ContextAbusive head trauma (AHT) is a dangerous form of child
abuse that can be difficult to diagnose in young children.ObjectivesTo determine how frequently AHT was previously missed
by physicians in a group of abused children with head injuries and to
determine factors associated with the unrecognized diagnosis.DesignRetrospective chart review of cases of head trauma
presenting between January 1, 1990, and December 31, 1995.SettingAcademic children's hospital.PatientsOne hundred seventy-three children younger than 3 years
with head injuries caused by abuse.Main Outcome MeasuresCharacteristics of head-injured children in
whom diagnosis of AHT was unrecognized and the consequences of the
missed diagnoses.ResultsFifty-four (31.2%) of 173 abused children with head
injuries had been seen by physicians after AHT and the diagnosis was
not recognized. The mean time to correct diagnosis among these children
was 7 days (range, 0-189 days). Abusive head trauma was more likely to
be unrecognized in very young white children from intact families and
in children without respiratory compromise or seizures. In 7 of the
children with unrecognized AHT, misinterpretation of radiological
studies contributed to the delay in diagnosis. Fifteen children
(27.8%) were reinjured after the missed diagnosis. Twenty-two (40.7%)
experienced medical complications related to the missed diagnosis. Four
of 5 deaths in the group with unrecognized AHT might have been
prevented by earlier recognition of abuse.ConclusionAlthough diagnosing head trauma can be difficult in the
absence of a history, it is important to consider inflicted head trauma
in infants and young children presenting with nonspecific clinical
signs.

http://www.nccpeds.com/rotations/AFCCP/Reading%20List/AHT/Jenny%20classic%20missed%20AHT.pdf

Analysis of missed cases of abusive head trauma.

Trauma is the most common cause of death in childhood, and inflicted head injury is the most common cause of traumatic death in infancy.1–3 Beginning with the classic descriptions of Kempe et al.4 and Caffey5 and with subsequent clinical, biomechanical, and radiologic studies, the diagnostic features of nonaccidental head injury in infants and toddlers have become widely recognized. This review outlines the mechanisms, typical features, differential diagnosis, and acute management of the most frequently encountered form of infantile inflicted head injury, the so-called shaken-baby syndrome. Biomechanics and Terminology The names applied to the syndromes of inflicted head injury in . . .

Nonaccidental head injury in infants--the "shaken-baby syndrome".

Shaken baby syndrome.

The objective of this study was to understand the biomechanics in age-related primary traumatic brain injuries (TBI) causing initial severity and secondary progressive damage and to develop strategy reducing TBI outcome variability using biomechanical reconstruction to identify types of causal mechanisms prior to clinical trials of neuro-protective treatment. The methods included the explanation of TBI biomechanics and physiopathological mechanisms from dual perspectives of neurosurgery and biomechanical engineering. Scaling of tolerances for skull failure and brain injuries in infants, children and adults are developed. Diagnostic assumptions without biomechanical considerations are critiqued. Methods for retrospective TBI reconstruction for prevention are summarized. Mechanisms of TBI are based on the differences between the mechanical properties of the head and neck related to age. Skull fracture levels correlate with increasing cranial bone thickness and in the development of the cranial sutures in infants and in adults. Head injury tolerance levels at three age categories for cerebral concussion, skull fracture and three grades of diffuse axonal injuries (DAI) are presented. Brain mass correlates inversely for TBI caused by angular head motions and locations of injurious stresses are predictable by centripetal theory. Improved quantitative diagnosis of TBI type and severity levels depend primarily on age and biomechanical mechanisms. Reconstruction of the biomechanics is feasible and enables quantitative stratification of TBI severity. Experimental treatment has succeeded in preventing progressive damage in animal TBI models. In humans this has failed, because the animal model received biomechanically controlled TBI and humans did not. Clinical similarities of human TBI patients do not necessarily predict equivalent biomechanics because such trauma can be produced in various ways. We recommend 'reverse engineering' for in-depth reconstruction of the TBI injury mechanism for qualitative diagnoses and reduction of outcome variability.

/pdf/biomechanics-and-neuropathology-of-adult-and-paediatric-head-53qblvi50u.pdf

Biomechanics and neuropathology of adult and paediatric head injury.

Objective To characterize neuroimaging, physical, neurobehavioral, and developmental findings in children with inflicted and noninflicted traumatic brain injury (TBI) and to identify characteristic features of inflicted TBI Methods and Patients Forty children, 0 to 6 years of age, hospitalized for TBI who had no documented history of previous brain injury were enrolled in a prospective longitudinal study TBI was categorized as either inflicted (n = 20) or noninflicted (n = 20) based on the assessment of hospital and county protective services Glasgow Coma Scale scores and neonatal history were comparable in both groups Outcome Measures Acute computed tomography/magnetic resonance imaging studies and physical findings were evaluated Glasgow Outcome Scale scores, cognitive development, and motor functioning were assessed an average of 13 months after TBI χ2 analyses assessed differences in the distribution of findings in the inflicted and noninflicted TBI groups Results Signs of preexisting brain injury, including cerebral atrophy, subdural hygroma, and ex vacuo ventriculomegaly, were present in 45% of children with inflicted TBI and in none of the children with noninflicted TBI Subdural hematomas and seizures occurred significantly more often in children with inflicted TBI Intraparenchymal hemorrhage, edema, skull fractures, and cephalohematomas were similar in both groups Retinal hemorrhage was only identified in the inflicted TBI group Glasgow Outcome Scale scores indicated a significantly less favorable outcome after inflicted than noninflicted TBI Mental deficiency was present in 45% of the inflicted and 5% of the noninflicted TBI groups Conclusions Characteristic features of inflicted TBI included acute computed tomography/magnetic resonance imaging findings of preexisting brain injury, extraaxial hemorrhages, seizures, retinal hemorrhages, and significantly impaired cognitive function without prolonged impairment of consciousness

Neuroimaging, Physical, and Developmental Findings After Inflicted and Noninflicted Traumatic Brain Injury in Young Children

Head injury in the youngest age group is distinct from that occurring in older children or adults because of differences in mechanisms, injury thresholds, and the frequency with which the question of child abuse is encountered. To analyze some of these characteristics in very young children, the authors prospectively studied 100 consecutively admitted head-injured patients 24 months of age or younger who were drawn from three institutions. Mechanism of injury, injury type, and associated injuries were recorded. All patients underwent ophthalmologic examination to document the presence of retinal hemorrhages. An algorithm incorporating injury type, best history, and associated findings was used to classify each injury as inflicted or accidental. The results confirmed that most head injuries in children younger than 2 years of age occurred from falls, and while different fall heights were associated with different injury types, most household falls were neurologically benign. Using strict criteria, 24% of injuries were presumed inflicted, and an additional 32% were suspicious for abuse, neglect, or social or family problems. Intradural hemorrhage was much more likely to occur from motor vehicle accidents and inflicted injury than from any other mechanism, with the latter being the most common cause of mortality. Retinal hemorrhages were seen in serious accidental head injury but were most commonly encountered in inflicted injury. The presence of more serious injuries associated with particular mechanisms may be related to a predominance of rotational rather than translational forces acting on the head.

A J Alario

Papers

Head injury in very young children: mechanisms, injury types, and ophthalmologic findings in 100 hospitalized patients younger than 2 years of age.