatric head trauma at a free-standing tertiary care children's hospital from 2012 to 2019. Statistical odds ratios were evaluated to assess the significance of skull fracture extension to sutures in abusive versus accidental injury. A two-proportion Z-test was used to determine the statistical significance of suture type contacted by skull fractures in accidental versus abusive injury. RESULTS. The records of 47 children with 57 abusive skull fractures and 47 children with 54 accidental skull fractures were evaluated. The patients were 1-36 months old. Fifty-one abusive skull fractures (89%) terminated in contact with a cranial suture; 35 of the 51 (69%) touched two or more sutures, and 12 touched three or more sutures. Forty-two of the 54 (78%) accidental skull fractures contacted a suture; only 3 of the 42 (7%) touched two sutures, and none touched more than two sutures (odds ratio, 28.4 [95% CI, 7.6-105.9]; p < .001). In the abusive fractures, the suture most commonly contacted by a fracture line was the lambdoid (43%; p < .04), followed by the sagittal (23%), coronal (21%), temporal-squamous (12%), and metopic (1%) sutures. There was no statistical difference in which suture was contacted by fracture lines in accidental cases. CONCLUSION. Skull fracture contacting cranial sutures is common in abusive and accidental pediatric head trauma. However, that a fracture contacts two or more cranial sutures is an imaging finding not previously described that has a significantly higher association with abusive than with accidental head injury.

Characteristics of rib fractures in young abused children.

BACKGROUND: The presumed mechanism of rib fractures in abuse is violent grasping of the torso causing anterior-posterior chest compression. We hypothesized an asymmetrical distribution of rib fractures in abused infants given the greater incidence of right-hand dominance within the general population. OBJECTIVE: The objective of this study was to characterize rib fractures in abused children, particularly sidedness; additionally, we evaluated the sidedness of other abusive skeletal fractures. MATERIALS AND METHODS: We reviewed medical records from abused children (0-18 months old) with rib fractures. We also retrospectively reviewed their radiographs to determine characteristics of rib fractures (number, side, rib region, level, acuity) and other skeletal fractures (number, side, location), as well as differences in the distribution of rib and other skeletal fractures. RESULTS: A total of 360 rib fractures were identified on 273 individual ribs involving 78 abused children. Sixty-three children (81%) had multiple rib fractures. There was a significantly greater number of left-side rib fractures (67%) than right-side fractures (P<0.001). Fractures were most often identified in the posterior and lateral regions and mid level of the ribcage (Ribs 5 through 8). Fifty-four percent of subjects had other skeletal fractures; these non-rib fractures were also predominantly on the left side (P=0.006). CONCLUSION: In our study of abused children, there was a higher incidence of rib fractures in the posterior, lateral and mid-level locations. Additionally, we found a predominance of left-side rib and other skeletal fractures. Further research is needed to understand whether factors such as perpetrator handedness are associated with these unequal distributions of fractures in abused children.