Abusive Head Trauma? A Biomechanics-Based Approach

Abstract

Medical professionals frequently evaluate infants and children with head trauma. If the child's cranial injuries are not explained by the history, child abuse must be considered. A significant body of research regarding cranial injury mechanisms is available. This article presents a synthesis of a subset of the biomechanics literature relevant to head injury. The potential application of this knowledge base is explored through five questions: (a) What physical laws govern the response of the head-brain complex to the application of a mechanical force? (b) What are the causal mechanisms of head injury? (c) What properties of living tissues affect responses to the application of a mechanical force? (d) How can specific cranial injuries be linked to their biomechanical origins? and (e) Can the biomechanical history explain the cranial injuries? The authors propose a biomechanics-based paradigm for analysis of pediatric head trauma and seek a qualitative rather than a quantitative understanding.

Get full access to this article

View all access options for this article.

References

Adams, J. H. , Doyle, D. , Ford, I. , Gennarelli, T. A. , Graham, D. I. , & McLellan, D. R. (1989). Diffuse axonal injury in head injury: definition, diagnosis, and grading. Histopathology, 15, 49-59.

Adams, J. H. , Gennarelli, T. A. , & Graham, D. I. (1982). Brain damage in non-missile head injury: Observations in man and in subhuman primates. In R. Smith & J. Cavanagh (Eds.), Recent advances in neuropathology (pp. 165-190). Edinburgh, Scotland: Churchill.

Adams, J. H. , Graham, D. I. , & Gennarelli, T. A. (1981). Acceleration induced head injury in the monkey: 2. Neuropathology. Acta Neuropathologica, 7(suppl.), 26-28.

Adams, J. H. , Graham, D. I. , & Gennarelli, T. A. (1982). Neuropathology of acceleration-induced head injury in the subhuman primate. In R. Grossman (Ed.), Seminars in neurological surgery: Proceedings of the 4th annual conference on neural trauma (pp. 141-152). New York: Raven.

Adams, J. H. , Graham, D. I. , Murray, L. S. , & Scott, G. (1982). Diffuse axonal injury due to nonmissle head injury in humans: An analysis of 45 cases. Annals of Neurology, 12, 557-563.

Adams, J. H. , Mitchell, D. E. , Graham, D. I. , & Doyle, D. (1977). Diffuse brain damage of intermediate impact type. Its relationship to “primary brain stem damage” in head injury. Brain, 100, 489-502.

Alexander, R. C. , Schor, D. P. , & Smith, W. L. (1986). Magnetic resonance imaging of intracranial injuries from child abuse. Journal of Pediatrics, 146, 97-102.

Aoki, N. , & Masuzawa, H. (1986). Subdural hematomas in abused children: Report of six cases from Japan. Neurosurgery, 18, 475-477.

Bandak, F. A. (1995). On the mechanics of neurotrauma: A review and critical synthesis. The Journal of Neurotrama, 12, 645-649.

10.

Bandak, F. A. (1997). Biomechanics of impact traumatic brain injury. In J.A.C. Ambrosio , F. O. Seabra Periera , & F. Pina de Silva . (Eds.), Crashworthiness of transportation systems: Structural impact and occupant protection (pp. 53-93). Kluwer Academic Publishers.

11.

Bandak, F. A. , Eppinger, R. H. , & Ommaya, A. K. (Eds.) (1996). Traumatic brain injury bioscience and mechanics. Larchmont, NY: Mary Ann Liebert.

12.

Barlow, B. , Niemirska, M. , Gandhi, R. P. , & Leblanc, W. (1983). Ten years of experience with falls from a height in children. Journal of Pediatric Surgery, 18, 509-511.

13.

Briss, P. A. , Sacks, J. J. , Addiss, D. G. , Kresnow, M. , & O'Neil, J. (1994). A nationwide study of the risk of injury associated with day care attendance. Pediatrics, 93, 364-368.

14.

Bruce, D. A. , & Zimmerman, R. A. (1989). Shaken impact syndrome. Pediatric Annals, 18, 482-494.

15.

Calder, I. M. , Hill, I. , & Scholtz, C. L. (1984). Primary brain trauma in non-accidental injury. Journal of Clinical Pathology, 37, 1095-1100.

16.

Chadwick, D. L. , Chin, S. , Salerno, C. , Landsverk, J. , & Kitchen, L. (1991). Death from falls in children: How far is fatal? Journal of Trauma, Injury, Infection and Critical Care, 31, 1353-1355.

17.

Chadwick, D. L. , & Salerno, J. J. (1993). The rarity of serious head injury in day care centers [Letter to the editor]. Journal of Trauma, Injury, Infection and Critical Care, 35, 968.

18.

Chang, A. , Lugg, M. M. , & Nebedum, A. (1989). Injuries among preschool children enrolled in day-care centers. Pediatrics, 83, 272-277.

19.

Cohen, R. A. , Kaufman, R. A. , Myers, P. A. , & Towbin, R. B. (1986). Cranial computed tomography in the abused child with head injury. American Journal of Roentgenology, 146, 97-102.

20.

Denny-Brown, D. , & Russell, W. R. (1941). Experimental cerebral concussion. Brain, 64, 93-164.

21.

DiMaio, D. J. , & DiMaio, V.J.M. (1989). Trauma to the skull and brain: Craniocerebral injuries. In D. DiMaio & V. DiMaio (Eds.), Forensic pathology (pp. 139-169). New York: Elsevier.

22.

Duhaime, A. C. , Alario, A. J. , Lewander, W. J. , Schut, L. , Sutton, L. N. , Seidl, T. S. , Nudelman, S. , Budenz, D. , Hertle, R. , Tsiaras, W. , & Loporchio, S. (1992). Head injury in very young children: Mechanisms, injury types, and ophthalmologic findings in 100 hospitalized patients younger than 2 years of age. Pediatrics, 90, 179-185.

23.

Duhaime, A. C. , Eppley, M. , Margulies, S. , Heher, K. L. , & Bartlett, S. P. (1995). Crush injuries to the head in children. Neurosurgery, 37, 401-406.

24.

Duhaime, A. C. , Gennarelli, T. A. , Thibault, L. E. , Bruce, D. A. , Margulies, S. S. , & Wiser, R. (1987). The shaken baby syndrome. Journal of Neurosurgery, 66, 409-415.

25.

Evans, F. G. , Lissner, H. R. , & Lebow, M. (1958). The relation of energy, velocity, and acceleration to skull deformation and fracture. Surgery, Gynecology, & Obstetrics, 107, 593-601.

26.

Gennarelli, T. A. (1984). Clinical and experimental head injury. In B. Aldman & A. Chapon (Eds.), The biomechanics of impact trauma (pp. 103-115). Amsterdam: Elsevier Science.

27.

Gennarelli, T. A. , & Meany, D. F. (1996). Mechanisms of primary brain injury. In R. Wilkins & S. Rengachery (Eds.), Neurosurgery (pp. 2611-2621). New York: McGraw-Hill.

28.

Gennarelli, T. A. , & Thibault, L. E. (1982). Biomechanics of acute subdural hematoma. Journal of Trauma, Injury, Infection and Critical Care, 22, 680-686.

29.

Gennarelli, T. A. , Thibault, L. E. , Adams, J. H. , Graham, D. I. , Thompson, C. J. , & Marcincin, R. P. (1982). Diffuse axonal injury and traumatic coma in the primate. Annals of Neurology, 12, 564-574.

30.

Gilliland, M.G.F. , & Folberg, R. (1996). Shaken babies—Some have no impact injuries. Journal of Forensic Sciences, 41, 114-116.

31.

Gurdjian, E. S. , Webster, J. E. , & Lissner, H. R. (1950). The mechanism of skull fracture. Radiology, 54, 313-338.

32.

Guthkelch, A. N. (1971). Infantile subdural haematoma and its relationship to whiplash injuries. British Medical Journal, 2, 430-431.

33.

Hajivassiliou, C. A. , & Azmy, A. (1996). Physical parameters of free fall in a child. Injury, 27, 739-741.

34.

Helfer, R. E. , Slovis, T. L. , & Black, M. (1977). Injuries resulting when small children fall out of bed. Pediatrics, 60, 533-535.

35.

Hiss, J. , & Kahana, T. (1995). The medicolegal implications of bilateral cranial fractures in infants. Journal of Trauma, Injury, Infection and Critical Care, 38, 32-34.

36.

Holbourn, A.H.S. (1943). Mechanics of head injuries. Lancet, 2, 438-441.

37.

Hymel, K. P. , Abshire, T. C. , Luckey, D. W. , & Jenny, C. (1997). Coagulopathy in pediatric abusive head trauma. Pediatrics, 99, 371-375.

38.

Hymel, K. P. , Rumack, C. M. , Hay, T. C. , Strain, J. D. , & Jenny, C. (1997). Comparison of intracranial computed tomographic (CT) findings in pediatric abusive and accidental head trauma. Pediatric Radiology, 27, 743-747.

39.

Johnson, D. L. , Boal, D. , & Baule, R. (1995). Role of apnea in nonaccidental head injury. Pediatric Neurosurgery, 23, 305-310.

40.

Landman, P. F. , & Landman, G. B. (1987). Accidental injuries in day care centers. American Journal of Diseases of Children, 141, 292-293.

41.

Leland, N. L. , Garrard, J. , & Smith, D. K. (1993). Injuries to preschool-age children in day care centers. American Journal of Diseases of Children, 147, 826-831.

42.

Lindenberg, R. , Fisher, R. S. , Durlacher, S. H. , Lovitt, V. W. , & Freytag, E. (1955). Lesions of the corpus callosum following blunt mechanical trauma to the head. American Journal of Pathology, 31, 259-317.

43.

Lindenberg, R. , & Freytag, E. (1969). Morphology of brain lesions from blunt trauma in early infancy. Archives of Pathology, 87, 298-305.

44.

Lyons, T. J. , & Oates, R. K. (1993). Falling out of bed, a relatively benign occurrence. Pediatrics, 92, 125-127.

45.

Merten, D. F. , & Carpenter, B.L.M. (1990). Radiologic imaging of abusive injury in the child abuse syndrome. Pediatric Clinics of North America, 37, 815-837.

46.

Merten, D. F. , Osborne, D.R.S. , Radowski, M. A. , & Leonidas, J. C. (1984). Craniocerebral trauma in the child abuse syndrome: Radiological observation. Pediatric Radiology, 14, 272-277.

47.

Mitchell, D. E. , & Adams, J. H. (1973). Primary focal impact damage to the brain stem in blunt head injuries—Does it exist? Lancet, 2, 215-218.

48.

Mittl, R. L. , Grossman, R. I. , Hiehle, J. F. , Hurst, R. W. , Kauder, D. R. , Gennarelli, T. A. , and Alburger, G. W. (1994). Prevalence of MR evidence of diffuse axonal injury in patients with mild head injury and normal CT findings. American Journal of Neuroradiology, 15, 1583-1589.

49.

Musemeche, C. A. , Barthel, M. , Cosentino, C. , & Reynolds, M. (1991). Pediatric falls from heights. Journal of Trauma, Injury, Infection and Critical Care, 31, 1347-1349.

50.

Naumenko, J. , & Feigin, I. (1967). A stable silver solution for axon staining in paraffin sections. Journal of Neuropathology and Experimental Neurology, 26, 669-673.

51.

Nimityongskul, P. , & Anderson, L. (1987). The likelihood of injuries when children fall out of bed. Journal of Pediatric Orthopaedics, 7, 184-186.

52.

Ommaya, A. K. (1996). Head injury mechanisms and the concept of preventive management: A review and critical synthesis. In F. A. Bandak , R. H. Eppinger , & A. K. Ommaya (Eds.), Traumatic brain injury bioscience and mechanics (pp. 19-38). Larchmont, NY: Mary Ann Liebert.

53.

Ommaya, A. K. , Faas, F. , & Yarnell, P. (1968). Whiplash injury and brain damage. Journal of the American Medical Association, 204, 285-289.

54.

Ommaya, A. K. , & Gennarelli, T. A. (1974). Cerebral concussion and traumatic unconsciousness. Brain, 97, 633-654.

55.

Ommaya, A. K. , Grubb, R. L. , & Nauman, R. A. (1971). Coup and contre-coup injury: Observations on the mechanics of visible brain injuries in Rhesus monkey. Journal of Neurosurgery, 35, 503-516.

56.

Ommaya, A. K. , & Hirsch, A. E. (1971). Tolerance for cerebral concussion from head impacts and whiplash in primates. Journal of Biomechanics, 4, 13-22.

57.

Ommaya, A. K. , Thibault, L. , & Bandak, F. A. (1994). Mechanisms of impact head injury. International Journal of Impact Engineering, 15, 535-560.

58.

Ommaya, A. K. , Thibault, L. E. , Boock, R. I. , & Meany, D. F. (1994). Head injured patients who talk before deterioration and death: The TADD syndrome. In E. F. Hoerner (Ed.), Proceedings of the ASTM, International Symposium on Head and Neck Injuries in Sports, May, 1993. Philadelphia: American Society for Testing and Materials.

59.

Rivara, F. P. , DiGuiseppi, C. , Thompson, R. S. , & Calonge, N. (1989). Risk of injury to children less than 5 years of age in day care versus home settings. Pediatrics, 84, 1011-1016.

60.

Russell, W. R. , & Schiller, F. (1949). Crushing injuries to the skull: Clinical and experimental observations. Journal of Neurology, Neurosurgery and Psychiatry, 12, 52-60.

61.

Sacks, J. J. , Smith, J. D. , Kaplan, K. M. , Lambert, D. A. , Sattin, R. W. , & Sikes, R. K. (1989). The epidemiology of injuries in Atlanta day-care centers. Journal of the American Medical Association, 262, 1651-1655.

62.

Sato, Y. , Yuh, W.T.C. , Smith, W. L. , Alexander, R. C. , Kao, S.C.S. , & Ellerbroek, C.J. (1989). Head injury in child abuse: Evaluation with MR imaging. Radiology, 173, 653-657.

63.

Shugerman, R. P. , Paez, A. , Grossman, D. C. , Feldman, K. W. , & Grady, M. S. (1996). Epidural hemorrhage: Is it abuse? Pediatrics, 97, 664-668.

64.

Strich, S. J. (1956). Diffuse degeneration of the cerebral white matter in severe dementia following head injury. Journal of Neurology, Neurosurgery and Psychiatry, 19, 163-185.

65.

Strich, S. J. (1961). Shearing of nerve fibres as a cause of brain damage due to head injury. Lancet, 2, 443-448.

66.

Symonds, C. (1962). Concussion and its sequelae. Lancet, 1, 1-5.

67.

Tsai, F. Y. , Zee, C. S. , Apthorp, J. S. , & Dixon, G. H. (1980). Computed tomography in child abuse head trauma. Journal of Computed Tomography, 4, 277-286.

68.

Vowles, G. H. , Scholtz, C. L. , & Cameron, J. M. (1987). Diffuse axonal injury in early infancy. Journal of Clinical Pathology, 40, 185-189.

69.

Wilberger, J. E. , Rothfus, W. E. , Tabas, J. , Goldberg, A. L. , & Deeb, Z. L. (1990). Acute tissue tear hemorrhages of the brain: Computed tomography and clinical pathological correlations. Neurosurgery, 27, 208-213.

70.

Williams, R. A. (1991). Injuries in infants and small children resulting from witnessed and corroborated free falls. Journal of Trauma, Injury, Infection and Critical Care, 31, 1350-1352.

71.

Zauner, A. , & Bullock, R. (1996). The role of excitatory amino acids in severe brain trauma: Opportunities for therapy: A review. In F. A. Bandak , R. H. Eppinger , & A. K. Ommaya (Eds.), Traumatic brain injury bioscience and mechanics (pp. 97-104). Larchmont, NY: Mary Ann Liebert.

72.

Zimmerman, R. A. , Bilaniuk, L. T. , & Gennarelli, T. A. (1978). Computed tomography of shearing injuries of the cerebral white matter. Radiology, 127, 393-396.