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Child Abuse

Reclaiming Baby with Skull Fracture

04/28/2000

Question:

My child was seen by an emergency doctor on Mar.1, 2000. We were told that he had a skull fracture with an epidural bleed. We were then refered to the local Dept. of Human Services and our child was taken away because of abuse. Could the injury have happened at birth with out any one noticing it? We have never been under investigation for abuse and this is our fourth child. We are looking for some info that might help. Thank you.

Answer:

It is not possible to answer specific questions about your son`s diagnosis without being directly involved in his care but I can help you understand the diagnosis of skull fracture with epidural hematoma. An epidural hematoma is a collection of blood between the dura (the outermost membrane covering the brain) and the inner skull. The epidural bleeding results from an injury to an artery or vein between these two layers. Epidural hematomas are usually associated with a skull fracture and most often result from direct impact to the head, most typically from a fall. Epidural hematomas are infrequent in infancy and are not commonly associated with abusive head injury. However, any unexplained head injury in infancy is concerning for abuse. Occasionally, radiographic studies are misinterpreted. Skull fractures may be difficult to differentiate from suture lines, which are normal in infants. Epidural hematomas, if very small, may be difficult to differentiate from subdural hematomas. A subdural hematoma is a collection of blood between the dura and the arachnoid. The arachnoid is another membrane surrounding the brain and lies between the dura and the brain. Subdural hemorrhage is the most common type of head injury associated with abuse. A review of your son’s films by a pediatric Neuroradiologist may be helpful. An evaluation for suspected child abuse also includes other radiographs, such as a complete skeletal survey, to look for other occult injures. The question of possible birth trauma is an important one. Most significant head injuries secondary to delivery are identified shortly after birth. Skull fractures are typically associated with the use of forceps. Although birth trauma rarely causes epidural hematomas, the birth history should be reviewed for a traumatic delivery and considered as a possible cause of the trauma or ruled out. Your son’s age and the length of time of his symptoms will be important in the consideration of possible birth injury.

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Response by:

Robert Shapiro, MD
Professor of Clinical Pediatrics
College of Medicine
University of Cincinnati

Elena Duma, MD
Assistant Professor of Pediatrics
College of Medicine
University of Cincinnati