Neuropediatrics 2005; 36(4): 240-245
DOI: 10.1055/s-2005-872812
Review Article

Georg Thieme Verlag KG Stuttgart · New York

Fall or Shaken: Traumatic Brain Injury in Children Caused by Falls or Abuse at Home - A Review on Biomechanics and Diagnosis

M. Oehmichen1 , 2 , C. Meissner1 , K.-S. Saternus3
  • 1Institut für Rechtsmedizin, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
  • 2Institut für Rechtsmedizin, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
  • 3Institut für Rechtsmedizin, Georg-August-Universität, Göttingen, Germany
Further Information

Publication History

Received: February 9, 2005

Accepted after Revision: July 26, 2005

Publication Date:
01 September 2005 (online)


In cases of traumatic brain injuries in children it may be difficult to differentiate between physical abuse and accidental occurrence. This review will shed light on discriminating epidemiological as well as biomechanical data, morphological findings, and clinical features. As a basic principle, simple injuries are caused by simple mechanisms like falls whereas life-threatening injuries should be attributed to abuse until proven otherwise. Implausibilities between reported events and mechanisms by caregivers as well as more than one explanation of injury indicate suspicion of child abuse. From reviewing the literature, it can be stated that falls from less than 1.5 m lead only in few cases to severe brain injuries. Children who experienced a fall at home seldom exhibit fractures of the skull but just minor intracranial injuries without neurological deficits. Regarding biomechanical aspects, multiple or complex skull fractures, depression fractures, additional fractures of the body, and intracranial hemorrhages as a consequence of an impact are the most important findings in child abuse. Moreover, additional specific morphological criteria give evidence of clinical and/or post-mortem diagnosis of the shaken baby syndrome. These include subdural hemorrhage and laceration of the brain and retinal bleeding, epidural hemorrhage of the cervical cord, gripping marks (bruises) on chest and/or shoulders, and tearing injuries of the throat and neck muscles. Post-mortem signs of recurrent shaken baby syndrome are indicated by iron-positive cells or microglial cells in neuronal or retinal tissue. A clinical diagnosis will be dependent on the one hand on the exclusion of coagulation diseases, on the other hand on the demonstration of a subdural hemorrhage by means of neuroimaging techniques, i.e., CT and MRI, as well as retinal hemorrhage. The shaken baby syndrome will usually be observed within the first year of life. The doctor has to manifest his diagnosis to the caregivers and - before informing the caregivers - he must be sure of his diagnosis.


  • 1 Adams J H, Graham D I, Doyle D, Lawrence A E, McLellan D R. Diffuse axonal injury in head injuries caused by a fall.  Lancet. 1984;  ii 1421-1422
  • 2 Alario A, Duhaime T. Do retinal hemorrhages occur with accidental head trauma in young children?.  (Abstract) Am J Dis Child. 1990;  144 445
  • 3 Alexander R, Sato Y, Smith W, Bennett T. Incidence of impact trauma with cranial injuries ascribed to shaking.  Am J Dis Child. 1990;  144 724-726
  • 4 Alexander R C, Levitt C J, Smith W L. Abusive head trauma. Reece RM, Ludwig S Child Abuse: Medical Diagnosis and Management. 2nd ed. Philadelphia, Baltimore, New York; Lippincott Williams & Wilkins 2001: 47-80
  • 5 Barlow B, Niemirska M, Ghandi R P, Leblanc W. Ten years experience with falls from a height in children.  J Pediatr Surg. 1983;  18 509-511
  • 6 Barnes P D. Ethical issues in imaging nonaccidental injury: child abuse.  Topics in Magnetic Resonance Imaging. 2002;  13 85-93
  • 7 Billmire M E, Myers P A. Serious head injury in infants: accident or abuse?.  Pediatrics. 1985;  75 340-342
  • 8 Bohn D, Armstrong D, Becker L, Humphreys R. Cervical spine injuries in children.  J Trauma. 1990;  30 463-469
  • 9 Calder I M, Hill I, Scholtz C L. Primary brain trauma in non-accidental injury.  J Clin Pathol. 1984;  37 1095-1100
  • 10 Chadwick D L, Chin S, Salerno C, Landsverk J, Kitchen L. Deaths from falls in children: how far is fatal?.  J Trauma. 1991;  31 1353-1355
  • 11 Cory C Z, Jones M D, James D S, Leadbeatter S, Nokes L DM. The potential and limitations of utilising head impact injury models to assess the likelihood of significant head injury in infants after a fall.  Forensic Sci Int. 2001;  123 89-106
  • 12 Duhaime A C, Alario A J, Lewander W J. et al . Head injury in very young children: mechanisms, injury types, and ophthalmologic findings in 100 hospitalized patients younger than two years of age.  Pediatrics. 1992;  90 179-185
  • 13 Duhaime A C, Christian C W, Rorke L B, Zimmerman R A. Nonaccidental head injury in infants - the “shaken-baby syndrome”.  N Engl J Med. 1998;  338 1822-1829
  • 14 Duhaime A C, Gennarelli T A, Thibault L E, Bruce D A, Margulies S S, Wiser R. The shaken baby syndrome: a clinical, pathological, and biomechanical study.  J Neurosurg. 1987;  66 409-415
  • 15 Feldman K, Weinberger E, Milstein J, Fligner C. Cervical spine MRI in abused infants.  Child Abuse & Neglect. 1997;  21 199-205
  • 16 Geddes J F, Hackshaw A K, Vowles G H, Nickols C D, Whitwell H L. Neuropathology of inflicted head injury in children: I. Pattern of brain damage.  Brain. 2001;  124 1290-1298
  • 17 Geddes J F, Vowles G H, Hackshaw A K, Nickols C D, Scott I S, Whitwell H L. Neuropathology of inflicted head injury in children: II. Microscopic brain injury in infants.  Brain. 2001;  124 1299-1306
  • 18 Geddes J F, Whitwell H L. Inflicted head injury in infants.  Forensic Sci Int. 2004;  146 83-88
  • 19 Gennarelli T A, Thibault L E, Ommaya A K. Pathophysiologic responses to rotational and translational accelerations of the head. Proc 16th Stapp Car Crash Conf. 1972: 296-308
  • 20 Gilliland M GF, Folberg R. Shaken babies - some have no impact injuries.  J Forens Sci. 1996;  41 114-116
  • 21 Graham D I, McIntosh T K, Maxwell W L, Nicoll J A. Recent advances in neurotrauma.  J Neuropathol Exp Neurol. 2000;  59 641-651
  • 22 Greenes D S, Schutzman S A. Clinical indicators of intracranial injury in head-injured infants.  Pediatrics. 1999;  104 861-867
  • 23 Hadley M, Sonntag V, Rekate M, Murphy A. The infant whiplash-shake injury syndrome: a clinical and pathological study.  Neurosurgery. 1989;  24 536-539
  • 24 Hahn Y S, Raimondi A J, McLone D G, Yamanouchi Y. Traumatic mechanisms of head injury in child abuse.  Child's Brain. 1983;  10 229-241
  • 25 Hanigan W C, Peterson R A, Njus G. Tin ear syndrome rotational acceleration in pediatric head injuries.  Pediatrics. 1987;  80 618-622
  • 26 Helfer R W, Slovis T L, Black M. Injuries resulting when small children fall out of bed.  Pediatrics. 1977;  60 533-535
  • 27 Hobbs C J. Skull fracture and the diagnosis of child abuse.  Arch Dis Child. 1984;  59 246-252
  • 28 Hymel K P, Bandak F A, Partington M D. et al . Abusive head trauma? A biomechanical approach.  Child Maltreatment. 1998;  3 116-128
  • 29 Joffe M, Ludwig S. Stairway injuries in children.  Pediatrics. 1988;  82 457-461
  • 30 Johnson D L, Boal D, Baule R. Role of apnea in nonaccidental head injury.  Pediatr Neurosurg. 1995;  23 305-310
  • 31 Kirschner R H, Stein R J. The mistaken diagnosis of child abuse. A form of medical abuse?.  Am J Dis Child. 1985;  139 873-875
  • 32 Kirschner R H, Wilson H. Fatal child abuse: The pathologist's perspective. Reece RM, Ludwig S Child Abuse: Medical Diagnosis and Management. 2nd edn. Philadelphia, Baltimore, New York; Lippincott Williams & Wilkins 2001: 467-490
  • 33 Koch L E, Biedermann H, Saternus K S. High cervical stress and apnoea.  Forens Sci Int. 1998;  97 1-9
  • 34 Laskey A L, Holsti M, Runyan D K, Socolar R RS. Occult head trauma in young suspected victims of physical abuse.  J Pediatr. 2004;  144 719-722
  • 35 Lehman D, Schonfeld N. Falls from heights: a problem not just in the northeast.  Pediatrics. 1993;  92 121-124
  • 36 Levitt M A, Sutton M, Goldman J, Mikhail M, Christopher T. Cognitive dysfunction in patients suffering minor head trauma.  Am J Emerg Med. 1994;  12 172-175
  • 37 Lyons T, Oates R K. Falling out of bed: a relatively benign occurrence.  Pediatrics. 1993;  92 125-127
  • 38 Merten D F, Osborne D R, Radkowski M A, Leonidas J C. Craniocerebral trauma in the child abuse syndrome: Radiological observations.  Pediatr Radiol. 1984;  14 272-276
  • 39 Nimityongskul P, Anderson L D. The likelihood of injuries when children fall out of bed.  J Pediatr Orthop. 1987;  7 184-186
  • 40 Oehmichen M, Meissner C, Schmidt V, Pedal I, König H G, Saternus K S. Axonal injury - a diagnostic tool in forensic neuropathology? A review.  Forensic Sci Int. 1998;  95 67-83
  • 41 Oehmichen M, Meissner C. Kindesmißhandlung - Diagnostische Aspekte und rechtliche Hintergründe.  Monatsschr Kinderheilkd. 1999;  147 363-368
  • 42 Oehmichen M, Auer R N, König H G. Forensic Neuropathology and Associated Neurology. Berlin, Heidelberg, New York; Springer Verlag 2005
  • 43 Oehmichen M, Saternus K S, Pedal I, Gerling I, Meissner C. Neuropathological Features of Shaken Infant Syndrome. 2005 (in preparation)
  • 44 Ommaya A K. Head injury mechanisms and the concept of preventive management: a review and critical synthesis.  J Neurotrauma. 1995;  12 527-546
  • 45 Reece R M, Sege R. Childhood head injuries. Accidental or inflicted?.  Arch Pediatr Adolesc Med. 2000;  154 11-15
  • 46 Rivara F P, Alexander B, Johnston B. et al . Population-based study of fall injuries in children and adolescents resulting in hospitalization or death.  Pediatrics. 1993;  92 61-63
  • 47 Roshkow J E, Haller J O, Hotson G C, Sclafani S JA, Mezzacappa P M, Rachlin S R. Imaging evaluation of children after falls from a height: review of 45 cases.  Radiology. 1990;  175 359-363
  • 48 Rutty G N, Squier W MV, Padfield C JH. Epidural haemorrhage of the cervical spinal cord: a post-mortem artefact?.  Neuropathol Appl Neurobiol. 2005;  31 247-257
  • 49 Ryan G A, McLean A J, Vilenius A TS. et al . Brain injury patterns in family injured pedestrians.  J Trauma. 1994;  36 469-476
  • 50 Saternus K S, Kernbach-Wighton G, Oehmichen M. The shaking trauma in infants - kinetic chains.  Forensic Sci Int. 2000;  109 203-213
  • 51 Weber W. Experimentelle Untersuchungen zu Schädelbruchverletzungen des Säuglings.  Z Rechtsmed. 1984;  92 87-94
  • 52 Weber W. Zur biomechanischen Fragilität des Säuglingsschädels.  Z Rechtsmed. 1985;  94 93-101
  • 53 Weston J T. The battered child in medicolegal investigation of death. Spitz WV, Fisher RS Guidelines for the Application of Pathology in Crime Investigation. Springfield, IL; Charles C Thomas 1980: 477-498
  • 54 Wilkins B. Head injury - abuse or accident?.  Arch Dis Child. 1997;  76 393-396
  • 55 Williams R A. Injuries in infants and small children resulting from witnessed and corroborated free falls.  J Trauma. 1991;  31 1350-1352
  • 56 Williams A N, Sunderland R. Neonatal shaken baby syndrome: an aetiological view from Down Under.  Arch Dis Child Fetal Neonatal Ed. 2002;  86 F29-F30

Prof. Dr. med. Manfred Oehmichen

Institut für Rechtsmedizin
Universitätsklinikum Schleswig-Holstein
Campus Lübeck

Kahlhorststraße 31 - 35

23562 Lübeck



Campus Kiel

Arnold-Heller-Straße 12

24105 Kiel