PMC10098721_01
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).
JFO-68-315-g003.jpg
PMC10098721_01_JFO-68-315-g003.jpg
jfo15168-fig-0001
The postmortem radiographic skeletal survey revealed multiple fractures to the neurocranium and radiographic evidence consistent with metaphyseal fractures of the left humerus, ulna, and radius (Figure 1).
An image of the scalp reflected showing a soft tissue hemorrhage (arrow) and skull fractures (arrowheads). [Color figure can be viewed at wileyonlinelibrary.com]
JFO-68-315-g006.jpg
PMC10098721_01_JFO-68-315-g006.jpg
jfo15168-fig-0002
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 hemorrhages (Figure 2).
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).
JFO-68-315-g005.jpg
PMC10098721_01_JFO-68-315-g005.jpg
jfo15168-fig-0003
The skull cap was radiographed (Figure 3) and photographed (Figure 4A,D,G) prior to histological sampling and maceration, revealing numerous fractures.
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. [Color figure can be viewed at wileyonlinelibrary.com]
JFO-68-315-g011.jpg
PMC10098721_01_JFO-68-315-g011.jpg
jfo15168-fig-0004
The skull cap was radiographed (Figure 3) and photographed (Figure 4A,D,G) prior to histological sampling and maceration, revealing numerous fractures. Histological samples were resected from three cranial fractures prior to processing (Figure 4B). The left parietal demonstrated a comminuted, slightly depressed defect (Fracture 1) with four associated simple, linear, radiating fractures (Fractures 2 through 5), all with rounded fracture margins and extensive subperiosteal new bone formation (Figure 4D-F). Also evident in the left parietal region was a curvilinear fracture (Fracture 6) and linear fracture (Fracture 7) adjacent to the craniotomy cut (Figure 4D-F). 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 observed (Fracture 14) was a simple, linear fracture of the left lateral occipital, extending between the lambdoid suture and the craniotomy cut (Figure 4D-F).
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. [Color figure can be viewed at wileyonlinelibrary.com]
JFO-68-315-g009.jpg
PMC10098721_01_JFO-68-315-g009.jpg
jfo15168-fig-0005
A metaphyseal 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).
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. [Color figure can be viewed at wileyonlinelibrary.com]
JFO-68-315-g007.jpg
PMC10098721_01_JFO-68-315-g007.jpg
jfo15168-fig-0006
The left radius had subperiosteal new bone formation along the shaft, proximally at the radial tuberosity and distally at the metaphysis (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).
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. [Color figure can be viewed at wileyonlinelibrary.com]
JFO-68-315-g001.jpg
PMC10098721_01_JFO-68-315-g001.jpg
jfo15168-fig-0007
The left ulna exhibited evidence of a healed fracture in the distal one-third of the diaphysis with the distal metaphysis rotated approximately 45 degrees medially relative to the proximal two-thirds of the diaphysis (Figure 7B,C). There was also a metaphyseal fracture of the distal metaphysis of the ulna observed radiographically (Figure 7A) and grossly on the physeal surface (Figure 7E).
Histology of fracture 4 (H&E stain) overall fracture (top, scale 400 mum) and detailed view of the fracture gap (bottom, scale 200 mum) highlighting cartilage (Ca), fibrous connective tissue (FCT), and capillaries (C). [Color figure can be viewed at wileyonlinelibrary.com]
JFO-68-315-g004.jpg
PMC10098721_01_JFO-68-315-g004.jpg
jfo15168-fig-0008
When observed histologically (Figure 8); however, the fracture gap was resolving on the ectocranial and endocranial surfaces with bone formation and the gap was infiltrated with fibrous connective tissue and areas of cartilage formation.
Histology of fracture 8 (H&E stain) overall fracture (top, scale 400 mum) and detailed view (bottom, scale 200 mum) highlighting dense fibrous connective tissue (FCT) and capillaries (C). [Color figure can be viewed at wileyonlinelibrary.com]
JFO-68-315-g002.jpg
PMC10098721_01_JFO-68-315-g002.jpg
jfo15168-fig-0009
Histological assessment indicated minimal bone resorption, moderate fibrous connective tissue that bridged the ectocranial fracture gap, and minimal new capillary formation (Figure 9).
Histology of fracture 9 (H&E stain) overall (top, scale 400 mum) and detailed view (bottom, scale 200 mum) highlighting fibrous connective tissue (FCT) and capillaries (C). [Color figure can be viewed at wileyonlinelibrary.com]
JFO-68-315-g008.jpg
PMC10098721_01_JFO-68-315-g008.jpg
jfo15168-fig-0010
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).
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. [Color figure can be viewed at wileyonlinelibrary.com]
JFO-68-315-g010.jpg
PMC10098721_01_JFO-68-315-g010.jpg
jfo15168-fig-0011
These mechanisms are modeled in Figure 11.