15564029, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/1556-4029.15168 by INASP/HINARI - INDONESIA, Wiley Online Library on [13/11/2022].

See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
| |
Received: 5 August 2022    Revised: 4 October 2022    Accepted: 24 October 2022

DOI: 10.1111/1556-4029.15168

CASE REPORT
A n t h r o p o l o g y ; P a t h o l o g y/B i o l o g y

An unusual blunt force trauma pattern and mechanism to the

cranial vault: Investigation of an atypical infant homicide

Carolyn V. Isaac PhD1 | Jered B. Cornelison PhD2 | Clara J. Devota BS1 |

Brandy L. Shattuck MD3 | Rudolph J. Castellani MD4

1
Department of Anthropology, Michigan
State University, East Lansing, Michigan, Abstract
USA
This case report presents an unusual fracture pattern in the cranium of a four-­month-­
2
Department of Pathology, Western
Michigan University Homer Stryker M.D.
old infant indicative of child abuse. Upon postmortem examination, the infant pre-
School of Medicine, Kalamazoo, Michigan, sented with numerous bilateral linear cranial fractures running perpendicular to
USA
3
the sagittal suture with depressed and curvilinear fractures apparent on the supra-­
BLS Forensic Pathology, New York,
Syracuse, USA auricular surfaces of the cranium. Histological evidence indicates multiple traumatic
4
Department of Pathology, Northwestern events to the cranium. In addition, the stair-­step pattern of a parietal fracture may
University, Feinberg School of Medicine,
represent multiple contiguous fractures from repeated loading of the head at differ-
Chicago, Illinois, USA
ent times with variation of the focal points of compressive force. Additionally, the left
Correspondence
humerus, left radius, and left ulna have healing metaphyseal fractures, and the left
Carolyn V. Isaac, Department of
Anthropology, Michigan State University, ulna also has an antemortem diaphyseal fracture which resulted in the distal meta-
655 Auditorium Road, East Lansing, MI
physis being rotated 45 degrees medially. Integration of autopsy, anthropological, and
48824, USA.
Email: cvisaac@msu.edu neuropathological reports for this case suggest multiple inflicted injury episodes with
a repeated atypical mechanism(s) to the cranial vault of the infant. During investiga-
Funding information
National Institute of Justice, Grant/Award tive interviews, the caretaker admitted to squeezing the infant's head and neck on
Number: 2017-­DN-­BX-­0166
multiple occasions to quiet the child. This reported abusive mechanism is consistent
with the pattern of symmetric cranial fractures and soft tissue injuries indicating as-
phyxiation. This case report provides forensic investigators with a potential trauma
mechanism to explore in cases when a similar pattern of cranial trauma is observed
and highlights the need for greater research on fracture propagation and fracture
healing in the infant cranium.

KEYWORDS
abusive head trauma, asphyxiation, child abuse, classic metaphyseal lesions, forensic
anthropology, forensic pathology, inflicted injury, metaphyseal fractures, non-­accidental injury,
skull fracture

Highlights
• Multiple cranial and postcranial, including metaphyseal, fractures indicative of abuse.
• Gross and histological analyses revealed multiple stages of cranial fracture healing.

Presented at the American Academy of Forensic Sciences 68th Annual Meeting, February 22–­27, 2016, in Las Vegas, NV.

This is an open access article under the terms of the Creative Commons Attribution-­NonCommercial-­NoDerivs License, which permits use and distribution in
any medium, provided the original work is properly cited, the use is non-­commercial and no modifications or adaptations are made.
© 2022 The Authors. Journal of Forensic Sciences published by Wiley Periodicals LLC on behalf of American Academy of Forensic Sciences.

J Forensic Sci. 2022;00:1–12.  |

wileyonlinelibrary.com/journal/jfo     1
 |
2      ISAAC et al.
• Perpetrator admits to manually compressing the infant's head and neck on multiple occasions.
• Bilateral cranial fractures perpendicular to the sagittal suture are consistent with compression.
• Stair-­step pattern of parietal fracture may indicate multiple contiguous fractures from differ-
ent traumatic events.
1  |  I NTRO D U C TI O N
Differentiating accidental from inflicted injury is a principal element
of medico-­legal death investigations in cases of infant mortality and
suspected child abuse. Non-­ambulatory infants with unexplained
fracture(s) upon postmortem examination often prompt suspicions
of inflicted injury. Fractures in these cases require a differential diag-
nosis between child abuse, accidental injury, birth trauma, and natu-
ral disease. Determination of abuse rarely hinges upon the presence
of a single fracture or fracture type, rather, in cases of suspected
inflicted injury, forensic investigators must consider contextual in-
formation to understand the proximate cause.
Clinical literature provides guidelines for evaluating suspected
cases of child abuse including assessing the developmental stage
of the child, the full scope of injuries, their severity, relative de-
grees of healing, and medical history including the reported mech-
anism of injury [1–­3]. Suspicions for child maltreatment are raised
if the child is a preambulatory infant with any injury, there are
injuries to multiple organ systems, different stages of healing are
present, patterned injuries are observed, there are injuries to un-
usual locations like the torso, ears, face, neck or upper arm, there
are unexplained serious injuries, or there is evidence of neglect [1,
2]. Additionally, if no explanation or only a vague explanation of
the cause of the injury is provided, a history which is implausible
for the child's physical or developmental stage, a delay in seeking
medical care, inconsistencies in caretaker or witness accounts of
the injury event, or an explanation that is inconsistent with the
pattern, severity, or age of the injury could also be indicators of
child abuse [1, 2].
An important part of the investigation is determining whether
the caretaker's explanation of the traumatic event is consistent
with the injuries observed. This requires an evaluation of the frac-
ture pattern to estimate the trauma mechanism or the correlation
of the fracture pattern with a known injury mechanism. The injury
context and fracture pattern interpretation are especially important
for cranial fractures as they are common injuries in children for both
accidental and non-­accidental circumstances and have a lower speci-
ficity for abuse than other injuries, such as rib fractures and metaph-
yseal fractures [1, 4–­7]. The percentage of pediatric cranial fractures
attributed to abuse is relatively low compared to cranial fractures
resulting from accidental injury [1, 7–­9]. However, the association
between a cranial fracture and abuse dramatically increases in in-
fants and young children. According to clinical studies, approxi-
mately one in three infants and toddlers with cranial fractures are
victims of inflicted injury [10–­12]. These studies largely reflect pat-
terns of abusive cranial trauma in living children. The frequency of
cranial fractures in cases where the child died due to abusive activity
15564029, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/1556-4029.15168 by INASP/HINARI - INDONESIA, Wiley Online Library on [13/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
remains unknown; however, it is estimated that abusive head trauma
in children less than a year old has an annual incidence of 33 to 38
cases per 100,000 children and nearly 25% of those cases result in
death [13, 14]. Several studies have found that the presence of mul-
tiple cranial fractures and variable degrees of healing is more sug-
gestive of abuse [4, 8, 10, 12, 15], rather than the complexity of the
fracture as was previously thought [6, 16].
Understanding fracture patterns in forensic cases is difficult as
few controlled studies of cranial impacts have been completed for
human skeletal material. While there are some experimental studies
on fracture initiation and propagation in the human cranium [17–­
26], few address the structural or biomechanical differences of the
developing infant head [27, 28] while others have utilized immature
porcine models as a proxy for the infant cranium [29–­33]. These
studies have demonstrated significant differences in the biome-
chanical properties of infant bone and sutures compared to adults
[27, 28] and have shown that the age of the child [29, 30], impact
energy [30], impact surface [29, 30, 32, 34, 35], head entrapment
[31], and impact shape [33] all influence the degree and pattern of
fracturing. To supplement the limited number of controlled experi-
ments, retrospective clinical studies and case reports are often used
to inform fracture pattern interpretation in subadult individuals.
Unfortunately, in cases of suspected abuse, the trauma mechanism
is often unknown or unsubstantiated [1, 2, 36, 37].
This report presents a case of an infant who died with acute
and remote injuries indicative of an abusive history, including evi-
dence of asphyxia, an unusual pattern of multiple cranial fractures,
and multiple metaphyseal and diaphyseal fractures of the left arm.
Subsequently, the perpetrator admitted to a trauma mechanism
which may explain the atypical cranial fracture pattern. The findings
of this case expand the spectrum of abusive head trauma mecha-
nisms in infants, provide a pattern of skeletal trauma indicative of
abuse potentially resulting from bilateral compression of the cra-
nium, and provide radiographic, gross, and histological evidence of
the fractures resulting from inflicted injury. Furthermore, this case
report highlights the need for further research into patterns of blunt
force trauma in the infant cranium and the development of methods
for fracture age estimation.
2  |  C A S E R E P O RT
A four-­month-­old male infant was found unresponsive in a crib in the
early morning by the infant's mother. The mother attempted cardio-
pulmonary resuscitation (CPR) and law enforcement were called to
the residence. Upon arrival, police continued CPR while the infant
was transported to the hospital where he subsequently died.

ISAAC et al.
2.1  |  Medical history
The infant was born vaginally at 33-­weeks gestational age with no
recorded complications or medical interventions associated with the
delivery. The child was hospitalized for prematurity. Both the infant
and the mother tested positive for tetrahydrocannabinol (THC) fol-
lowing birth and a caseworker with Child Protective Services (CPS)
was assigned to the family. A cranial ultrasound was performed
11 days after birth and was normal with no evidence for traumatic
brain injury or cranial fractures. The infant was released from the
hospital 25 days after birth and was under the care of his parents for
3 months until his death.
2.2  |  Autopsy findings
The postmortem radiographic skeletal survey revealed multiple
fractures to the neurocranium and radiographic evidence consist-
ent with metaphyseal fractures of the left humerus, ulna, and radius
(Figure 1). External examination of the remains indicated florid pete-
chial hemorrhage of the conjunctiva and face, most notable around
the right eye. Two blue-­purple contusions, measuring 1.2 and 0.8
centimeters, were observed on the left arm. According to World
Health Organization growth charts, the infant's body weight at the
time of postmortem examination was less than the 5th percentile,
the crown-­heel length was in the 10th percentile, and the head cir-
cumference was less than the 5th percentile for a 10-­week adjusted
age male.
Internal examination revealed hemorrhagic cerebrospinal fluid,
two areas of hemorrhage in the soft tissues of the left and right
fronto-­parietal regions of the scalp, and corresponding hemorrhages
in the soft-­tissues adherent to the skull underlying the scalp hem-
orrhages (Figure  2). Multiple cranial fractures extending from the
areas of soft tissue hemorrhage were also observed. Scant amounts
of subarachnoid hemorrhage were noted on the brain. The brain was
retained for neuropathological analysis. The skull cap and elements
of the left arm were resected and submitted for anthropological
analysis.
F I G U R E 1  Radiographic series
taken prior to postmortem examination
indicating (A) multiple fractures of the
cranial vault, (B) a metaphyseal fracture
of the left humerus (circled), and (C)
metaphyseal injuries of the left radius and
ulna (circled).
|
15564029, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/1556-4029.15168 by INASP/HINARI - INDONESIA, Wiley Online Library on [13/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
      3
2.3  |  Neuropathology findings
Consistent with the forensic pathology findings, neuropathological
analysis revealed focal subacute subarachnoid hemorrhages in the
right frontal parasagittal region and left inferior parietal lobule of the
brain, approximately 1 centimeter in diameter and less than 1 cen-
timeter in diameter, respectively. There were no other observed ab-
normalities, pathological conditions of the brain tissues, or retinal
hemorrhages.
2.4  |  Anthropological examination
The skull cap was radiographed (Figure  3) and photographed
(Figure  4A,D,G) prior to histological sampling and maceration, re-
vealing numerous fractures. Histological samples were resected
from three cranial fractures prior to processing (Figure 4B). The cal-
varium, left humerus, left radius, and left ulna were macerated in an
incubator over a two-­week period with manual removal of the soft
tissues.
The left parietal demonstrated a comminuted, slightly depressed
defect (Fracture 1) with four associated simple, linear, radiating frac-
tures (Fractures 2 through 5), all with rounded fracture margins and
extensive subperiosteal new bone formation (Figure  4D–­F ). The
majority of the Fracture 1 defect had no remaining fracture gap
and the inferior margin was nearly obliterated. While Fracture 2 ex-
tended between Fracture 1 and the anterior left parietal, Fractures
3 through 5 extended to the sagittal suture. Also evident in the left
parietal region was a curvilinear fracture (Fracture 6) and linear frac-
ture (Fracture 7) adjacent to the craniotomy cut (Figure 4D–­F ). Since
only the cranial vault was available for anthropological evaluation,
the extent, number, and location of terminal points of these frac-
tures could not be evaluated, but rounded fracture margins and sub-
periosteal new bone formation associated with Fracture 7 provided
evidence of healing.
The right parietal exhibited a simple fracture (Fracture 8) with
an unusual morphology, changing direction multiple times in a stair-­
step pattern that extended between the sagittal suture and the
 |
4      ISAAC et al.
F I G U R E 2  An image of the scalp reflected showing a soft tissue
hemorrhage (arrow) and skull fractures (arrowheads).
F I G U R E 3  Superior radiograph of the calvarium prior to
maceration showing fractures in the right and left parietals (anterior
is oriented at the top of the image).
craniotomy cut. Fracture 9, a complex linear fracture with branching
(Fracture 10) extended between the sagittal suture with its other
terminus in the right parietal. A simple, linear fracture (Fracture 11)
connected Fractures 8 and 9. Fracture 12 is a simple curvilinear
fracture which extends between Fracture 8 and the intersection of
the lambdoid suture and craniotomy cut (Figure 4G–­I). Fracture 13
is a simple, curvilinear fracture that extends between Fracture 12
and the lambdoid suture (Figure 4G–­I). The final cranial fracture ob-
served (Fracture 14) was a simple, linear fracture of the left lateral
15564029, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/1556-4029.15168 by INASP/HINARI - INDONESIA, Wiley Online Library on [13/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
occipital, extending between the lambdoid suture and the craniot-
omy cut (Figure 4D–­F ).
In total, 14 fractures were identified in the cranial vault. In the
left parietal, Fractures 2 through 5 all communicated with Fracture
1. Fractures 6 and 7 did not intersect with any other fractures in the
portion of the cranial vault that was evaluated. The right parietal
presented a complicated fracture pattern with all identified frac-
tures [8–­13] intersecting with at least one other fracture. Fracture
14 was the only fracture observed in the occipital. All fractures ex-
hibited evidence of healing indicating they occurred antemortem
and were consistent with blunt force trauma to the head. There was
no evidence of perimortem trauma. It is important to note that each
fracture does not represent an individual impact as multiple frac-
tures may have occurred from the same traumatic event.
The left arm exhibited multiple healing osseous injuries. A me-
taphyseal fracture was observed radiographically (Figure 5A,B) and
grossly (Figure 5C,D) in the proximal humerus extending along the
supero-­posterior and supero-­lateral metaphyseal margin and across
the physeal surface (Figure 5E). Subperiosteal new bone formation
was present along the margin. The metaphyseal fracture was largely
healed in the lateral aspect with no visible fracture line, while the
fracture line was visible posteriorly.
Healing trauma was also identified in both the left radius and
ulna. The left radius had subperiosteal new bone formation along
the shaft, proximally at the radial tuberosity and distally at the me-
taphysis (Figure 6). There was also a healing metaphyseal fracture
of the anterior distal metaphysis (Figure 6B,C) that extends to the
physeal surface of the metaphysis (Figure  6E). The left ulna ex-
hibited evidence of a healed fracture in the distal one-­third of the
diaphysis with the distal metaphysis rotated approximately 45 de-
grees medially relative to the proximal two-­thirds of the diaphysis
(Figure 7B,C). Due to extensive remodeling, the fracture type was
indeterminate, but the rotation of the distal ulnar metaphysis sug-
gests an oblique or spiral fracture. There was also a metaphyseal
fracture of the distal metaphysis of the ulna observed radiographi-
cally (Figure 7A) and grossly on the physeal surface (Figure 7E). The
metaphyseal fractures of the humerus, radius, and ulna, and the
fracture of the distal ulnar diaphysis suggest at least one traumatic
event to the left arm.
2.5  |  Histological examination
Three cranial fractures were excised for histological analysis prior
to maceration to further investigate differential levels of healing.
Fracture 4 grossly appeared to have rounded fracture margins and
subperiosteal new bone formation. When observed histologically
(Figure 8); however, the fracture gap was resolving on the ectocra-
nial and endocranial surfaces with bone formation and the gap was
infiltrated with fibrous connective tissue and areas of cartilage for-
mation. In addition, the healing fracture exhibited blurred fracture
margins, numerous new capillaries, and new woven bone formation
along and within the fracture gap.
 |

15564029, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/1556-4029.15168 by INASP/HINARI - INDONESIA, Wiley Online Library on [13/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ISAAC et al.       5

F I G U R E 4  Cranial fractures identified in the calvarium from the superior (A–­C), left lateral (D–­F ), and right lateral (G–­I) views. The first
photo in each orientation (A, D, and G) shows the skull cap after resection with some fractures visible. The second set of photos (B, E, and H)
are of the cranial vault following histologic sampling, maceration, and soft tissue removal and highlights the fractures, several with open
margins. Cranial vault diagrams (C, F, and I) show the 14 fractures identified and areas of histological sampling indicated by the gray-­shaded
rectangles.

F I G U R E 5  Radiographic and gross evidence of skeletal trauma of the left humerus. (A) Anterior–­posterior radiograph; (B) lateral
radiograph; (C) anterior view; (D) posterior view; and (E) detailed superior view of the physeal surface of the proximal humerus.
Arrows indicate the radiographic and grossly observed evidence of a healing metaphyseal fracture.
 |

15564029, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/1556-4029.15168 by INASP/HINARI - INDONESIA, Wiley Online Library on [13/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
6      ISAAC et al.

F I G U R E 6  Radiographic and gross evidence of skeletal trauma of the left radius. (A) Anterior–­posterior radiograph showing a region
of subperiosteal new bone formation along the lateral margin, indicated by the white arrowhead; (B) lateral radiograph showing a healing
metaphyseal fracture in the anterior distal aspect indicated by the white arrow; (C) anterior view demonstrating subperiosteal new bone
formation at the radial tuberosity and distal metaphysis indicated by black arrowheads; (D) posterior view demonstrating subperiosteal
new bone formation indicated by black arrowheads along the shaft; and (E) detailed inferior view of the distal physeal surface of the radius
showing the healing metaphyseal fracture.

F I G U R E 7  Radiographic and gross evidence of skeletal trauma of the left ulna. (A) Anterior–­posterior radiograph showing a healing
metaphyseal fracture of the anterior distal metaphysis indicated by white arrow; (B) anterior view showing the healing metaphyseal fracture
indicated by the arrowhead and medial rotation of distal shaft; (C) lateral view showing a healed fracture between the white arrowheads;
(D) articulated ulna and radius demonstrating the medial rotation of the distal ulna; and (E) detailed inferior view of the distal ulnar physeal
surface showing the healing metaphyseal fracture.

The unusual stair-­step fracture (Fracture 8) presented grossly
with a wide fracture gap, rounded margins, and profuse subperios-
teal new bone formation along the margins. Histological assessment
indicated minimal bone resorption, moderate fibrous connective tis-
sue that bridged the ectocranial fracture gap, and minimal new capil-
lary formation (Figure 9). The fracture margins were also misaligned,
with the right side displaced inferiorly.
Visual examination of Fracture 9 near the sagittal suture exhib-
ited rounded margins and a distinct fracture gap while the area sam-
pled, located inferiorly, presented less distinct evidence of healing.
Histologically the sample did not exhibit a marked tissue response
compared to the other histological samples. There was minimal fibrous
connective tissue within the fracture gap, minimal new capillaries, and
minimal evidence of bone resorption of the fracture margins (Figure 10).
 |

15564029, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/1556-4029.15168 by INASP/HINARI - INDONESIA, Wiley Online Library on [13/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ISAAC et al.       7

F I G U R E 8  Histology of fracture 4 (H&E stain) overall fracture (top, scale 400 μm) and detailed view of the fracture gap (bottom, scale
200 μm) highlighting cartilage (Ca), fibrous connective tissue (FCT), and capillaries (C).

Histological and gross examination of the cranial fractures indi-
cated the presence of different degrees of fracture repair, providing
evidence of at least three levels of healing in the calvarium. These
different stages of healing include (1) an early stage in which the
fracture margin was open with rounded fracture margins, minimal
to moderate fibrous connective tissue, minimal new capillaries, and
minimal evidence of bone resorption; (2) a reparative stage with
complete infiltration of the fracture gap with extensive fibrous con-
nective tissue and cartilaginous tissue, numerous new capillaries,
and new woven bone along and within the fracture gap, and; (3) a re-
modeling stage in which the fracture margin was completely obliter-
ated with persistent subperiosteal new bone formation as observed
grossly in Fracture 1.
2.6  |  Additional investigative information
Interviews with the infant's parents were prompted after it was
discovered at autopsy that the infant had multiple fractures.
Initially, the father claimed he accidentally hit the infant's head on
a wall corner, but later admitted to repeatedly hitting the infant
the night the child was found unresponsive; however, it was un-
clear how many times the child was struck as the father was under
the influence of alcohol and marijuana. Eventually, the father ad-
mitted to repeated episodes of abuse in the attempt to quiet the
infant, including routinely striking the infant's head, tipping the
chin back and squeezing down on the neck, squeezing the infant's
neck and skull while pushing back on the chin and squeezing his
 |
8      ISAAC et al.
F I G U R E 9  Histology of fracture 8 (H&E stain) overall fracture (top, scale 400 μm) and detailed view (bottom, scale 200 μm) highlighting
dense fibrous connective tissue (FCT) and capillaries (C).
skull while covering the face. These mechanisms are modeled in
Figure 11.
3  |  D I S C U S S I O N
In this report, we detail the postmortem examination of a four-­
month-­old infant who presented with petechiae of the face and
eyes, scalp and subarachnoid hematomas, fourteen calvarial frac-
tures, three metaphyseal fractures and subperiosteal new bone
formation on the left arm, and a healed fracture in the left distal
ulna diaphysis. In the differential diagnosis process, birth trauma or
fractures due to prematurity in the cranium were ruled out based on
the normal results of the cranial ultrasound performed during the in-
fant's hospitalization after birth. In addition, there was no evidence
of natural disease or accidental injury in the infant's history nor on
examination. Based on the results of the autopsy, neuropathological,
15564029, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/1556-4029.15168 by INASP/HINARI - INDONESIA, Wiley Online Library on [13/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
and anthropological analyses, the medical examiner concluded the
death was a homicide. The cause of death was deemed asphyxia
due to obstruction of the airways as evidenced by the multiple pe-
techiae on the face and conjunctivae. The blunt force injuries to the
head, evidenced by multiple skull fractures at varied states of heal-
ing, bloody cerebrospinal fluid, and scalp and subarachnoid hemor-
rhages, were recorded as contributory causes of death.
While the pattern of skeletal injuries presented in this case ex-
ample are consistent with clinical studies and forensic reports of
child abuse, the cranial fracture pattern and purported mechanism
of abuse are unusual. The infant in this case presented with mul-
tiple bilateral fractures in the parietals, consistent with Meservy
and colleagues’ [12] characterization of pediatric cranial fractures
observed radiographically where multiple skull fractures, bilateral
fractures, and fractures crossing sutures were more common in
cases of abuse. Theoretical consideration of the pattern of linear
fractures running perpendicularly to the sagittal suture appears to

ISAAC et al.
F I G U R E 1 0  Histology of fracture 9 (H&E stain) overall (top, scale 400 μm) and detailed view (bottom, scale 200 μm) highlighting fibrous
connective tissue (FCT) and capillaries (C).
be consistent with low velocity bilateral compression applied to the
lateral aspects of cranial vault. This is supported by the findings of
a study by Hiss and Kahana [38] who reported bilateral temporo-
parietal fractures were only observed in infants who experienced
bilateral compression of the head. A slow loading compression
force is also congruent with the abusive mechanism described by
the suspect whereby the palm of the hand covers the face of the
child, and the fingers squeeze the lateral aspects of the cranium
(Figure 11). Furthermore, the curvilinear fractures (Fractures 6 and
12), and the depressed fracture on the left parietal (Fracture 1) may
represent focal trauma from the fingers and thumb to the supra-­
auricular sides of the head.
All of the cranial fractures were antemortem with evidence
of healing. Fracture 1 was the most advanced in fracture repair
with nearly obliterated fracture margins indicating remodeling.
Histological analysis revealed two potential additional stages of
|
15564029, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/1556-4029.15168 by INASP/HINARI - INDONESIA, Wiley Online Library on [13/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
      9
healing at the microscopic level evidenced by the progression from
soft-­tissue response to woven bone formation. Using the histological
method published by Naqvi and colleagues [39] to estimate the age
of fractures in infants, Fractures 8 and 9 with fibrin formation and
fibrous connective tissue/granulation tissue would most likely occur
between 12 hours and 3 days after injury. Fracture 4 with granu-
lation tissue, cartilage, and woven bone would be consistent with
an injury that is 5 to 7 days old. Although there was no histological
sample taken of the fracture with the most advanced gross healing
(Fracture 1), Naqvi and colleagues indicate fracture union occurred
in most fractures in their sample 22 to 28 days after injury [39].
However, Naqvi et al. [39] do not identify the skeletal ele-
ments utilized to develop the method nor has the method been
independently validated on a sample of infant cranial fractures
where the time elapsed since injury is known. The lack of re-
search and methods for the accurate estimation of infant cranial
 |
10      ISAAC et al.
F I G U R E 1 1  Three confessed mechanisms of abuse used by the caretaker to quiet the child. (A) Tipping the infant's chin back while
compressing the neck; (B) squeezing the infant's neck and skull while pushing back the chin; and (C and D) compressing both sides of the
cranium while covering the infant's face.
fracture age limits the ability to correlate the histologic differ-
ences between the fractures in this case with different traumatic
events. Additional factors such as differences in the extent of
the fracture gaps and reinjury of a pre-­e xisting fracture fur-
ther convolute determination of multiple traumatic events. The
stair-­s tep morphology of Fracture 8 was also atypical in this
case example, as this type of fracture has not previously been
reported in the literature except in cases of thermal fracturing
[40]. Considering the reported abuse mechanism, the stair-­s tep
pattern of Fracture 8 could represent multiple contiguous frac-
tures from repeated loading of the skull at different times with
variation of the focal points of compressive force (i.e., the place-
ment of the hand and fingers). As Berryman and colleagues [41]
describe, antemortem fractures may lengthen as the result of
a new traumatic event if the energy imparted cannot be dissi-
pated by the preexisting fracture. However, the morphology of
Fracture 8 is not observed elsewhere in the literature nor have
there been controlled fractography studies demonstrating the
pattern. As fractures initiate, they are expected to be straight,
propagating perpendicular to the maximum tensile stresses, but
the propagation path is influenced by intrinsic and extrinsic con-
ditions [42]. The conditions under which the stair-­s tep pattern
will occur remain unknown.
Provided the current lack of controlled experiments on cranial
fracture patterns and healing, the fracture pattern of the cranium
cannot solely indicate repeated traumatic events and a history of
abuse; however, clarity as to the circumstances in which these
15564029, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/1556-4029.15168 by INASP/HINARI - INDONESIA, Wiley Online Library on [13/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
injuries occurred is provided by the postcranial injuries which
are highly correlated with physical abuse. Metaphyseal fractures
in infants are due to the greater susceptibility of the developing
trabeculae in the primary spongiosa of long bone metaphysis
to planar failure near the bone's proximal or distal end and are
highly correlated with inflicted injury in young children –­ particu-
larly non-­a mbulatory infants [1, 43–­45]. Kleinman and colleagues
[43, 44] have suggested metaphyseal injuries are produced when
forces of torsion and/or tension are exerted on an infants' extrem-
ities. These forces are associated with yanking or twisting of the
arms and legs or the uncontrolled flailing of the limbs during shak-
ing episodes [43, 44, 46]. The medial rotation of the distal ulnar
head also indicates a torsional force applied over the left extrem-
ity causing a fracture.
4  |  CO N C LU S I O N
The interpretation of fracture pattern and timing is of utmost
importance in the differential diagnosis of trauma, particularly if
the injuries could be the result of either an accident or from an
inflicted injury and not from documented birth trauma or due to
an underlying health condition. Often, these determinations are
contingent upon the type and location of fractures, the age and
developmental status of the child, and the history provided by the
caretaker. This report is illustrative of an infant with multiple inju-
ries sustained over time. In this case, the perpetrator's admission is

ISAAC et al.
consistent with the observed cranial fracture patterns. However,
the mechanism of the injuries should be approached with caution
since there is no appropriate research to support the specific injury
patterns. Furthermore, this case provides radiographic, gross, and
histological evidence of healing cranial and postcranial fractures.
The limitations imposed on the interpretation of the fracture pat-
tern and histological data in this case demonstrate the need for
12. Meservy C, Towbin R, McLaurin R, Myers P, Ball W. Radiographic
increased research into fracture propagation under variable intrin-
sic and extrinsic factors and the progression of histomorphological
repair in the pediatric cranium.
13. Keenan HT, Runyan DK, Marshall SW, Nocera MA, Merten DF,
AC K N OW L E D G M E N T S
The authors would like to thank Kristi Bailey, H.T.L. and Jon
Langworthy, H.T.L. of Western Michigan University Homer Stryker
M.D. School of Medicine, Research Histology Laboratory, for their
work in creating the histological slides for this case. The authors
would also like to thank the two reviewers for their thoughtful evalu-
ations which helped to improve this manuscript.
F U N D I N G I N FO R M AT I O N
The histological component of this work was supported by the
National Institute of Justice [award number 2017-­DN-­BX-­0166]. The
opinions, findings, and conclusions or recommendations expressed
in this publication are those of the authors and do not necessarily
reflect those of the U.S. Department of Justice.
C O N FL I C T O F I N T E R E S T
The authors declare there are no conflicts of interest.
REFERENCES
1. Christian CW. The evaluation of suspected child physical abuse.
Pediatrics. 2015;135(5):e1337–­54. https://doi.org/10.1542/peds.​
2015-­0356
2. Flaherty EG, Perez-­Rossello JM, Levine MA, Hennrikus WL,
Christian CW, Crawford-­Jakubiak JE, et al. Evaluating children with
fractures for child physical abuse. Pediatrics. 2014;133(2):e477–­89.
https://doi.org/10.1542/peds.2013-­3793
3. Narang SK, Fingarson A, Lukefahr J, Sirotnak AP, Flaherty CEG, Gavril
AR, et al. Abusive head trauma in infants and children. Pediatrics.
2020;145(4):e20200203. https://doi.org/10.1542/PEDS.2020-­0203
4. Carty HM. Fractures caused by child abuse. J Bone Joint Surg Br.
1993;75:849–­57. https://doi.org/10.1302/0301-­620X.75B6.8245070
5. Kleinman PK. The spectrum of non-­accidental injuries (child abuse)
and its imitators. In: Hodler J, Zollikofer CL, von Schulthess GK, ed-
itors. Musculoskeletal diseases 2009–­2012. Milano, Italy: Springer
Milan; 2009. p. 227–­33.
6. Kleinman PK, Marks SC, Richmond JM, Blackbourne BD. Inflicted
skeletal injury: a postmortem radiologic-­histopathologic study
in 31 infants. Am J Roentgenol. 1995;165(3):647–­50. https://doi.
org/10.2214/​ajr.165.3.7645487
7. Reece RM, Sege R. Childhood head injuries: accidental or inflicted?
Arch Pediatr Adolesc Med. 2000;154(1):11–­5.
8. Kleinman PK, Coats B, Silvera VM. Abusive head trauma: scalp, sub-
scalp, and cranium. In: Kleinman PK, editor. Diagnostic imaging of child
abuse. Cambridge, UK: Cambridge University Press; 2015. p. 357–­93.
9. Wood JN, Christian CW, Adams CM, Rubin DM. Skeletal surveys in
infants with isolated skull fractures. Pediatrics. 2009;123(2):e247–­
52. https://doi.org/10.1542/PEDS.2008-­2467
|
15564029, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/1556-4029.15168 by INASP/HINARI - INDONESIA, Wiley Online Library on [13/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
      11
10. Kemp AM, Dunstan F, Harrison S, Morris S, Mann M, Rolfe K,
et al. Patterns of skeletal fractures in child abuse: systematic re-
view. BMJ. 2008;337(7674):859–­62. https://doi.org/10.1136/BMJ.
A1518
11. Leventhal JM, Thomas SA, Rosenfield NS, Markowitz RL. Fractures
in young children: distinguishing child abuse from unintentional in-
juries. Am J Dis Child. 1993;147:87–­92. https://doi.org/10.1001/
archp​edi.1993.02160​25008​9028
characteristics of skull fractures resulting from child abuse. Am
J Roentgenol. 1987;149(1):173–­5. https://doi.org/10.2214/ajr.​
149.1.173
Sinal SH. A population-­based study of inflicted traumatic brain
injury in young children. JAMA. 2003;290(5):621–­6. https://doi.
org/10.1001/JAMA.290.5.621
14. Shanahan ME, Zolotor AJ, Parrish JW, Barr RG, Runyan DK.
National, regional, and state abusive head trauma: application of
the CDC algorithm. Pediatrics. 2013;132(6):e1546–­53. https://doi.
org/10.1542/PEDS.2013-­2049
15. Carty H, Pierce A. Non-­accidental injury: a retrospective analysis
of a large cohort. Eur Radiol. 2002;12(12):2919–­25. https://doi.
org/10.1007/s0033​0 -­0 02-­1436-­9
16. Hobbs CJ. Skull fracture and the diagnosis of abuse. Arch Dis Child.
1984;59(3):246–­52. https://doi.org/10.1136/adc.59.3.246
17. Isa MI, Fenton TW, Wei F, Haut RC. Experimental investigation of
cranial fracture initiation in blunt human head impacts. Forensic
Sci Int. 2019;300:51–­62. https://doi.org/10.1016/J.FORSC​IINT.​
2019.04.003
18. Gurdjian ES, Lissner HR. Deformation of the skull in head injury;
a study with the stresscoat technique. Surg Gynecol Obstet.
1945;81:679–­87.
19. Gurdjian ES, Lissner HR, Webster JE. The mechanism of pro-
duction of linear skull fracture; further studies on deformation
of the skull by the stresscoat technique. Surg Gynecol Obstet.
1947;85(2):195–­210.
20. Gurdjian ES, Lissner HR. Deformations of the skull in head injury as
studied by the “stresscoat” technic. Am J Surg. 1947;73(2):269–­81.
https://doi.org/10.1016/0002-­9610(47)90321​-­8
21. Gurdjian ES, Webster JE, Lissner HR. Studies on skull fracture
with particular reference to engineering factors. Am J Surg.
1949;78(5):736–­42. https://doi.org/10.1016/0002-­9610(49)90315​
-­3
22. Gurdjian ES, Webster JE, Lissner HR. The mechanism of skull frac-
ture. J Neurosurg. 1950;7(2):106–­14. https://doi.org/10.3171/jns.​
1950.7.2.0106
23. Gurdjian ES, Webster JE, Lissner HR. The mechanism of skull
fracture. Radiology. 1950;54(3):313–­39. https://doi.org/10.1148/​
54.3.313
24. Gurdjian ES, Webster JE, Lissner HR. Observations on prediction of
fracture site in head injury. Radiology. 1953;60(2):226–­35. https://
doi.org/10.1148/60.2.226
25. Kroman A, Kress T, Porta D. Fracture propagation in the human cra-
nium: a re-­testing of popular theories. Clin Anat. 2011;24(3):309–­
18. https://doi.org/10.1002/CA.21129
26. Yoganandan N, Pintar FA, Sances A, Walsh PR, Ewing CL,
Thomas DJ, et al. Biomechanics of skull fracture. J Neurotrauma.
1995;12(4):659–­68. https://doi.org/10.1089/neu.1995.12.659
27. Margulies SS, Thibault KL. Infant skull and suture properties: mea-
surements and implications for mechanisms of pediatric brain in-
jury. J Biomech Eng. 2000;122(4):364–­71. https://doi.org/10.1115/​
1.1287160
28. Coats B, Margulies SS. Material properties of human infant skull
and suture at high rates. J Neurotrauma. 2006;23(8):1222–­32.
https://doi.org/10.1089/NEU.2006.23.1222
 |
12      ISAAC et al.
29. Baumer TG, Passalacqua NV, Powell BJ, Newberry WN,
Fenton TW, Haut RC. Age-­dependent fracture characteristics
of rigid and compliant surface impacts on the infant skull –­ a
porcine model. J Forensic Sci. 2010;55(4):993–­7. https://doi.
org/10.1111/J.1556-­4 029.2010.01391.X
3 0. Powell BJ, Passalacqua NV, Baumer TG, Fenton TW, Haut RC.
Fracture patterns on the infant porcine skull following severe
blunt impact. J Forensic Sci. 2012;57(2):312–­7. https://doi.
org/10.1111/J.1556-­4 029.2011.01969.X
31. Powell BJ, Passalacqua NV, Fenton TW, Haut RC. Fracture charac-
teristics of entrapped head impacts versus controlled head drops
in infant porcine specimens. J Forensic Sci. 2013;58(3):678–­83.
https://doi.org/10.1111/1556-­4 029.12094
32. Deland TS, Niespodziewanski E, Fenton TW, Haut RC. The role
of interface on the impact characteristics and cranial fracture
patterns using the immature porcine head model. J Forensic Sci.
2016;61(Suppl 1):53–­9. https://doi.org/10.1111/1556-­4 029.12939
33. Vaughan PE, Vogelsberg CCM, Vollner JM, Fenton TW, Haut RC.
The role of interface shape on the impact characteristics and cranial
fracture patterns using the immature porcine head model. J Forensic
Sci. 2016;61(5):1190–­7. https://doi.org/10.1111/1556-­4 029.13111
3 4. Weber W. Experimentelle untersuchungen zu schädelbruchver-
letzungen des säuglings [Experimental study of skull fractures in
infants]. Z Rechtsmed. 1984;92(2):87–­94. https://doi.org/10.1007/
BF021​16216
35. Weber W. Zur biomechanischen fragilität des säuglingsschädels
[biomechanical fragility of skull fractures in infants]. Z Rechtsmed.
1985;94(2):93–­101. https://doi.org/10.1007/BF001​98677
36. Hui C, Joughin E, Goldstein S, Cooper N, Harder J, Kiefer G, et al.
Femoral fractures in children younger than three years: the role
of nonaccidental injury. J Pediatr Orthop. 2008;28(3):297–­3 02.
https://doi.org/10.1097/BPO.0B013​E3181​653BF9
37. Piteau SJ, Ward MGK, Barrowman NJ, Plint AC. Clinical and radio-
graphic characteristics associated with abusive and nonabusive
head trauma: a systematic review. Pediatrics. 2012;130(2):315–­23.
https://doi.org/10.1542/PEDS.2011-­1545
38. Hiss J, Kahana T. The medicolegal implications of bilateral cranial
fractures in infants. J Trauma Inj Infect Crit Care. 1995;38(1):32–­4.
https://doi.org/10.1097/00005​373-­19950​1000-­0 0010
15564029, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/1556-4029.15168 by INASP/HINARI - INDONESIA, Wiley Online Library on [13/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
39. Naqvi A, Raynor E, Freemont AJ. Histological ageing of fractures
in infants: a practical algorithm for assessing infants suspected of
accidental or non-­accidental injury. Histopathology. 2019;75(1):74–­
80. https://doi.org/10.1111/his.13850
4 0. Symes SA, Rainwater CW, Chapman EN, Gipson DR, Piper AL.
Patterned thermal destruction of human remains in a forensic set-
ting. In: Schmidt CW, Symes SA, editors. The analysis of burned
human remains. San Diego, CA: Academic Press; 2015. p. 17–­59.
41. Berryman HE, Berryman JF, Saul TB. Bone trauma analysis in a
forensic setting: theoretical basis and a practical approach for
evaluation. In: Boyd CC, Boyd DC, editors. Forensic anthropology:
theoretical framework and scientific basis. Hoboken, NJ: John
Wiley & Sons, Ltd; 2018. p. 213–­3 4.
42. Christensen AM, Isa MI, Smith MA, Hefner JT, Berryman HE, Saginor
IS, et al. A guide to forensic fractography of bone. Washington, DC:
Federal Bureau of Investigation; 2022. p. 48–­71.
43. Kleinman PK, Rosenberg AE, Tsai A. Skeletal trauma: general
considerations. In: Kleinman PK, editor. Diagnostic imaging of
child abuse. Cambridge, U.K.: Cambridge University Press; 2015.
p. 23–­52.
4 4. Kleinman PK. Problems in the diagnosis of metaphyseal frac-
tures. Pediatr Radiol. 2008;38(Suppl 3):S388–­94. https://doi.
org/10.1007/S0024​7-­0 08-­0 845-­6
45. Kleinman PK, Perez-­Rossello JM, Newton AW, Feldman HA,
Kleinman PL. Prevalence of the classic metaphyseal lesion in infants
at low versus high risk for abuse. Am J Roentgenol. 2011;197:1005–­
8. https://doi.org/10.2214/AJR.11.6540
46. Love JC, Derrick SM, Wiersema JM. Long bone fractures. Skeletal
atlas of child abuse. New York, NY: Springer; 2011. p. 69–­83.
How to cite this article: Isaac CV, Cornelison JB, Devota CJ,
Shattuck BL, Castellani RJ. An unusual blunt force trauma
pattern and mechanism to the cranial vault: Investigation of
an atypical infant homicide. J Forensic Sci. 2022;00:1–12.
https://doi.org/10.1111/1556-4029.15168