Biomechanical fragility of the infant skull

Author:

W Weber

 

Following previous experiments on postmortem skull fractures of infants, falls from 82-cm heights onto stone (A), carpet (B) and foam-backed linoleum (C), 35 further falling tests were carried out onto softly cushioned ground. In 10 cases a 2-cm thick foam rubber mat (D) was chosen and in 25 further cases a double-folded (8-cm-thick) camel hair blanket (E). Hence the results of altogether 50 tests could be evaluated. In test groups A-C on a relatively hard surface, skull fractures of the parietale were observed in every case; in test group D this fracture was seen in one case and in test group E in four cases. Measurements along the fracture fissures showed bone thickness of 0.1-0.4 mm. The fracture injuries originated in paper-thin single-layer bone areas without diploe, which can also be considered the preferred regions for skull fractures of older infants following falls from low heights. These results indicate that it is no longer possible to assume that the skull of infants is not damaged after falls from table height.

 

Source:

http://www.biomedsearch.com/nih/Biomechanical-fragility-infant-skull/4002885.html

Skull Fracture-Child Abuse Or An Accident?

Ivan Blumenthal

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.

References

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

5 Bernard PA, Johnston C, Curtiss SE, King WD. Toppled television sets cause significant pediatric morbidity and mortality. Paediatrics 1998; 102: E32. PubMed

a Department of Paediatrics, The Royal Oldham Hospital, Oldham OL1 2JH, UK

Source:

http://www.lancet.com/journals/lancet/article/PIIS0140-6736%2805%2974515-3/fulltext

Also linked on The Amanda Truth Project:

http://www.theamandatruthproject.com/apps/forums/topics/show/1451280-skull-fracture-child-abuse-or-accident-

Contrecoup Injuries Of The Brain In Infancy

Hippocrates Treats His Patient

CYRIL B. COURVILLE, MD

Coroner-Medical Examiner’s Office, Los Angeles County, and the Department of Pathology (Cajal Laboratory of Neuropathology), Los Angeles County Hospital.

THE TERM “contrecoup” has long been associated with the mechanism of craniocerebral injury. Its first use was in reference to the occurrence of “contrecoup” fracture by Hippocrates,¹ in which a linear fracture appears opposite the point of a traumatic impact. It was used in this sense from the 16th to the 19th centuries.² It is not clear exactly when the term was applied to soft tissue contusions, but contrecoup lesions were the subject of numerous contributions by French surgeons during the middle of the 18th century.³ Here the matter rested until the early 20th century when the treatise of Le Count and Apfelbach⁴ on automobile injuries of the head and brain again called attention to the subject.

http://archsurg.highwire.org/cgi/content/summary/90/1/157

Coup And Contre-Coup Injury: Observations On The Mechanics Of Visible Brain Injuries In The Rhesus Monkey

Authors:

Ayub K. Ommaya, M.D., F.R.C.S., Robert L. Grubb, Jr., M.D., and Ronald A. Naumann, M.D.

The distribution of coup and contre-coup contusions and subdural hematomas after frontal and occipital impacts has been studied in the rhesus monkey. The effect of skull fracture on these lesions is noted, and the data compared to known postmortem observations in man. The translation/cavitation theory for brain injury as presently conceived is not supported by these data. The skull distortion and head rotation hypothesis offers opportunities for developing a better theory for brain injury by direct as well as indirect impact. The significance of these observations for design of protective devices is briefly discussed.

Source:

http://thejns.org/doi/abs/10.3171/jns.1971.35.5.0503

Ayub K. Ommaya, 78; Neurosurgeon and Authority on Brain Injuries

By Joe Holley

Washington Post Staff Writer
Monday, July 14, 2008

Dr. Ayub Khan Ommaya, 78, a neurosurgeon, an internationally known expert on brain injuries and the inventor of a device that facilitates treatment of brain tumors, died July 10 at his home in Islamabad, Pakistan, of complications from Alzheimer’s disease.

The longtime Bethesda resident was a retired chief of neurosurgery at the National Institute of Neurological Disorders and Stroke and professor of neurosurgery at George Washington University.

Before Dr. Ommaya’s work in the 1960s, there was no effective way to deliver chemotherapy treatments for brain tumors. His invention of the Ommaya reservoir, a plastic dome-shaped device with a catheter attached to the underside, made possible the delivery of chemotherapy to the brain and spinal cord. In addition, the device served as a prototype for all medical ports now in use.

Dr. Ommaya also developed the centripetal theory of traumatic brain injury, which allowed scientists to understand and model how brains are affected by blunt force. As chief medical adviser to the National Highway Traffic Safety Administration and director of NHTSA’s head injury prevention program, he created a model for brain injuries that led to design changes and the development of safety devices in motor vehicles worldwide.

Known as the “singing neurosurgeon,” Dr. Ommaya was a trained opera tenor who often sang before and after surgery, to the delight of patients and their families and his hospital colleagues.

Born in Rawalpindi, Pakistan, he was a national champion swimmer. He received his medical degree from King Edward Medical College in Pakistan in 1953 and, as a Rhodes Scholar, received his master’s degree from Balliol College, Oxford University, in 1956. During medical school, he trained as an amateur boxer and was a member of the crew team at Balliol.

He came to the United States in 1961 as a visiting scientist at the National Institutes of Health and later became an associate neurosurgeon. He was chief of neurosurgery from 1974 to 1979 and began teaching at George Washington University in 1970.

In 1977, Dr. Ommaya was part of a team of GWU surgeons that saved the life of a Rochester, N.Y., teacher by removing a snake-like tangle of blood vessels at the base of his brain, a rare abnormal growth that had paralyzed both his arms and legs and was threatening to cut off his breathing. In a history-making operation that lasted 19 hours, the man was chilled for a time to 65 degrees, his heart and lung were stilled and his brain activity was halted.

Dr. Ommaya, who told The Washington Post that he got through the surgery on just a couple of candy bars, said that it was “like dissecting out hundreds of tiny snakes — you have to dissect them out individually without cutting them or damaging the nerves and the spinal cord.”

As a transportation safety expert, he commissioned “Injury in America” (1985), a report that led to the creation of the Centers for Disease Control and Prevention’s National Center for Injury Prevention and Control. The center provides synthesis, direction and funding for the field.

He also invented an inflatable collar, similar to an airbag, that attaches to motorcycle helmets as a protection against spinal injury.

In 1997, Dr. Ommaya was called as a defense expert witness in the highly publicized trial of Louise Woodward, a British au pair accused of killing an 8-month-old baby in her care. He maintained that the child, Matthew Eappen, could not have been killed by violent shaking, as prosecutors claimed.

Sitting in the witness stand of a Cambridge, Mass., courtroom, he bounced a wad of Silly Putty on the floor to illustrate the damage that could be caused by impact. “The demonstration elicited a burst of laughter from jurors and observers — a rarity in a trial that has featured emotionally wrenching testimony from the baby’s parents and others,” the Patriot Ledger (Quincy, Mass.) reported at the time.

Dr. Ommaya retired in 2001.

His marriages to Parvaneh Modaber and Wendy Preece ended in divorce.

Survivors include his wife of 28 years, Ghazala N. Ommaya of Bethesda and Islamabad; three children from his second marriage, David Ommaya of Los Angeles, Alexander Ommaya of Bethesda and Shana Ommaya of Vienna; three children from his third marriage, Asha Ommaya of London and Iman Ommaya and Sinan Ommaya, both of Bethesda and Islamabad; two brothers; a sister; and five grandchildren.

Source:

http://www.washingtonpost.com/wp-dyn/content/article/2008/07/13/AR2008071301791.html

Injury Evidence Opposite The Point Of Impact

Contrecoup Injuries Of The Brain In Infancy

CYRIL B. COURVILLE, MD

AMA Arch Surg. 1965;90(1):157-165.

THE TERM “contrecoup” has long been associated with the mechanism of craniocerebral injury. Its first use was in reference to the occurrence of “contrecoup” fracture by Hippocrates,¹ in which a linear fracture appears opposite the point of a traumatic impact. It was used in this sense from the 16th to the 19th centuries.² It is not clear exactly when the term was applied to soft tissue contusions, but contrecoup lesions were the subject of numerous contributions by French surgeons during the middle of the 18th century.³ Here the matter rested until the early 20th century when the treatise of Le Count and Apfelbach⁴ on automobile injuries of the head and brain again called attention to the subject.

This principle of “contrecoup” as it concerns the mechanism of cerebral contusions has been used by the writer in several contributions.^5-10 In accord with the observations of Le . . . [Full Text PDF of this Article]

**There is no abstract available for this article so the first 150 words were used of the full PDF text.

Source:

Archives Of Surgery

http://archsurg.highwire.org/cgi/content/summary/90/1/157

Coup-Contrecoup Skull Fracture From Car Accident

Child skull fracture

Question:

My daughter is 3 1/2 years old, and we were involved in an accident where the impact was on the front passenger side of the vehicle. She had a bruise on her right eye which led me to believe that her car seat may have shifted towards the impact of the wreck. However, she was taken to the hospital 4 days later when she developed black eyes and it was found that she had a skull fracture and some bleeding. The skull fracture was on her left side of her head, which is very puzzling. Is this possible? If so are there documented medical cases, and where could I find such cases or articles?

Answer:

Yes, it is possible as a result of what is called the coup-contrecoup type of closed head injury. In this situation the brain suffers damage directly under the area of impact, but a second injury of equal or greater magnitude occurs directly opposite the point of contact. This occurs because the brain is suspended in the cranium or skull in cerebral spinal fluid with long nerve tracts extending from deep within the brain down into the spinal cord. When the head suffers a blow, the brain is first injured directly beneath the point of impact and then secondarily on the opposite side as the brain hurtles across the skull and slams into the  bony plates opposite the point of impact,  bouncing back yet again to the original site of injury. Children’s bones are much more porous than adult bones and hence are far more likely to fracture than are adult bones.

In addition to the direct injury and secondary injury, such a severe blow also results in what is called diffuse axonal injury from the stretching and shearing of nerves in the brain as they move to the contrecoup injury site across the skull. This may result in abnormal brain function for sometimes lengthy periods as the nerves swell in response to the injury and then eventually heal. It is not possible to know what the exact outcomes of any injury will be, particularly for children, since their brains have more flexibility in healing (plasticity) and in the transfer of skills to other neurons than do the brains of adults. There is no way to predict how many cells are affected or their degree of recovery.

Your daughter’s injury highlights the critical importance of using optimal restraint systems for children precisely in order to protect their brains, the most likely body part to be injured in a motor vehicle accident. Because children’s heads are so large and heavy compared to the rest of their bodies, their heads function like bullets in an accident, pulling the child forward toward impact. Children should be in approved and properly installed car seats and booster seats until they are 80 pounds in weight AND 4 feet 9 inches in height. Research shows that up to 80% of child restraint systems are installed or used incorrectly.

If you are interested in reading more, enter coup-contrecoup injury or diffuse axonal injury or closed head injury into a search engine – these terms should lead you to additional information. I hope this information is helpful.

Source:

http://www.netwellness.org/question.cfm/46710.htm

Child skull fracture

Question:

my child and I were involved in a car accident. As far as I know, she may have hit her head on her right side as she had a bruise on her right eye. However, she sustained a skull fracture on her left side. Is this possible?

Answer:

Yes, it is absolutely possible because of a phenomenon known as rebound injury, wherein the brain opposite the injury is also damaged. When the force that directly impacts the skull is significant, it causes the brain, it’s blood vessels, nerves, and cushioning fluid to move swiftly across the space inside the skull and literally smash up against the other side of the bony skull. This applies shearing or tearing forces to all of these tissues as they move at high velocity to slam into a the bony skull barrier and then rebound again to inflict more damage at the original site of impact.

I don’t know how old your child is, but the bony plates that make up the skull do not fuse completely with one another until sometime after 10 years of age. This allows for the rapid growth of brain tissue that occurs in the first decade of life that is necessary for normal development and learning. In younger children bones are also more likely to fracture than they are in adults because they are less calcified.

Your experience highlights the critical need for the proper restraint of all children in appropriate car seats and booster seats until they meet the weight AND the height criteria for moving into standard seatbelt usage. These milestones are 80 pounds and four feet nine inches. Use of booster seats and car seats reduces serious injury by 60-80%. Regular seat belts used on smaller individuals result in cutting across the trachea or windpipe,potentially collapsing it or the esophagus as the windpipe is driven back into the esophagus or food pipe, making swallowing and eating painful and difficult. They also can inflict significant bruising injury on the abdominal organs leading to internal bleeding as well as painful bruising over bony areas.

I hope both you and your daughter heal quickly and consistently use good restraint practices when back out on the road.

Source:

http://www.netwellness.org/question.cfm/46432.htm

Responses by:

Mary M. Gottesman, PhD, RN, CPNP, FAAN
Associate Professor, Specialty Program Director
Pediatric Nurse Practitioner Program
College of Nursing
The Ohio State University

Predilection Sites For Skull Fractures In Infants

Predilection sites of infantile skull fractures following blunt force

Weber W.

Abstract

Previous investigations on calvarial fractures in infants have shown that the flexibility and displacement of the infant calvarial are not sufficient to avoid fractures as a result of fall. From a table height onto hard ground – and in special cases, fractures cannot be avoided even after falls onto softly cushioned ground. The skull fractures are located in paper-thin, transparent, single-layer bone areas without diploe. The results of previous literature were compared with investigations of the skulls of 82 infants (from neonates up to infants 14 months of age). Congenital fissures, cranioschisis, locally retarded ossification in the cranium and craniotabes are all weak points where fracture has a tendency to occur even if the impact is minor. These ossification defects are increased in the ossa parietalia, but can also be found in the os frontale or in the os occipitale. The location is not always the same but can be detected by locating the skull transparency using diaphanoscopy.

Source:

http://www.ncbi.nlm.nih.gov/pubmed/3111120

Fragility Of The Infant Skull

Biomechanical fragility of the infant skull

Weber W.

Abstract

Following previous experiments on postmortem skull fractures of infants, falls from 82-cm heights onto stone (A), carpet (B) and foam-backed linoleum (C), 35 further falling tests were carried out onto softly cushioned ground. In 10 cases a 2-cm thick foam rubber mat (D) was chosen and in 25 further cases a double-folded (8-cm-thick) camel hair blanket (E). Hence the results of altogether 50 tests could be evaluated. In test groups A-C on a relatively hard surface, skull fractures of the parietale were observed in every case; in test group D this fracture was seen in one case and in test group E in four cases. Measurements along the fracture fissures showed bone thickness of 0.1-0.4 mm. The fracture injuries originated in paper-thin single-layer bone areas without diploe, which can also be considered the preferred regions for skull fractures of older infants following falls from low heights. These results indicate that it is no longer possible to assume that the skull of infants is not damaged after falls from table height.

Source:

http://www.ncbi.nlm.nih.gov/pubmed/4002885

Infant Brain Injury – The Contrecoup-Coup

The Contrecoup–Coup Phenomenon

A New Understanding of the Mechanism of Closed Head Injury

Laura B. Drew,1,* and William E. Drew,2

1Oakwood High School, Dayton, OH and 2Wright-Patterson Medical Center,
Wright-Patterson AFB, OH

Abstract

Acommon observation in closed head injuries is the contrecoup brain injury. As the
in vivo brain is less dense than the cerebrospinal fluid (CSF), one hypothesis explaining
this observation is that upon skull impact, the denser CSF moves toward the site of
skull impact displacing the brain in the opposite direction, such that the initial impact
of the brain parenchyma is at the contrecoup location.
A simple model was developed consisting of a balloon filled with water of density
1.00 g/mL enclosed in a clear plastic jar containing salt water of density 1.04 g/mL, simulating
the same relative densities of the CSF and brain. The initial movement of the balloon,
modeling the brain, was toward the contrecoup location with subsequent movement
toward the coup location.
The pattern of brain injury in which the contrecoup injury is greater than the coup
injury is a result of initial movement of the brain in the contrecoup location.
During the process of closed head injury, the brain parenchyma is initially displaced
away from the site of skull impact and toward the contrecoup site resulting in the more
severe brain contusion.

Introduction

When an individual suffers a closed head injury, forces on the brain within the cranial vault result in injury to the brain parenchyma. The exact mechanisms by which these forces injure the brain have been a matter of considerable debate. Giovanni Battista Morgagni, considered the father of anatomic pathology, and Henri Francois LeDran postulated
theories on the mechanisms of closed head injury in the 18th century (1). In 1766, a debate held in Paris and sponsored by the Academy of Surgeons, aggressively defended competing theories for the mechanism of coup and contrecoup injuries. For more than 200 years, the debate has continued. The primary matter of scientific curiosity is the frequent observation that the injury to the brain opposite the location at which the skull strikes an external object is frequently more severe than the injury to the brain that occurs adjacent to the area of skull contact. The following definitions are provided for clarity: the coup injury to the brain is the contusion to the brain that occurs at the area of brain adjacent to the location at which the skull impacts with a fixed external object. In contrast, the contrecoup injury to the brain is the contusion to the brain that occurs at the area of brain opposite the area

For Full Article Please See Source: http://www.springerlink.com/content/r1535u48q2226p6l/

Journal Neurocritical Care

Publisher Humana Press Inc.

Bilateral Cranial Fractures – Localized Impact Or Compression

The Medicolegal Implications of Bilateral Cranial Fractures in Infants

Abstract

There is considerable debate about the possibility of serious injuries associated with skull fractures caused by short-height falls in early childhood. In order to elucidate the mechanism and nature of blunt head trauma from such falls, we have investigated the possible correlation between patterns of skull fractures and the dynamics inducing these injuries.

In a 10-year survey of pediatric medicolegal autopsies conducted at the L. Greenberg Institute of Forensic Medicine in Tel Aviv, Israel, we have observed that all victims of alleged falls from low heights exhibited unilateral skull fractures. Only in four instances were bilateral temporoparietal fractures detected. Thorough investigation into the circumstances surrounding these four incidents, along with the evaluation of the forces exerted upon the cranium at the time of impact, suggest that symmetrical cranial fractures in infants are most likely the result of bilateral compression of the head between two surfaces, rather than the result of a localized impact.

Source:

http://journals.lww.com/jtrauma/Abstract/1995/01000/The_Medicolegal_Implications_of_Bilateral_Cranial.10.aspx