Child Abuse & Neglect 27 (2003) 1323–1329

Brief Communication

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

Anselm C.W. Leea,∗, Yvonne Oua, Dawson Fongb

aDepartment of Pediatrics, Tuen Mun Hospital, New Territories, Hong KongbDepartment of Neurosurgery, Tuen Mun Hospital, New Territories, Hong Kong

Received 10 December 2002; received in revised form 3 May 2003; accepted 18 May 2003

Abstract

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 carriedout. 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 wasattacked 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, intracranialbleeding, and brain contusion. Two brothers from a second family were attacked from behind with ahammer by their biological father, who was subsequently found to have undiagnosed schizophrenia. Adepressed occipital fracture, without intracranial injury, was found in each child. The elder brother alsohad metacarpal fractures. Both children recovered without surgical intervention.Conclusion: A pattern of abusive head injury was described in older children with depressed skullfractures from blunt injury. The abusing parents were seriously mentally disturbed, and the abusive actsclosely resembled child homicide.© 2003 Elsevier Ltd. All rights reserved.

Keywords: Hammer; Head injury; Homicide; Physical abuse; Skull fracture

Introduction

Head injury is the leading cause of death in child abuse, especially in young children (Levitt,Smith, & Alexander, 1994). In young infants and toddlers, shaking with or without impactresults in severe brain injury with acute subdural hemorrhage, cerebral hypoxia and diffuse

∗ Corresponding author.

0145-2134/$ – see front matter © 2003 Elsevier Ltd. All rights reserved.doi:10.1016/j.chiabu.2003.05.002

1324 A.C.W. Lee et al. / Child Abuse & Neglect 27 (2003) 1323–1329

axonal injury (Duhaime, Christian, Rorke, & Zimmerman, 1998). The condition is calledshaken-impact syndrome and occurs globally including Hong Kong (Lee, So, Fong, & Luk,1999). Severe abusive head injury in the older child is much less frequent, and no specificpattern has been described. We report three cases from two families, involving similar injuriesand scenarios.

Methods

Tuen Mun Hospital provides general and emergency medical services, including pediatricintensive care and neurosurgery, to a population of 800,000. All attending children suspectedto be victims of child abuse or neglect are referred to either one of the two authors (ACWLand YO) for further evaluation and notification. A retrospective chart review was carried outlooking at abused children who were hospitalized between 1999 and 2001 with the finding ofskull fracture and/or intracranial hemorrhage. The clinical features, circumstances about theabusive incident, social background, management and outcome of these cases are described.Children with shaken-impact syndrome are excluded.

Results

From the 293 cases of suspected child abuse and neglect evaluated over the 3-year period,there were 7 children suffering from severe head injury. Four cases under the age of 2 wereexcluded, of which one has been reported (Lee, Hau, & Fong, 2001), because of a diagnosisof shaken-impact syndrome. Three children, an 11-year-old girl and two brothers at ages 7and 9 years, were included. Their clinical features, the abusive incidents, and subsequentmanagement are described below.

Case 1

An 11-year-old girl was admitted to the hospital unconscious. She came from a single-parentfamily. Her father had a second marriage in mainland China, and he wanted to bring the girl’sstepmother and two half-siblings to Hong Kong for permanent residence. On visiting visas,the stepmother and the younger children came to live with the patient. However, the patientcould not tolerate the changes. She started complaining to her father and rejected the newfamily members. On the day of admission, a quarrel broke out during dinner among them. Thechild’s father then suggested that the stepmother move out and he went to his wife’s relativesto discuss this. While the father was out, the stepmother sent her own children to a neighbor.She returned home with a hammer and hit the patient while she was asleep. She then jumpedfrom the 10th floor of the building to her death. The patient was admitted to the hospital incoma. Multiple bruises and lacerations were found in the head and neck regions, over the upperchest, and the right shoulder.

Computed tomography (CT) showed multiple and bilateral depressed fractures over thefrontal, temporal and parietal bones (Figure 1). An emergency right craniotomy was performedwith evacuation of a subdural hematoma and placement of intracranial pressure monitor. With

A.C.W. Lee et al. / Child Abuse & Neglect 27 (2003) 1323–1329 1325

Figure 1. CT of head in the 11-year-old girl showing multiple and bilateral depressed fracture of the skull bones( ) and an acute subdural hematoma at the right temporal region ().

ventilatory and inotropic support, and vigorous measures of controlling the raised intracranialpressure, the patient’s condition gradually improved. She received intensive psychosocialrehabilitation and speech therapy for post-intubation vocal cord dysfunction in the next 2months. Her neurological recovery was remarkable. She remained well with no appreciableneurological deficit or epilepsy.

Cases 2 and 3

A pair of brothers, ages 9 and 7 years, were admitted after their father hit them witha hammer. Four months previously, their father lost his job, and their mother had to workpart-time to support the family. Before that, the children’s father had been switching from onejob to another because he could not get along with his colleagues. Since his unemployment,he became suspicious and paranoid—he thought someone was going to harm him, and hethought that he was not the biological parent of his children. Their mother felt helpless, buttheir father sought no medical attention. On the day of admission while the children’s motherwas preparing dinner, their father suddenly took a hammer and hit them on their heads. Their

1326 A.C.W. Lee et al. / Child Abuse & Neglect 27 (2003) 1323–1329

Figure 2. CT of head (bone window) in the 9-year-old boy showing a depressed fracture () over the right occipitalbone.

father was subsequently arrested by the police, and the children were admitted to the hospital. Ascalp laceration with surrounding hematoma over the right occipital region was noted on eachof the children’s heads. They remained fully conscious, and no abnormal neurological featureswere noted. Depressed occipital fractures corresponding to the site of the laceration were seenon CT (Figure 2) in both children. No extra-axial collection or intracerebral abnormality wasseen. The elder brother also sustained fractures of the second and third metacarpals of the righthand when he tried to defend himself from further hitting. No neurosurgical intervention wasneeded. They were subsequently discharged to their mother’s custody with follow-up by thechild protection service. Their father was eventually diagnosed as having schizophrenia andwas sentenced to receive treatment in a mental health institution.

Discussion

Inflicted head injury in children usually affects the young infant or toddler and is com-monly referred to as the shaken-impact syndrome (Duhaime et al., 1998). Rapid acceleration–deceleration forces are believed to be the underlying mechanical factor which produces the

A.C.W. Lee et al. / Child Abuse & Neglect 27 (2003) 1323–1329 1327

Table 1Comparison of the two incidents of depressed fractures

Case 1 Cases 2 and 3

Day/time of incident Saturday evening Saturday eveningLocation Home HomeWeapon Hammer HammerWarning No No

Child attacked while asleep Children attacked from behindBlunt of injury Head HeadRelationship of perpetrator to victim(s) Stepmother FatherMental illness in perpetrator Probable depression Undiagnosed schizophrenia

Suicide following attackConflict between perpetrator and victim(s) Perpetrator felt rejected from

the family unionPerpetrator suspected thechildren were not his ownbiological offsprings

characteristic constellation of acute subdural hematoma, retinal hemorrhages and axonal dam-age. The case mortality rate is high, and survivors are frequently left with serious neurode-velopmental handicaps. Why the affected infants were shaken is less well understood, butconfessions from some perpetrators indicate that the shaking was initiated in a state of rage tostop the infants’ incessant crying. The perpetrators’ intent to produce serious harm may notbe apparent at the time of shaking.

Serious non-accidental head injury in the older child has received little attention in themedical literature. If a skull fracture is taken as a marker of severe head injury, its occurrenceis not uncommon in abused children with skeletal injuries. It occurred in 1% of childrenevaluated for child abuse and neglect in our hospital. Among battered children presenting withskeletal injuries, as many as 19% (36 out of 189) were found to have skull fractures (King,Diefendrof, Apthorp, Negrete, & Carlson, 1988). To date, no specific pattern of head injuryhas been described in the older pediatric age group.

Examination of the two incidents of depressed fractures in this report reveals remarkablesimilarities (Table 1) that distinguish them from an ordinary case of child abuse involvingchild discipline. On both occasions, a hammer was used for the attack. A search in the med-ical literature failed to identify any case in which a hammer was used as an abusive in-strument, suggesting that children are extremely unlikely to be injured non-accidentally inthis manner. However, an autobiographic account of Munchausen syndrome by proxy hasbeen reported in which the victim had been repeatedly hit with a hammer over her legs toproduce cellulitis as one form of fabricated illnesses among other injuries (Bryk & Siegel,1997).

The circumstances of these cases closely resemble other reports of assaults that ended inthe death of the child victims. The presence of psychiatric illnesses is a common featureamong parents who have killed their children (Cheung, 1986; Lucas et al., 2002). Althoughthe perpetrator from Case 1 had not been evaluated, experience from cases of combinedhomicide-suicide either locally (Lee, Ou, Lam, So, & Kam, 2002) or elsewhere (Felthous& Hempel, 1995) suggests that she was probably suffering from a depressive disorder. The

1328 A.C.W. Lee et al. / Child Abuse & Neglect 27 (2003) 1323–1329

victims were not aware or warned of the attack, which is again typical in child homicidecases (Stanton, Simpson, & Wouldes, 2000). Similarly, the victims’ head and cranium borethe blunt of injuries (Pollanen, Smith, Chiasson, Cairns, & Young, 2002; Vanamo, Kauppi,Karkola, Merikanto, & Rasanen, 2001) as exemplified in these cases. In both families, theperpetrators’ motives of attack might have been hinted by a sense of hatred that had been builtup towards the child victims prior to the incidents. The fact that both incidents occurred onSaturday evenings was intriguing. With a 6-day working week for most people in Hong Kong,Saturday was supposed to be the time when one did not have to worry about work the nextday. Child homicide cases have been reported to occur more frequently on weekends (Lucaset al., 2002), especially during the early morning and evening hours (Schmidt, Grab, & Madea,1996).

The case reports presented are, therefore, suggestive of a pattern of abusive head injury inthe older children. They are near-miss cases of child homicide and may provide a link to theunderstanding of why older children are killed by their parents.

References

Bryk, M., & Siegel, P. T. (1997). My mother caused my illness: The story of a survivor of Munchausen by proxysyndrome.Pediatrics, 100, 1–7.

Cheung, P. T. K. (1986). Maternal filicide in Hong Kong, 1971–1985.Medicine, Science & The Law, 26, 185–192.Duhaime, A. C., Christian, C. W., Rorke, L. B., & Zimmerman, R. A. (1998). Nonaccidental head injury in

infants—the “shaken-baby syndrome.”New England Journal of Medicine, 338, 1822–1829.Felthous, A. R., & Hempel, A. (1995). Combined homicide-suicides: A review.Journal of Forensic Sciences, 40,

846–857.King, J., Diefendorf, D., Apthorp, J., Negrete, V. F., & Carlson, M. (1988). Analysis of 429 fractures in 189 battered

children.Journal of Pediatric Orthopedics, 8, 585–589.Lee, A. C. W., Hau, K. L., & Fong, D. (2001). CT finding in hyperacute non-accidental brain injury.Pediatric

Radiology, 31, 673–674.Lee, A. C. W., Ou, Y., Lam, S. Y., So, K. T., & Kam, C. W. (2002). Non-accidental carbon monoxide poisoning from

burning charcoal in attempted combine homicide-suicide.Journal of Paediatrics & Child Health, 38, 465–468.Lee, A. C. W., So, K. T., Fong, D., & Luk, S. H. (1999). The shaken baby syndrome: Review of 10 cases.Hong

Kong Medical Journal, 5, 337–341.Levitt, C., Smith, W. L., & Alexander, R. C. (1994). Abusive head trauma. In R. M. Reece (Ed.),Child abuse:

Medical diagnosis and management (pp. 1–22). Philadelphia, PA: Lea & Febiger.Lucas, D. R., Wezner, K. C., Milner, J. S., McCanne, T. R., Harris, I. N., Monroe-Posey, C., & Nelson, J. P. (2002).

Victim, perpetrator, family, and incident characteristics of infant and child homicide in the United States AirForce.Child Abuse & Neglect, 26, 167–186.

Pollanen, M. S., Smith, C. R., Chiasson, D. A., Cairns, J. T., & Young, J. (2002). Fatal child abuse-maltreatmentsyndrome: A retrospective study in Ontario, Canada, 1990–1995.Forensic Science International, 126, 101–104.

Schmidt, P., Grab, H., & Madea, B. (1996). Child homicide in Cologne (1985–94).Forensic Science International,79, 131–144.

Stanton, J., Simpson, A., & Wouldes, T. (2000). A qualitative study of filicide by mentally ill mothers.Child Abuse& Neglect, 24, 1451–1460.

Vanamo, T., Kauppi, A., Karkola, K., Merikanto, J., & Rasanen, E. (2001). Intra-familial child homicide in Finland1970–1994: Incidence, causes of death and demographic characteristics.Forensic Science International, 117,199–204.

A.C.W. Lee et al. / Child Abuse & Neglect 27 (2003) 1323–1329 1329

Résumé

Objectif: Décrire un pattern de blessures à la tete chez des enfants de plus de 4 ans.Méthode: On a passé en revue les dossiers hospitaliers d’enfants ayant subi des fractures du crane entre1999 et 2001. Les caractéristiques cliniques, la situation sociale, les mesures prises et les résultats fontl’objet de l’article.Résultats: Une fillette de 11 ans et deux frèresagés de 7 et 9 ans ont été identifiés. La fillette a étéattaquée par sa belle-mère avec un marteau pendant qu’elle dormait, après quoi la belle-mère s’estsuicidée peu de temps après. La fillette a survécu à ses blessures multiples, y compris des saignementsinter-craniens et des contusions cérébrales. Les deux frères appartenant à une autre famille ont étéagressés par leur père naturel qui les a frappés avec un marteau derrière la tete. On a ensuite découvertqu’il souffrait de schizophrénie qu’on n’avait jamais diagnostiquée. On a noté une fracture occipitalesans blessure inter-cranienne chez chacun des deux frères. L’aıné des deux souffrait de fractures dumétacarpe. Les deux frères on guéri sans intervention chirurgicale.Conclusion: On a décrit un pattern de blessures à la tete dans une population d’enfants ayant subides fractures du crane. Les parents maltraitants étaient de sérieux malades mentaux et les agressionss’apparentaient à l’homicide infantile.

Resumen

Objetivo: Describir un patrón de daño cerebral provocado por maltrato infantil en una serie de niños/asmayores de cuatro años de edad.Método: Se llevó a cabo una revisión de los archivos hospitalarios de todos los niños maltratados confracturas de cráneo ocurridos entre el año 1999 y el año 2001. Se describen los datos clınicos, la historiasocial y las consecuencias posteriores.Resultados: Se identificaron los casos de una niña de 11 años y de dos hermanos de 7 y 9años. La niñahabıa sido atacada por su madrastra (que posteriormente se suicidó) con un martillo mientras estabadormida. Después de practicar una craneotomıa y estar en cuidados intensivos, la niña sobrevivió a susmúltiples fracturas, hemorragia intracraneal y contusión cerebral. Los dos hermanos fueron atacadoscon un martillo por su padre biológico, a quien posteriormente se le diagnosticó de esquizofrenia. Encada uno de los niños se observó una fractura en la zona occipital sin daño intracraneal. El niño másmayor también tuvo fracturas en el metacarpo. Ambos niños se recuperaron sin intervención quirúrgica.Conclusión: Se describe un patrón de lesiones en la cabeza provocadas por maltrato fısico en niñosmayores con fracturas de cráneo. Los padres maltratadores presentaban graves trastornos mentales ylos actos de maltrato estaban muy cercanos al homicidio infantil.