To determine whether the presence or absence of bruising can be used to differentiate between abusive and nonabusive fractures, a retrospective study was conducted of patients with acute fractures referred to a child abuse team. A bruise and fracture were considered associated if both occurred on the same body site. Chart summaries, excluding information on bruising, were reviewed by 2 abuse experts to assign cause of injury. Of the 150 participants, fractures of 93 (62%) were categorized as abusive and 57 (38%) as nonabusive. Bruising associated with a fracture was found for 26% of abused and 25% of nonabused children. Most children (61%) had no bruises anywhere on the body, and this did not differ significantly by cause of injury. The sensitivity of a bruise associated with a fracture to predict abuse was only 26%. The presence or absence of bruising was not useful to differentiate between abusive and nonabusive fractures.

Abuse is a frequent cause of infant subdural haemorrhages, retinal haemorrhages and neurological dysfunction. Confessed shaking, without impact, is one reported injury cause. However, this remains legally controversial. We evaluated whether witnessed shaking alone can cause typical abusive head trauma (AHT). Cases were collected by Helfer Society list-serve solicitation for infants who developed signs and symptoms of AHT after independently witnessed shaking. We also reviewed a cross-sectional observational, multicentre study (Examining Siblings to Recognize Abuse (ExSTRA)) of 2890 children evaluated for abuse between January 2010 and April 2011 who experienced independently witnessed shaking. Four children identified by the Helfer Society experienced witnessed shaking and developed clinical and radiological evidence of AHT, including subdural and retinal haemorrhages. Another two had neurological symptoms, but normal imaging. Nineteen (0.7%) ExSTRA subjects experienced witnessed shaking without impact injuries. Among them, one (5.9%) of the 17 subjects who were neuroimaged had AHT findings and additional abusive injuries. Three had neurologic symptoms but normal neuroimaging. Although shaking is rarely witnessed, these cases support that shaking alone can cause typical AHT injuries, including, but not limited to, acute neurological impairment, subdural haemorrhages and retinal haemorrhages. This information is important to the legal management of abused children. K E Y W O R D S abusive head trauma, child abuse, infant shaking, subdural haemorrhage Key Practitioner Messages• Confessions document that infant shaking can cause abusive head trauma (AHT); however, this is disputed in courtrooms and by some physicians. • Ten infants developed clinical neurologic symptoms with or without radiologic findings of AHT after independently witnessed shaking. None had a history of cranial impacts, and all lacked physical findings suggesting impacts. They provide support for isolated shaking as a cause of AHT.

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BackgroundBilateral skull fractures in infancy often raise suspicion for abuse. Nevertheless, literature suggests that they may occur accidentally. However, empiric data are lacking.ObjectiveThis multicenter retrospective review aimed to characterize bilateral skull fractures in a large sample.Participants and SettingMedical 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.MethodsStandardized 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.ResultsFor 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).ConclusionsA 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.