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

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.

Knowledge of child abuse and neglect in nursing students: Assessment and perspectives

“…Particularly, they are experts on child abuse and neglect who have worked for many years at the ambulatory center of the University Pediatric Hospital of Turin (Italy), which is dedicated to the diagnosis, treatment, and management of violence against children. The questionnaire was created following indications in the scientific literature on physical maltreatment, sexual abuse, and neglect of children [3, 10–14]. To validate the questionnaire, two nurses (experts in child abuse and neglect fields) were asked to answer all questions, ascertaining that the questions effectively captured the topic under investigation.…”

“…According to the scientific literature[10], during infancy which fractures can be considered highly suspicious for physical abuse? a. vertebral bodies fractures-15 (8.6%) b. linear skull fractures-26 (14.9%) c. posterior ribs fractures-52 (29.7%) d. two or more linear skull fractures-49 (28%) e. clavicle fractures-30 (17.1%)13. All these conditions/signs can be considered red flags of abuse, except for: a. delay in accessing care-16 (9.1%) b.…”

Clinical and Forensic Investigation Protocols for Diagnosing Abusive Head Trauma: A Literature Review

“…In the face of numerous studies focused on brain and retinal lesions, few studies have been conducted on injuries of other types, such as skeletal or skin lesions. Feld et al analyzed a series of 72 cases of children undergoing a coroner's examination in Germany [36]. Fractures were found in approximately 30% of cases, especially in the clavicle and skull.…”

“…In 50-60% of cases, the father is responsible, in 9% of cases, the mother's partner is responsible, and in approximately 30% of cases, it is the mother herself. A recent study showed that 50% of cases in Germany involving suspected abuse cases were closed without trial due to the lack of evidence against a specific person [36]. In another study, Clauß et al found that in 33% of the cases examined, the proceedings were terminated by the Public Prosecutor due to a lack of suspects [42].…”

Prosecuting cases of abusive head trauma in Switzerland: a descriptive study of the impact of medical documentation and delay of reporting on judicial outcome

“…The main criteria to diagnose AHT, that were established by the “Comity of High authority of health in France” (HAS) [ 2 ] includes: Intracranial injuries, including subdural hematomas (SDH) [ 4 , 6 , 7 ], spinal cord injuries [ 8 ] and retinal haemorrhages (RH) [ 4 , 9 ]. Additional lesions such as fractures and skin lesions are present in 80–85% of cases [ 4 , 10 ]. These can be related to the process of shaking or more general child abuse [ 11 , 12 ].…”