Depressed skull fractures: a pattern of abusive head injury in three older children

OBJECTIVE: To describe a pattern of abusive head injury in a series of children older than 4 years of age. METHODS: A hospital chart review of abused children with skull fractures from 1999 to 2001 was carried out. The clinical features, social background, and subsequent outcome and management are described. RESULTS: An 11-year-old girl and a pair of brothers of ages 7 and 9 were identified. The girl was attacked with a hammer during sleep by her stepmother, who committed suicide shortly afterwards. After craniotomy and intensive care, the child survived her multiple depressed fractures, intracranial bleeding, and brain contusion. Two brothers from a second family were attacked from behind with a hammer by their biological father, who was subsequently found to have undiagnosed schizophrenia. A depressed occipital fracture, without intracranial injury, was found in each child. The elder brother also had metacarpal fractures. Both children recovered without surgical intervention. CONCLUSION: A pattern of abusive head injury was described in older children with depressed skull fractures from blunt injury. The abusing parents were seriously mentally disturbed, and the abusive acts closely resembled child homicide.