A 5-month-old girl is brought to your facility for decreased level of consciousness. According to the parents, the infant reportedly fell out of her car seat earlier this morning.
Prenatal history is unremarkable; immunizations are up to date. Initial examination shows a lethargic female infant with vital signs as follows: temperature, 99.7°F; blood pressure, 91/65 mm Hg; heart rate; 180 beats/min; and initial O2 saturation, 86% on room air. Supplemental oxygen and an IV fluid bolus are given, which correct the hypoxia and tachycardia.
Physical exam shows a depressed anterior fontanelle and bilateral periorbital ecchymosis, as well as multiple bruises of varying ages on the face and body. An old scar on the left side of the forehead is noted as well. While still somewhat lethargic, the infant does move all extremities to painful stimuli. A weak cry is present.
Initial radiographs of the chest and skull are obtained; the one of the skull is shown. What is your impression?
ANSWER
The plain film demonstrates bilateral parietal skull fractures, more evident on the left than right side. Subsequent noncontrast CT of the skull confirmed these fractures, and also showed bilateral subdural hematomas.
Such findings, both clinically and radiographically, are highly worrisome and suggestive of nonaccidental injury (ie, abuse). This unfortunate infant was placed immediately under the care of the Department of Family and Children Services and moved to the pediatric ICU for close monitoring.
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