O'Hara Mandy A, Valvano Thomas J, Kashyap Marisha, Daly Jennie C, Bachim Angela N, Care Marguerite M, Egge Melissa K, Kondis Jamie S, Lenane Ann M, Maddocks Alexis B R, Metz James B, Nielsen Anne K, Reeder Kristen N, Ruda Michelle T, Segal Rachel, Sugarman Jacqueline M, Weeks Kerri, Oral Resmiye
Department of Pediatrics, Oregon Health and Science University, Portland, OR.
Mailman School of Public Health, Columbia University, New York, NY.
Pediatr Emerg Care. 2023 May 1;39(5):329-334. doi: 10.1097/PEC.0000000000002704. Epub 2022 Apr 13.
Bilateral skull fractures in infancy often raise suspicion for abuse. Nevertheless, literature suggests that they may occur accidentally. However, empiric data are lacking.
This multicenter retrospective review aimed to characterize bilateral skull fractures in a large sample.
Medical records for infants younger than 24 months with bilateral skull fractures involving hospital consultation with a child abuse pediatrician (CAP) were reviewed from 2005 to 2020 at 13 nationally represented institutions.
Standardized data collection across institutions included historical features, fracture characteristics, and additional injuries, as well as the CAP's determination of accident versus abuse. Pooled data were analyzed for descriptive and bivariate analyses.
For 235 cases, 141 were accidental, and 94 abuse. The majority occurred in young infants, and a history of a fall was common in 70% of cases. More than 80% involved both parietal bones. Bilateral simple linear fractures were more common in accidental cases, 79% versus 35%, whereas a complex fracture was more frequent in abuse cases, 55% versus 21% ( P < 0.001). Almost two thirds of accidental cases showed approximation of the fractures at the sagittal suture, compared with one third of abuse cases ( P < 0.001). Whereas focal intracranial hemorrhage was seen in 43% of all cases, diffuse intracranial hemorrhage was seen more in abuse cases (45%) than accidents (11%). Skin trauma was more common in abusive than accidental injury (67% vs 17%, P < 0.001), as were additional fractures on skeletal survey (49% vs 3%, P < 0.001).
A fall history was common in bilateral skull fractures deemed accidental by a CAP. Most accidental cases involved young infants with biparietal simple linear fractures, without skin trauma or additional fractures. A skeletal survey may aid in the determination of accidental or abusive injury for unwitnessed events resulting in bilateral skull fractures in infants.
婴儿双侧颅骨骨折常引发虐待嫌疑。然而，文献表明它们可能是意外发生的。但缺乏实证数据。
这项多中心回顾性研究旨在对大量样本中的双侧颅骨骨折进行特征描述。
对2005年至2020年期间在全国13家具有代表性的机构中，因双侧颅骨骨折而咨询儿童虐待儿科医生（CAP）的24个月以下婴儿的病历进行了回顾。
各机构的标准化数据收集包括病史特征、骨折特点、其他损伤，以及CAP对意外与虐待的判定。对汇总数据进行描述性和双变量分析。
在235例病例中，141例为意外，94例为虐待。大多数发生在小婴儿中，70%的病例有跌倒史。超过80%累及双侧顶骨。双侧单纯线性骨折在意外病例中更常见，分别为79%和35%，而复杂骨折在虐待病例中更频繁，分别为55%和21%（P<0.001）。近三分之二的意外病例在矢状缝处骨折对位，而虐待病例中这一比例为三分之一（P<0.001）。虽然43%的所有病例都有局灶性颅内出血，但弥漫性颅内出血在虐待病例中（45%）比意外病例（11%）更常见。皮肤创伤在虐待性损伤中比意外损伤更常见（67%对17%，P<0.001），骨骼检查中其他骨折也是如此（49%对3%，P<0.001）。
CAP判定为意外的双侧颅骨骨折中，跌倒史很常见。大多数意外病例涉及有双侧顶骨单纯线性骨折的小婴儿，无皮肤创伤或其他骨折。对于导致婴儿双侧颅骨骨折的无目击事件，骨骼检查可能有助于确定是意外还是虐待性损伤。
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