Skull Fracture-Child Abuse Or An Accident?
In November, 1999, a Bangladeshi boy aged 8 months was admitted to hospital with a linear parietal fracture. The mother had noticed a haematoma on the right side of his head and had consulted her general practitioner who arranged a skull radiograph. There were no retinal haemorrhages or other injuries. A skeletal survey was normal.
The parents, both unemployed, were the child’s only carers. They also had a daughter aged 18 months. The parents were unable to provide an explanation for the injury. They were adamant that the boy had not fallen or been dropped. On the day before admission his mother was alone with the two children, when she heard him scream. At the time she was in the kitchen adjoining the lounge, where the children were playing with a toy aeroplane. When she left the room the boy had been sitting on a carpeted floor. After the scream she found him lying on his side and his sister who was holding the aeroplane was standing next to him.
Toy aeroplane (above) believed to have caused linear parietal fracture.
The child was admitted to hospital for 3 weeks, after which the local authority obtained an interim care order. Both children were removed from the parents and initially placed in foster care before being moved to their grandparent’s home. Eventually, after social-worker assessment they were reunited with their parents.
A linear parietal fracture is a common accidental injury in infants. It usually occurs when children are dropped or fall from a height. It is because this explanation is so plausible that many inflicted injuries are said to have been caused accidentally. These parents, who claimed not to know the cause, insisted that he had not fallen or been dropped despite their awareness of the probability that he would be removed from their care. Such behaviour would be unusual had the injury been inflicted. The likely cause of the fracture was a freak accident, which could not be explained, because it was not witnessed. The aeroplane (480 g) probably landed on the boy’s head after it had been dropped or tossed in the air by his sister, who was 79 cm in height. She did not have sufficient strength to forcefully bang it against his head.
There is evidence that shows that on impact the momentum resulting from short falls can cause skull fracture. Still-born babies allowed to fall 41 cm head down onto a paved surface sustained skull fractures.1 Weber showed that skull fractures occurred when cadaver infants were dropped 82 cm onto a firm surface.2 In a survey of children under age 3 years, who presented to an emergency department a third had parietal fractures after falling from a height less than 60 cm (beds and chairs).3 There is a report of a child of 7 months who sustained a depressed fracture after falling out of bed into a toy car.4 In the literature there are reports of fractures from falling domestic objects such as television sets, but no reports of fractures caused by falling toys.5
This case report shows that a heavy toy falling a short distance onto an infant’s head can cause a fracture. As toys become more complex and heavier this message should not be lost on toy manufacturers. The report also highlights the plight of some innocent families that arises from our desire to protect children.
1 Taylor AS. Medical jurisprudence. Philadelphia: Blanchard and Lee, 1856.
2 Weber W. Zur biomechanischen Fragilitat des Sauglingsschadels. Zeitschrift fur Rechtsmedizin 1985; 94: 93-101. PubMed
3 Levethal JM, Thomas SA, Rosenfield NS, Makowitz RI. Fractures in young children, distinguishing child abuse from unintentional injuries. AJDC 1993; 147: 87-92. PubMed
4 Wheeler DS, Shope TR. Depressed skull fracture in 7-month old who fell from bed. Pediatrics 1997; 100: 1033-1034. PubMed
a Department of Paediatrics, The Royal Oldham Hospital, Oldham OL1 2JH, UK
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Categories: Skull Fracture-Child Abuse Or An Accident?