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  • Clinical Research Article
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Age-related skull fracture patterns in infants after low-height falls

Pediatric Research volume 93, pages 1990–1998 (2023)Cite this article

Abstract

Background

Prior research and experience has increased physician understanding of infant skull fracture prediction. However, patterns related to fracture length, nonlinearity, and features of complexity remain poorly understood, and differences across infant age groups have not been previously explored.

Methods

To determine how infant and low-height fall characteristics influence fracture patterns, we collected data from 231 head CT 3D reconstructions and quantified length and nonlinearity using a custom image processing code. Regression analysis was used to determine the effects of age and fall characteristics on nonlinearity, length, and features of fracture complexity.

Results

While impact surface had an important role in the number of cracks present in a fracture, younger infants and greater fall heights significantly affected most features of fracture complexity, including suture-to-suture spanning and biparietal involvement. In addition, increasing fracture length with increasing fall height supports trends identified by prior finite-element modeling. Finally, this study yielded results supporting the presence of soft tissue swelling as a function of fracture location rather than impact site.

Conclusions

Age-related properties of the infant skull confer unique fracture patterns following head impact. Further characterization of these properties, particularly in infants <4 months of age, will improve our understanding of the infant skull’s response to trauma.

Impact

  • Younger infant age and greater fall heights have significant effects on many features of fracture complexity resulting from low-height falls.

  • Incorporating multiple crack formation and multiple bone involvement into computational models of young infant skull fractures may result in increased biofidelity.

  • Drivers of skull fracture complexity are not well understood, and skull fracture patterns in real-world data across infant age groups have not been previously described.

  • Understanding fracture complexity relative to age in accidental falls will improve the understanding of accidental and abusive head trauma.

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Fig. 1: Fracture characteristics.
Fig. 2: Custom image processing code rendering for quantification of fracture nonlinearity and length.
Fig. 3: Infant who fell from caregiver’s arms onto tile floor; third-degree witness.
Fig. 4: Age-related effects.
Fig. 5: Length and nonlinearity effects.

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Data availability

In accordance with Springer Nature’s Data Policy Type 3, all relevant raw data will be freely available to any researcher wishing to use them for non-commercial purposes, without breaching subject confidentiality. The datasets generated or analyzed during the current study are available from the corresponding author upon reasonable request.

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Acknowledgements

Statistical support was provided by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1TR002538. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. In addition, the authors would like to acknowledge Primary Children Hospital’s Pediatric Radiology Department for guidance and assistance with a radiological review.

Funding

This work was supported by Award No. 2016-DN-BX-0160 and 2020-75-CX-0014, provided by the National Institute of Justice, Office of Justice Programs, U.S. Department of Justice. The opinions, findings, and conclusions or recommendations expressed in this publication are those of the authors and do not necessarily reflect those of the Department of Justice.

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Authors and Affiliations

  1. Department of Pediatrics, University of Utah, Salt Lake City, UT, USA

    Tagrid M. Ruiz-Maldonado

  2. Department of Mechanical Engineering, University of Utah, Salt Lake City, UT, USA

    Yousef Alsanea & Brittany Coats

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Contributions

T.M.R.-M. has substantially contributed to the conception and design of this study; has collected, analyzed, and interpreted data; and has written the manuscript. Y.A. performed image analysis and collected data. B.C. designed this study, analyzed and interpreted the data, and also wrote the manuscript. All three authors read, critically revised, and approved the final manuscript.

Corresponding author

Correspondence to Tagrid M. Ruiz-Maldonado.

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Competing interests

T.M.R.-M. has provided medicolegal consultation and expert testimony on cases of suspected child abuse and neglect. No other competing interests were noted by the authors.

Ethics approval and consent to participate

This study was reviewed and approved by the University of Utah Institutional Review Board (IRB) and was deemed to be exempt research. Therefore, consent was not required for this study.

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Ruiz-Maldonado, T.M., Alsanea, Y. & Coats, B. Age-related skull fracture patterns in infants after low-height falls. Pediatr Res 93, 1990–1998 (2023). https://doi.org/10.1038/s41390-022-02345-9

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