Bruising in non-accidental head injured children; a retrospective study of the prevalence, distribution and pathological associations in 24 cases

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Abstract

Non-accidental head injury, be it shaking, impact(s) or a combination of the two, is characterised by subdural and/or subarachnoid haemorrhages with retinal haemorrhages, but minimal or absent external cranio–facial trauma. The classical assault scenario depicts the infant being gripped around the head, face, chest and abdomen and shaken or being gripped by a limb and swung. This gripping might be expected to leave physical evidence in the form of bruising. A study was undertaken to establish the prevalence, distribution and pathological associations of external bruising in 24 cases of fatal non-accidental head injury in children. At autopsy, 17 cases had new external bruises, 15 old external bruises and 13, a combination of both. However, seven (29%) cases showed no fresh external bruising and five (21%) showed no external bruising at all. Thus, external bruising may be absent in children with fatal intracranial injury. The face was shown to be the commonest site of bruising followed by the forehead and buttocks. Limb, chest and abdominal bruising were found to be uncommon. Retinal haemorrhages were confirmed in 23 (96%) cases. It is hypothesised that bruising, when present, may be a result of abuse in the form of punches and slaps rather than due to gripping during the assault. We discuss why gripping does not necessarily result in external bruising.

Introduction

Non-accidental injury is an important cause of death world-wide and, in children less than 1 year old, is the commonest cause of serious head injury as typified by `Shaken Baby Syndrome' [1]. Shaken Baby Syndrome is characterised by subdural and/or subarachnoid haemorrhages with associated retinal haemorrhages, but minimal or absent external cranio–facial trauma [2], and results from the infant having being shaken violently with or without a head impact. Duhaime et al. [3]believe that shaking alone does not generate sufficient force to produce life-threatening cerebral trauma; an impact, albeit against a soft surface, is always necessary.

Previous published accounts of the assault describe the infant being gripped around the head, face, chest or abdomen and shaken, or being gripped by a limb and swung [4]. Such gripping might be expected to leave some form of physical evidence, usually in the form of external bruising. However, it has been our experience that at autopsy, those infants dying of non-accidental head injury may have no external marks of violence. If any are present, they are usually in areas classically associated with other blunt force injuries, rather than gripping injuries. This paucity or lack of bruising may cause difficulties during any subsequent court proceedings.

Although injuries associated with child abuse are well documented in the literature, observations of the distribution of external bruising in those suspected of having been shaken, with or without an impact, are infrequent and poorly documented. We therefore undertook a study to establish the prevalence, distribution and pathological associations of external bruises in non-accidentally head injured children to determine whether the findings reflected the previous published descriptions hypothesising how a child may be held during the assault. The carer's account as to how the child was held during the incident was analysed, although in our experience assault is usually denied.

Section snippets

Method

Twenty-four cases of fatal non-accidental head injury in children were retrieved from the archival records of the Department of Forensic Pathology, University of Sheffield from 1990–1996. All the children were younger than 5 years of age and had sustained fatal intracranial injuries attributed to child abuse. External bruises were classified as new or old according to their colour at the time of autopsy. For the purposes of the study new bruises were classified as those which were swollen, red,

Results

The 24 cases showed a male:female ratio of 14:10 with a mean age of 9 months (range 1.5–32 months). Seventeen (71%) cases had new external bruises, 15 (63%) cases had old external bruises and 13 (54%) cases had a combination of new and old external bruises. Seven (29%) cases showed no evidence of new external bruising. Of these, six had internal bruising to the face, scalp and chest. Only one case showed no fresh external or internal bruising. Five (21%) cases showed no evidence of either new

Discussion

Non-accidental injury is an important cause of death world-wide and, in children less than 1 year old, is the commonest cause of head injury as typified by the Shaken Baby Syndrome [1]. Although Caffey (1946) is credited with first drawing attention to the combination of long bone fractures and subdural haemorrhages as a result of child abuse [5], Knight draws our attention to the fact that Ingraham had previously suggested in 1939 that some subdural haemorrhages in infants were traumatic in

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