Infant skull fracture risk for low height falls


Skull fractures are common injuries in young children, typically caused by accidental falls and child abuse. The paucity of detailed biomechanical data from real-world trauma in children has hampered development of biomechanical thresholds for skull fracture in infants. The objectives of this study were to identify biomechanical metrics to predict skull fracture, determine threshold values associated with fracture, and develop skull fracture risk curves for low-height falls in infants. To achieve these objectives, we utilized an integrated approach consisting of case evaluation, anthropomorphic reconstruction, and finite element simulation. Four biomechanical candidates for predicting skull fracture were identified (first principal stress, first principal strain, shear stress, and von Mises stress) and evaluated against well-witnessed falls in infants (0–6 months). Among the predictor candidates, first principal stress and strain correlated best with the occurrence of parietal skull fracture. The principal stress and strain thresholds associated with 50 and 95% probability of parietal skull fracture were 25.229 and 36.015 MPa and 0.0464 and 0.0699, respectively. Risk curves using these predictors determined that infant falls from 0.3 m had a low probability (0–54%) to result in parietal skull fracture, particularly with carpet impact (0–1%). Head-first falls from 0.9 m had a high probability of fracture (86–100%) for concrete impact and a moderate probability (34–81%) for carpet impact. Probabilities of fracture in 0.6 m falls were dependent on impact surface. Occipital impacts from 0.9 m onto the concrete also had the potential (27–90% probability) to generate parietal skull fracture. These data represent a multi-faceted biomechanical assessment of infant skull fracture risk and can assist in the differential diagnosis for head trauma in children.

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We gratefully acknowledge Sarah Sullivan, Sarah van Kuelen, and Megan Weil for their assistance in conducting the drop tests, Erica Palma for reviewing clinical records and enrolling cases, Lorre Atlan for creating and running early versions of the computational model, and Dr. Larissa Bilaniuk for her careful review of the radiological data.


This study if supported by the Centers for Disease Control and Prevention grant NCIPC R49CE000411 and the National Institutes of Health (NIH)/National Institute of Neurological Disorders and Stroke (NINDS) grant R01NS039679.

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Correspondence to Marzieh Hajiaghamemar.

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Hajiaghamemar, M., Lan, I.S., Christian, C.W. et al. Infant skull fracture risk for low height falls. Int J Legal Med 133, 847–862 (2019).

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  • Pediatric traumatic brain injury
  • Head impact
  • Anthropomorphic surrogate
  • Accidental falls
  • Finite element modeling
  • Injury risk curve