Non-Accidental Head Injury With Particular Reference to Whiplash Shaking Injury and Medico-legal Aspects

Citation:

Brown JK, Minns RA: Non-accidental head injury with particular reference to whiplash shaking injury and medico-legal aspects. Dev Med Child Neurology 35:849-869, 1993.

Notes:

• "One should never venture an opinion as to who did the injuries on the evidence of their type and pattern." (p. 849)
• The number of new cases has not decreased with increased awareness of the public.
• Infants often present as generally unwell, irritable or too quiet, refusing food, vomiting, having seizures, apnea. The infant may have low blood pressure or hypothermia.
• Vitamin K deficiency can predispose children to this pattern of injury.
• O'Hare and Eden found coagulation abnormalities in 10 of 50 children with bruising thought to be a result of abuse. These included inhibitors to coagulation in the plasma, von Willebrand's disease and platelet aggregation disorders.
• Depressed, branching, and growing fractures suggest abuse.
• Osteogenesis imperfecta, a condition causing bones to break easily, may coexist with coagulation difficulties.
• Other metabolic bone diseases may mimic abuse.
• Whiplash shaking injuries are rare after the second year of life.
• Grey and white matter in the brain are of different densities, so they swirl at different speeds.
• Cerebral edema (swelling) is often severe and is thought to take about six hours to appear after injury.
• "Retinal hemorrhage alone can be a result of accidental injury, resuscitation or possibly prolonged fits, but when combined with subdural hemorrhage, cerebral edema and fractured ribs, the syndrome becomes reliable as a pointer to non-accidental injury." (p. 860)
• Retinal hemorrhages may resolve within days, but may occasionally take weeks. Dating of the injury may be difficult.
• A subdural hemorrhage is called acute if it is apparent within three days of injury. Those during the first two years of life are usually acute, the result of child abuse.
• "Rotation of the brain, causing shearing of bridging veins, is the causal mechanism in most shaking injuries." (p. 862)
• Concerning timing, often lawyers push doctors for a degree of accuracy that is not possible. The article contains some guidelines for determining time.
• The parents should be interviewed separately and all inconsistencies, alterations or disagreements must be documented.
• Child protection registers should be searched for any previous injury to the child or siblings.