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Non Accidental Head Injury Cases (NAHI, formerly referred to as Shaken Baby Syndrome [SBS]) - Prosecution Approach

Published: 6 January 2011

Annex E: Short distance falls

  • Short distance falls in infants and young children may rarely be accompanied by skull fracture, but in the vast majority such fractures are not accompanied by intracranial injuries. The fractures are generally simple and linear with unseparated edges. They are not depressed and are confined to one bone (usually a parietal bone) and do not cross suture lines.
  • Injuries accompanying such falls are usually trivial and only in very exceptional cases are they life threatening or fatal. When serious injury does occur, the short fall may not be simple, but involve some accelerated or rotational component, for example a fall from playground equipment such as a roundabout.
  • Serious head injuries with an intracranial component arising from short falls may involve injury to a large venous channel causing a subdural collection of blood (haematoma). Such haematomas are space-occupying lesions within the confines of the skull. They are unilateral and cause pressure on the brain (increased intracranial pressure) that, if unrelieved, may result in unconsciousness and death.
  • Space occupying lesions in these circumstances are to be distinguished from the subdural haemorrhages of inflicted, rotational / acceleration head injuries. They are unilateral, focal and space occupying rather than bilateral, multifocal and thin layered. Brain damage is secondary to increased intracranial pressure rather than forming an integral part of the head injury.
  • Even in the very rare instances of intracranial injury accompanying short falls, retinal haemorrhages are often absent and when present, are usually the result of increased intracranial pressure and generally have different characteristics to haemorrhages in inflicted injury.
  • Clinical differences are as follows:
  1. Short distance accidental falls usually occur in children old enough to be independently mobile, whereas inflicted injuries are commoner under the age of one year.
  2. Accidental falls are often independently witnessed; inflicted injuries usually occur in the presence of only the alleged perpetrator.
  3. After accidents carers call for medical attention without delay and provide a plausible explanation. Reporting inflicted injury is often delayed; the history is unconvincing and frequently changes.
  4. Apparently inflicted injuries to parts of the body other than the head are not a feature of short distance accidental falls but occur in over half the cases with inflicted head injuries.
  5. Space occupying lesions can be accompanied by lucid intervals whereas subdural haemorrhages are far less likely to be.
  6. Because the subdural bleeding in the very rare short falls complicated by serious intracranial pathology is space-occupying, craniotomy to remove the blood and release intracranial pressure is often required. In inflicted head injury subdural bleeding is of too small a volume to require craniotomy; increase intracranial pressure in these cases is due to brain swelling as a result of hypoxic-ischaemic brain injury.

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