The opinion
WR 59,201-03
COURT OF CRIMINAL APPEALS
AUSTIN, TEXAS
Transmitted 4/20/2015 12:00:00 AM
Accepted 4/20/2015 8:11:52 AM
ABEL ACOSTA
WR 59,201-03 CLERK
RECEIVED
COURT OF CRIMINAL APPEALS
EX PARTE RICHARD VASQUEZ 4/20/2015
ABEL ACOSTA, CLERK
***
IN THE DISTRICT COURT
148TH DISTRICT
NUECES COUNTY, TEXAS
Returnable to
THE TEXAS COURT OF CRIMINAL APPEALS
AUSTIN, TEXAS
***
STATE’S MOTION TO DISMISS AS ABUSIVE
SUBSEQUENT 11.071 APPLICATION FOR
WRIT OF HABEAS CORPUS
AND TO DENY MOTION TO STAY EXECUTION
Douglas K. Norman
State Bar No. 15078900
Assistant District Attorney
105th Judicial District of Texas
901 Leopard, Room 206
Corpus Christi, Texas 78401
(361) 888-0410
(361) 888-0399 (fax)
douglas.norman@co.nueces.tx.us
Attorney for the State
1
WR-59,201-03
EX PARTE § IN THE DISTRICT COURT
§
§ 148TH JUDICIAL DISTRICT
§
RICHARD VASQUEZ § NUECES COUNTY, TEXAS
COMES NOW the State of Texas, by and through its Assistant District
Attorney for the 105th Judicial District of Texas, and pursuant to Texas Code
of Criminal Procedure arts. 11.071 and 11.073, files this motion to dismiss
as abusive the present subsequent application for writ of habeas corpus and
to deny the motion to stay execution.
EXPLANATION FOR UNTIMELY PLEADING
The State is cognizant of this Court’s “Miscellaneous Rule 11-003"
pertaining to procedures in death penalty cases involving requests for stay of
execution and related filings, and if it applies to responsive pleadings such as
this motion to dismiss Applicant’s subsequent application for writ of habeas
corpus, the State offers this explanation for filing its motion less than seven
days before the date of Applicant’s execution:
Applicant’s execution is scheduled for Thursday, April 23, 2015.
Applicant did not file his motion for stay of execution and his subsequent
application for post-conviction writ of habeas corpus until late in the
2
afternoon of Wednesday, April 15, 2015, the last day permitted for such
filings pursuant to this Court’s “Miscellaneous Rule 11-003.”
Consequently, it was impossible for the State to read and file a response to
the 92-page application and exhibits attached thereto prior to the expiration
of the deadline for a timely filing in this case. The State has worked
diligently to prepare such response and is filing this, its motion to dismiss
Applicant’s subsequent application for writ of habeas corpus as quickly as it
can.
The State prays that this Court deem such circumstances as good
cause for the untimely filing of this motion, if in fact this motion is
considered a “pleading requesting affirmative relief in an impending
execution case” under Miscellaneous Rule 11-003, and if in fact that rule
applies to responsive pleadings such as this motion to dismiss.
STATEMENT OF FACTS
The State relies on this Court’s own knowledge of the facts of the case
as set forth in its opinion on the direct appeal. In addition, the State would
point this court to the following testimony that it believes to be particularly
relevant to the present claims being made.
Deputy Constable Eric Giannamore, the first person to arrive at the
scene, asked Vasquez what had happened. Vasquez replied that Miranda was
3
brushing her teeth in a hall bathroom and fell off a wooden stool, hitting her
head. Giannamore testified, however, that there was no wooden stool in the
area. (R.R. XXXIV - 19-21, 74-77; XLI - State's Exh. 37).
Emergency medical technician Eugenio Rangel asked what had
happened and Vasquez replied that Miranda had fallen off a stool in the
bathroom while brushing her teeth. While Vasquez kind of pointed when he
said this, Rangel never saw a stool in the area. (R.R. XXXV - 76-78, 83, 85,
101, 108). As the paramedics cut Miranda's clothes off and turned her in
order to place her on a back board, noticeable bruising of various stages was
apparent down her back, as well as on her legs and arms. Miranda also had a
bump on the back of her head and bruising around her eyes. There was no
sign of toothpaste in Miranda's mouth. (R.R. XXXIV - 21-22; XXXV - 78-
82, 85-87, 93-98, 101-102, 108-112; XLI - State's Exh. 37-39).
Dr. Michael Burke, a pediatric neurosurgeon, testified that Miranda
had multiple bruises on her body. (R.R. XXXV - 95; XXXVI - 69-89; XLII -
State's Exh. 60-63; C.R. I - 38-39, 51-53, 56-61, 69-71, 156-158). Burke
said that her subdural hematoma was caused by trauma to the head and that
Miranda's brain injuries were the equivalent to those she would have
sustained had she been ejected from a car traveling 65 m.p.h. Miranda's
injuries were consistent with being struck multiple times in the head. Burke
4
said his final diagnosis was severe brain injury from child abuse. He
described this as a massive injury and summarized Miranda's condition by
saying, "This child got the living daylights beat out of her to the point that
she quit breathing and there was nothing that could be done at that point."
(R.R. XXXVI - 78-79, 87, 91-94). Dr. Burke used his car accident and
Shaken Baby Syndrome comments only as analogies to attempt to explain
the force of the direct impact injuries in the present case and the lack of
external signs, and he never testified or implied that Miranda had been in a
car accident or that she had Shaken Baby Syndrome. (R.R. XXXVI - 92-
93).
Leann Box, a sexual assault nurse examiner (SANE) at the hospital,
testified that Miranda had extensive bruising in various stages of healing all
over her body--head, face, chest, pelvic region, genitalia area, ankle, thigh,
shoulder, back, and arms--and described each of those bruises. (R.R. XXXV
- 175-185, 208-211; XLI - State's Exh. 46-48; C.R. I - 23, 27, 75-83, 175).
There were multiple abrasions and tears on her labia majora, fossa, labia
minora, fourchette, perineum, and anal area. Many were oozing tears, which
meant they were fresh enough that they had not begun to scab, which
generally started to occur within a few hours of injury. One such injury
would have probably bled a great deal. Because very little blood was present
5
in the area when the examination took place, Box assumed it had been
cleaned up. (R.R. XXXV - 185-197, 205-208, 211-215; XLII - State's Exh.
49-57; C.R. I - 18-21, 42, 50, 54-55, 72). The bruising on Miranda's hips
was very consistent with injuries that could be caused by being held from
behind while being sexually assaulted. The injuries to Miranda's genital-anal
area were not consistent with a straddle injury. Rather, they were extremely
consistent with someone or something passing over the area below the anus,
tearing the top of the skin, skidding over the anus, and ripping apart the skin
at the perineum. In over 200 sexual assault examinations, this was the first
time Box had seen a complete full thickness tear at the perineum. (R.R.
XXXV - 177, 197-200).
In his formal statement to the police, Vasquez said that he had
repeatedly asked Miranda why she always acted scared of him. She kept
saying she was not scared of him until Vasquez "got pissed off" and pushed
her. When she still replied that she was not scared of him, Vasquez told her
to stop lying and hit her in the head. She did not fall down because he was
holding her with his other hand. He hit her several more times. She just
looked at him and looked stunned. He told her to go out and play and she
went downstairs and out of the house. About 30 minutes later, Vasquez
called out to Miranda through the window and told her to come inside and
6
brush her teeth or she would not get to go to his sister's house. When she
walked in, Miranda's head was down. She went to Vasquez's mother's room
and got the stool she used when she brushed her teeth. As she started to carry
it to the other bathroom, she fell down. Vasquez told her to get up and go
brush her teeth. Miranda staggered into the bathroom and began to brush her
teeth. Then Vasquez heard what sounded like the stool tipping over. He
called Miranda but she did not answer. He went in the bathroom and saw her
lying on her back on the floor. He hit Miranda because he had a lot of anger
because he couldn't straighten his life out. He could have hit her more than
three times. He just lost it. He was sorry for what he did to her. (R.R.
XXXIV - 56-59; XLI - Sx8).
Dr. Lloyd White, the Nueces County medical examiner who
performed an autopsy on Miranda's body, noted bruising all over her body
and head of various ages. (R.R. XXXVI - 23-33, 40, 49-50; XLII - State's
Exh. 58-59). The damage to Miranda's genital region was typical of blunt
trauma--pressure exerted to the area that caused scrapes of the skin and
membranes and caused tears of those membranes. They could have been the
result of being poked with an object. A penis could cause bruising,
laceration, and fairly severe injuries in small children. (R.R. XXXVI - 39-
40, 53-54, 58). White said the cause of Miranda's death was blunt force
7
injuries of the head and brain with cocaine intoxication as a contributing
factor. He ruled the manner of death to be homicide. White could not say
how many blows Miranda received but there were at least 20-30 areas of
contusion on her body, including evidence of perhaps dozens of impacts to
all areas of her head--back, under the chin, front, either side, and top. The
bruising around Miranda's eyes, ear, surrounding face, and scalp, which was
edematous, was due to recent impact. He could also not say how hard she
was struck except that it was hard enough to produce fatal injury. He said it
was very unlikely that Miranda would die from falling off the stool. White
was of the opinion that the bruises to Miranda's back and chest were not the
result of resuscitation efforts. The bruises to Miranda's hips were consistent
with her being restrained and sexually assaulted from behind. (R.R. XXXVI
- 38-43, 55-57; XLI - State's Exh. 45; C.R. I - 31-36). Dr. White explained
that most fatal falls require at least 10 to 15 feet in height, but conceded that
“[f]alls from so-called ground level or falls from a very low level producing
fatal injuries are very, very rare; although they do occur.” (R.R. XXXVI -
41-42).
Dr. James Lukefahr, a pediatrician who devotes a large part of his
practice to child abuse, testified that he had reviewed the medical records
and photographs in the case, and was of the opinion that Miranda's injuries
8
were the result of a sexual assault. He discussed the various injuries to the
genital-anal area, noting in particular the large penetrating injury into the
perineal body. That injury was quite deep as evidenced by deeper tissues
which were visible in the photographs and the fact that a doctor had had to
repair it with sutures that were completely buried well beneath the surface of
the skin. Lukefahr said that the injuries were not consistent with a straddle
injury. The bruises on Miranda's hips were very unlikely to be accidental
because they were localized in an area that would generally be well
cushioned by clothing. Lukefahr opined that they were sustained during the
sexual assault and were probably the result of being restrained during the
time the really violent act of penetration was occurring in Miranda's anal
area. The injuries were also unusually symmetrical. They were more
consistent with Miranda being conscious and struggling when they occurred
than being sustained when she was unconscious. There was a suggestion that
Miranda's anus had been penetrated but Lukefahr could not say for sure. The
fact that semen was not found did not change Lukefahr's opinion that a
sexual assault had occurred. He felt that most of the injuries were most
consistent with having been caused by contact with an object which was in
motion, so that the skin basically was rubbed off in those areas. The really
deep wound in the perineal body, on the other hand, was a penetrating injury,
9
caused by an object penetrating into the substance of the perineal body. It
would have taken a very substantial amount of penetrating force to have
caused that injury because that area of the body has a lot of resilience and
padding. There was no way to know whether that injury was caused by a
man's penis or some other foreign object.
Vasquez testified in his own defense that he was mad and hit Miranda
in the head. While he acknowledged hitting her in the head, Vasquez denied
hitting her in her face. She was not doing anything wrong that required
discipline. He claimed to not know how many times he hit her. Although in
his written statement, Vasquez said he held Miranda by the head when he hit
her, he testified that he did not do so. (R.R. XXXVII - 92-94, 116-117, 121-
122, 135). When Miranda appeared, she looked dazed and could not keep
her head up. Vasquez knew something was wrong with her. He told her to
get her stool from his parents' room and go brush her teeth. As she returned
with the stool, she fell down. She still could not keep her head up. (R.R.
XXXVII - 94-96, 112-113, 136). Vasquez later went into the bathroom and
found her with her head down and toothpaste on her face, and still later went
back to the bathroom and found her with her head in the sink. He thought
she hit her head with the faucet although he could not recall what type of
faucet it was. (R.R. XXXVII - 96-97, 119-121). Vasquez repeatedly tried to
10
make Miranda stand by herself but she kept falling down. He then shook her
and asked her what was going on. As he did that, he took her into his parents'
bedroom and either threw or laid her on their bed. (R.R. XXXVII - 97-99,
117, 140). Vasquez said he did not try to kill Miranda and he did not know
what his intent was when he hit her. He did not remember whether he had hit
her until she became unconscious. (R.R. XXXVII - 110, 134-135, 140-141,
147). Vasquez admitted that he was the only adult in the house that
morning. (R.R. XXXVII - 113, 125-126).
STATE’S RESPONSE TO THE PRESENT CLAIMS
The crux of all of Vasquez’s claims in this subsequent writ is that new
scientific evidence supposedly shows that the victim’s fall from a small stool
might reasonably have caused her fatal injury, contradicting trial testimony
from Dr. Burke and Dr. White implying that this was not a plausible theory.
Specifically, in the “Introduction” to his application, Vasquez asserts that
“[i]n light of modern scientific knowledge, it is now clear that the child had
actually died after falling from a stool, and that the science underlying the
State experts’ conclusions [that Vasquez beat her to death] was
fundamentally flawed.” (Subsequent Application p. 6) In discussing his
primary claim, Vasquez further explains his claim that “science has now
clarified that short falls, such as the one taken by Miranda from the stool,
11
can and in fact do cause the type of catastrophic head injury observed upon
Miranda’s arrival in the emergency room.” (Subsequent Application p. 16)
Vasquez’s other claims of new evidence regarding Shaken Infant Syndrome,
biomechanics, and Second Impact Syndrome are either dependent upon the
validity of the fall theory or are clearly unsupported and insufficient to
justify relief.
Certainly it might be possible to imagine a case where the defendant
claimed at trial that the victim fell from a sufficient height to have caused a
fatal injury, where that theory was discredited by expert testimony
considered valid at the time, and where new scientific evidence would
suggest that the theory in question was a valid explanation for the fatal
injury based on data comparing substantially similar fatal and non-fatal falls.
Such a case might justify relief under Article 11.073. This is not that case,
for many reasons.
This was not a case of a single head injury that could equally have
been explained by either an intentional blow or an accidental fall. It was
multiple blows to the head, as admitted by Vasquez himself, causing severe
and extensive injury to the brain. This was not a case of an otherwise loving
parent who had no proclivity to hurt the child in question. Vasquez was
clearly an abusive parental figure by anyone’s measure, who the evidence
12
suggests not only hit the victim but also lethally injected her with cocaine
and sexually assaulted her. This was not a case of an accidental fall from
two-to-ten feet in the air. It was a stepping stool depicted in SX # 16 and
which the State has measured to be approximately 10&1/2 inches high. (See
Appendices A & B). This is not a case where the fall in question had been
seen by some disinterested witness or otherwise verified. Vasquez was the
only adult home at the time, the emergency responders did not even see the
stool in question, and no toothpaste was found in the victim’s mouth, in spite
of the fact that she had supposedly been brushing her teeth when she fell and
lost consciousness.
Supporting Affidavits.
Vasquez has attempted to support his “new science” allegations with
attached affidavits from two pathologists, Dr. Thomas Young and Dr.
Waney Squier. These affidavits fall far short.
Dr. Young’s Affidavit.
Dr. Young, in his affidavit, pointed to two journal articles that
supposedly “falsified the notion that short falls do not cause death in
children.” (Exhibit A, Young Affidavit p. 3) However the two medical
articles cited by Dr. Young do not even involve fatal brain injuries from falls
that could reasonably be compared with the present short fall from a
13
10&1/2-inch stool by four-year-old Miranda.
Fatal Pediatric Head Injuries Caused by Short-Distance Falls (See
Appendix C) – The only children four years and older who died from falls
fell from at least three feet or from an undetermined height at least two feet
but possibly as much as six to eight feet, these being falls from a swing. The
falls in the study were from playground equipment and not from falling off
something like a stool in the home. It stands to reason that the dynamics and
motions involved in falling from a swing or other movable playground
equipment are different from those involving in falling from a stationary
stool, as well as the nature of the surface or structure onto which the child
fell.
Delayed Sudden Death in an Infant Following an Accidental Fall
(See Appendix D) – The case study involved only one death of a nine-
month-old, who fell from a bed some 30 inches high, onto a concrete floor.
The authors of the case study admit that “lethality of short falls … are still
controversial. One widely held belief is that short falls are almost never
fatal.” The authors further submit, “We do not argue the widely noted
observation that simple falls from low heights rarely result in significant
primary brain injury.” (p. 373)
Moreover, both of these articles are based strictly on data from cases
14
where the falls in question did cause death, and do not contain data or
comparisons with cases of non-fatal falls. Accordingly, there is no attempt
in either article to address the frequency with which short falls of this nature
are fatal or to refute the proposition that in the vast majority of cases short
falls are not fatal, as is consistent with Dr. Burke’s and Dr. White’s
testimony at trial.
Although Dr. Young also disagreed with certain statements made by
Dr. Burke at trial concerning Shaken Baby Syndrome and comparison with
injuries suffered in a high speed car accident, and with Dr. White and Dr.
James Lukefahr’s opinions concerning sexual assault , he offered nothing to
support a “new science” claim on these grounds. (Exhibit A, Young
Affidavit pp. 3-4)
Dr. Squier’s Affidavit.
Dr. Squier, in her affidavit, asserted that “Miranda’s primary cause of
death was blunt force injuries to the head consistent with a fall from a stool,”
and that “[t]he strikes to Miranda’s head by Mr. Vasquez, on their own, were
probably insufficient to cause fatal injuries.” However, she bases this
conclusion on an unverified assumption that Vasquez, the only adult present
at the time, was telling the truth about the sequence of events at the time of
the injury. (Exhibit B, Squire Affidavit p. 2)
15
Dr. Squier also disagreed with Dr. Burke’s Shaken Baby Syndrome
and high speed accident analogies, but not based on any “new science.” On
the contrary, Dr. Squier attempts to support her assertions based on a study
published in 1987, well before Vasquez’s trial. (Exhibit B, Squire Affidavit
p. 3, n.2)
The only assertions that Dr. Squier makes that are arguably supported
by new science involve her Second-Impact Syndrome claim that Miranda
died as a result of the combined impact of being initially hit by Vasquez and
then falling from the stool. (Exhibit B, Squire Affidavit p. 4) However, as
discussed below, under Texas’ law concerning concurrent causation, this
would not have relieved Vasquez of responsibility for the death.
Concurrent Causation.
With regard to causation, the Penal Code provides that “[a] person is
criminally responsible if the result would not have occurred but for his
conduct, operating either alone or concurrently with another cause, unless
the concurrent cause was clearly sufficient to produce the result and the
conduct of the actor clearly insufficient.” Tex. Pen. Code Ann. § 6.04 (a).
The Court of Criminal Appeals has interpreted this to mean that, “[i]f the
additional cause, other than the defendant's conduct, is clearly sufficient, by
itself, to produce the result and the defendant's conduct, by itself, is clearly
16
insufficient, then the defendant cannot be convicted.” Robbins v. State, 717
S.W.2d 348, 351 (Tex. Crim. App. 1986); see also Turner v. State, 435
S.W.3d 280, 283 (Tex. App.—Waco 2014, pet. ref’d).
In the present case, there is no showing that Vasquez’s repeated blows
to Miranda’s head were clearly insufficient to cause her death, and it remains
highly unlikely that her fall from a short stool would have been sufficient, by
itself, to cause the death. Accordingly, even under the supposedly newly-
developing science of Second-Impact Syndrome, Vasquez cannot escape
responsibility for her murder.
In addition, Vasquez’s initial blows arguably themselves caused
Miranda to be in such a dazed state that she fell from the stool in question,
making the second impact as well a direct result of his own conduct.
The Prejudice Prong.
In order to prevail under 11.073, the Court not only has to find that
there is new, admissible, previously unavailable scientific evidence, but also
that “had the scientific evidence been presented at trial, on the
preponderance of the evidence, the person would not have been convicted.”
(Emphasis added).
In the present case, even if some or all of the “new science”
arguments are found to have some validity, it is highly unlikely that this new
17
science would have changed the outcome, as the evidence of guilt was
overwhelming.
PRAYER
WHEREFORE, the State prays that the Court will dismiss as abusive
the present subsequent application for writ of habeas corpus and deny the
motion to stay execution.
Respectfully submitted,
/s/ Douglas K. Norman
___________________
Douglas K. Norman
State Bar No. 15078900
Assistant District Attorney
105th Judicial District of Texas
901 Leopard, Room 206
Corpus Christi, Texas 78401
(361) 888-0410
(361) 888-0399 (fax)
CERTIFICATE OF SERVICE
This is to certify that a copy of this document was e-served on April
18, 2015, on Applicant’s attorneys, Mr. Andrew M. Edison,
Andrew.edison@emhllp.com, and Mr. James Chambers,
james.chambers@emhllp.com.
/s/ Douglas K. Norman
___________________
Douglas K. Norman
18
APPENDIX A
APPENDIX B
AFFIDAVIT
THE STATE OF T E X A S
C O U N T Y OF N U E C E S
B E F O R E M E , the undersigned authority, on this day personally
appeared John Mitchell, who after being by me duly swom upon oath says:
M y name is John Mitchell and I am a Deputy District Clerk for
Nueces County and the Records Management Supervisor for the office. I
am over 18 years of age, I have never been convicted of a crime, and I am
tliliy competent to make this affidavit. I have personal knowledge of the
facts stated herein, and they are all true and correct.
On A p r i l 17, 2015,1 reviewed the attached photographs of a stool that
had been admitted into evidence as SX#9 in the murder trial o f Richard
Vasquez, Cause N o . 98-CR-0730-E, in the 14^^^ District Court of Nueces
County, Texas, and that I am presently holding as custodian ofthe evidence.
The attached photographs, with tape measure next to them, accurately
show the height of the stool, which was measured to be approximately 10
&1/2 inches t a l l
Further affiant saith naught.
Subscribed and sworn to before me by the said John Mitchell this 17th day o f
A p r i l , 2015, to certify which witness my name and seal of office.
2
APPENDIX C
r
I
I The
American Journal of
Forensic Medicine
and Pathology
Volume 22 Number I March 2001
1 Fatal Pediatric Head Injuries Caused by Short-Distance Falls
John Plunkett
13 Case Report of Sudden Death After a Blow to the Baell' of the Neck
Gregory G. Davis and Jay M. Glass
19 Sudden Cardiac Death and Right Ventricular Dysplasia
E. N. Michalodirnitrakis, D. D.-A. Tsiftsis, A. M. Tsatsakis, and I. Stiakakis
23 Simultaneous Sudden Infant Death Syndrome: A Proposed Definition and Worldwide Review of Cases
Steven A. Koehler, Shaun Ladham, Abdulrezzak Shakir, and Cyril H. Wecht
33 Simultaneous Sudden Infant Death Syndrome: A Case Report
Shaun Ladham, Steven A. Koehler, Abdulrezzak Shakir, and Cyril H. Wecht
(Continued)
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Fatal Pediatric Head.Injuries Caused by Short-Distance Falls
John Plunkett, M.D.
Physicians disagree on several issues regarding head in- Many physicians believe that a simple fall can-
jury in infants and children, including the potential not cause serious injury or death (1-9), that a
lethality of a short-distance fall, a lucid interval in an ul- lucid interval does not exist in an ultimately fatal
timately fatal head injury, and the specificity of retinal
hemorrhage for inflicted trauma. There is scant objective pediatric head injury (7-13), and that retinal hem-
evidence to resolve these questions, and more informa- orrhage is highly suggestive if not diagnostic for
tion is needed. The objective of this study was to deter- inflicted trauma (7,12,14-21). However, several
mine whether there are witnessed or investigated fatal have questioned these conclusions or urged cau-
short-distance falls that were concluded to be accidental. tion when interpreting head injury in a child
The author reviewed the January l, 1988 through June
30, 1999 United States Consumer Product Safety Com- (15,22-28). This controversy exists because most
mission database for head injury associated with the use infant injuries occur in the home (29,30), and if
of playground equipment. The author obtained and re- there is history of a fall, it is usually not witnessed
viewed the primary source data (hospital and emergency or is seen only by the caretaker. Objective data are
medical services' records, law enforcement reports, and needed to resolve this dispute. It would be helpful
coroner or medical examiner records) for all fatalities in-
volving a fall. if there were a database of fatal falls that were
The results revealed 18 fall-related head injury fatali- witnessed or wherein medical and law enforce-
ties in the database. The youngest child was 12 months ment investigation unequivocally concluded that
old, the oldest 13 years. The falls were from 0.6 to 3 me- the death was an accident.
ters (2-10 feet). A noncaretaker witnessed 12 of the 18, The United States Consumer Product Safety
and 12 had a lucid interval. Four of the six children in
whom funduscopic examination '"'as documented in the Commission (CPSC) National Injury Information
n1edical record had bilateral retinal hemorrhage. The au- Clearinghouse uses four computerized data sources
thor concludes that an infant or ciiild may suffer a fatal (31). The National Electronic Injury Surveillance
bead injury from a fall of less than 3 meters (10 feet). System (NEISS) file collects current injury data as-
The injury may be associated with a lucid interval and sociated with 15,000 categories of consumer prod-
bilateral retinal hemorrhage.
Key Words: Child abuse-Head injury-Lucid interval- ucts from 101 U.S. hospital emergency depart-
Retinal hemorrhage-Subdural hematoma. ments, including 9 pediatric hospitals. The file is a
probability sample and is used to estimate the num~
ber and types of consumer product-related injuries
each year (32). The Death Certificate (DC) file is a
demographic summary created by information pro-
vided to the CPSC by selected U.S. State Health
Departments. Tbe Injury/Potential Injury Incident
(IR) file contains sun1Illaries, indexed by consun1er
product, of reports to the CPSC from consumers,
medical examiners and coroners' (Medical Exam-
iner and Coroner Alert Project [MECAP]), and
newspaper accounts of product-related incidents
discovered by local or regional CPSC staff (33).
The In-Depth Investigations (AI) file contains sum-
maries of investigations performed by CPSC staff
1\1anuscript received April 10, 2000; revised September 15, based on reports received from the NEISS, DC, or
2000; accepted September 24, 2000. IR files (34). The AI files provide details about
From the DepartmentS of Pathology and Medical Education,
Regina Medical Center, 1175 Nininger Road, Hastings MN the incident from victim and witness interviews,
55033, U.S.A.; Email: plunkettj@reginarnedical.com. accident reconstruction, and review of law enforce-
I
2 J. PLUNKETT
ment, health care facility, and coroner or medical be the highest point of the arc. Twelve of the 18
examiner records (if a death occurred). falls were witnessed by a noncaretaker or were
videotaped; 12 of the children had a lucid interval
(5 minutes-48 hours); and 4 of the 6 in whom fun-
METHODS
duscopic examination was performed had bilateral
I reviewed the CPSC, DC, IR, and AI files for all retinal hemorrhage (Table 1).
head and neck injuries involving playground equip-
ment recorded by the CPSC from January 1, 1988
through June 30, 1999. There are 323 entries in the CASES
playground equipment IR file, 262 in the AI file, 47
Case 1
in the DC file, and more than 75,000 in the NEISS
This 12-month-old was seated on a porch swing
file. All deaths in the NEISS file generated an IR or
between her mother and father when the chain on
AI file. If the file indicated that a death had oc-
her mother's side broke and all three fell sideways
curred from a fall, I obtained and reviewed each
and backwards 1.5 to 1.8 meters (5-6 feet) onto
original source record from law enforcement, hos-
decorative rocks in front of the porch. The mother
pitals, emergency medical services (EMS), and
fell first, then the child, then her father. It is not
coroner or medical examiner offices except for one
known if her father landed on top of her or if she
autopsy report. However, I discussed the autopsy
struck only the ground. She was unconscious im-
findings with the pathologist in this case.
mediately. EMS was called; she was taken to a
local hospital; and was ictal and had decerebrate
RESULTS posturing in the emergency room. She was intu-
bated, hyperventilated, and treated with mannitol.
There are 114 deaths in the Clearinghouse data-
A computed tomography (CT) scan indicated a
base, 18 of which were due to head injury from a
subgaleal hematoma at the vertex of the skull, a
fall. The following deaths were excluded from this
comrninuted fracture of the vault, parafalcine sub-
study: those that iuvolved equipment that broke or
dural hemorrhage, and right parietal subarachnoid
collapsed, striking a person on the head or neck
hemorrhage. There was also acute cerebral edema
(41); those in which a person became entangled in
with effacement of the right frontal horn and com-
the equipment and suffocated or was strangled (45),
pression of the basal cisterns. She had a cardiopul-
those that involved equipment or incidents other
monary arrest while the CT scan was being done
than playground (6 [including a 13.7-meter fall
and could not be resuscitated.
from a homemade Ferris wheel and a 3-meter fall
from a cyclone fence adjacent to a playground]);
and falls in which the death was caused exclusively Case2
by neck (carotid vessel, airway, or cervical spinal A 14-month-old was on a backyard "see-saw"
cord) injury (4 ). and was being held in place by his grandmother.
The falls were from horizontal ladders (4), The grandmother said that she was distracted for a
swings (7), stationary platforms (3), a ladder at- moment and he fell backward, striking the grass-
tached to a slide, a "see-saw'', a slide, and a retain- covered ground 0.6 meters (22.5 inches) below the
ing wall. Thirteen occurred on a school or public plastic seat. He was conscious but crying, and she
playground, and five occurred at home. The data- carried him into the house. Within 10 to 15 minutes
base is uot limited to infants and children, but a he became lethargic and limp, vomited, and was
13-year-old was the oldest fatality (range: 12 taken to the local hospital by EMS personnel. He
months-13 years; mean, 5.2 years; median, 4.5 was unconscious but purposefully moving all ex-
years). The distance of the fall, defined as the dis- tremities when evaluated, and results of fundus-
tance of the closest body part from the ground at copic examination were normal. A CT scan indi-
the beginning of the fall, could be determined from cated an occipital subgaleal hematoma, left-sided
CPSC or law enforcement reconstruction and actual cerebral edema with complete obliteration of the
measurement in 10 cases and was 0.6 to 3.0 meters left frontal horn, and small punctate hemorrhages
(mean, 1.3 ± 0.77; median, 0.9). The distance in the left frontal lobe. There was no fracture or
could not be accurately determined in the seven fa- subdural hematoma. He was treated with mannitol;
talities involving swings and one of the falls from a his level of consciousness rapidly improved; and he
horizontal ladder, and may have been from as little was extubated. However, approximately 7 hours I
as 0.6 meters to as much as 2.4 meters. The maxi- after admission he began to have difficulty breath-
mum height for a fall from a swing was assumed to ing, both pupils suddenly dilated, and he was rein-
A1n J Forensic Med Pathol, VoL 22. No. 1, March 2001 I
j
TABLE 1. Summary of cases
Lucid Retinal Subdural
No. CPSC No. Age Sex Fall from Distance M/F Witnesse;d interval hemorrhage hemorrhage Autopsy Cause of death FP
DC 9108013330 12 mos F Swing 1.5--1.8/5.0-6.0 No No N/R Yes +IHF No Complex calvarial fracture No
with edema and
contusions
2 Al 890208HBC3088 14 mos M See~saw 0.6/2.0 No 10-15 No No No Malignant cerebral edema No
minutes with herniation
3 IR F910368A 17 mos F Swing 1.5-1.8/5.0-6.0 No No N/R Yes +IHF Yes Acute subdural hematorna Yes
wit~.secondary cerebral
edema
4 Al 921001 HCC2263 20 mos F Platform 1.1/3.5 No 5-10 Bilateral Yes +IHF Limited Occipital fracture with Yes
minutes multilayered subdural/subarachnoid ~
hemorrhage progreSsing S2
to cerebral edema and r
5' DC 9312060661 23 mos F Platform 0.70/2.3 Yes 10 minutes Bilateral, NOS Yes Yes
herniation
Acute subdural hematoma Yes ~
;,,:
6 DC 9451016513 26 mos M Swing 0.9-1 c8/3.0-6.0 Yes No Bilateral Yes +IHF Yes Subdural hematoma··Yflth Yes ti
multi!ayered associated cerebral
edema ~
<..,
7' Al 891215HcC2094 3 yrs M Platform 0.9/3.0 Yes 10 minutes N/R Yes No Acute cerebral edema with
"
8 Al 910515HCC2182 3 yrs F Ladder 0.6/2.0 yes 15 minutes N/R Yes Yes
herniation
Complex calvarial fracture,
No
Yes ~
' (autopsy only) contusions, cerebral t;J
~
edema with herniation
9 DC 9253024577 4 yrs M Slide 2.1/7.0 Yes 3 hours N/R No Yes Epidural hematoma Yes
10 Al920710HIVE4014 5 yrs M Horizontal
ladder
2.1/7.0 No No N/R Yes No Acute subdural hematoma
with acute cerebral
Yes ~
edema ~
11 Al 960517HCC5175 6 yrs M Swing 0.6-2.4/2.0-8.0 No 10 minutes No Yes +IHF No Acute subdural hematoma Yes a
;,,,
12 Al 970324HCC3040 6 yrs M Horizontal 3.0/10.0 Yes 45 minutes N/R No No Malignant cerebral edema Yes
ladder with herniation
';-I
,,. 13 Al 881229HCC3070 6 yrs F Horizontal
ladder
0.9/3.0 Yes 1 +hour N/R Yes +IHF Yes Subdural and subarachnoid
hemorrhage, cerebral
Yes ti
[;i
~
'-. infarct, and edema
:ii 14 Al 930930HIVE5025 7 yrs M Horizontal 1.2-2.4/4.0-8.0 Yes 48 hours N/R No Yes Cerebral infarct secondary Yes
,
",.
<
ladder to carotid/vertebral artery
thrombosis
f;l
.
~ 15
16
Al 970409HCC1096
Al 890621 HCC3195
8 yrs
10 yrs M
F Retaining
.wall
Swing
0.9/3.0
0.9-1.5/3.0-5.0
Yes
Yes
12+ hours
10 minutes
N/R
Bilateral
Yes
(autopsy only)
Yes
Yes
Yes
Acute subdura! hematoma
Acute subdural hematoma
Yes
No
;,;,
~
"'""
0
~
mum layered contiguous with an AV
malformatiorl
/ii
~ 17 Al 920428HCC1671 12 yrs F Swing 0.9-1.8/3.0-6.0 Yes No N/R No Yes Occipital fracture With Yes
,..,
N extensive contra-coup
contusions
,..~
18 Al 891016HCC1511 13 yrs F Swing 0.6-1.8/2.0-6.0 Yes No N/R Yes +IHF Yes Occipital fracture, subdural Yes
hemorrhage 1 cerebral
edema
§:
,.
Cl ~he original CT scan for case #7 and the soft tissue CT windows for case #5 could not be located and were unavailable for review.
N CPSC, Consumer Products Safety Commission; Al, accident investigation; IR, incident report; DC, death certificate; M, male; F, female; Distance, the distance of the closest body part
§ from the ground at the start of the fall (see text); M/F, meters/feet; Witnessed, witnessed by a noncaretaker or videotaped; N/R, not recorded; IHF, including interhemispheric or fa!x; FP,
forensic pathologist-directed death investigation system. "'
4 J. PLUNKETT
tubated. A second CT scan demonstrated progres- Cases
sion of the left hemispheric edema despite medical A 23-month-old was playing on a plastic gym set
management, and he was removed from life sup- in the garage at her home with her older brother.
port 22 hours after admission. She had climbed the attached ladder to the top rail
above the platform and was straddling the rail, with
her feet 0.70 meters (28 inches) above the floor.
Case3 She lost her balance and fell headfirst onto a I-cm
This 17-month-old had been placed in a baby
(%-inch) thick piece of plush carpet remnant cover-
carrier-type swing. attached to an overhead tree
ing the concrete floor. She struck the carpet first
limb at a daycare provider's home. A restraining
with her outstretched hands, then with the right
bar held in place by a snap was across her waist.
front side of her forehead, followed by her right
She was being pushed by the daycare provider to
shoulder. Her grandmother had been watching the
an estimated height of 1.5 to 1.8 meters (5-6 feet)
children play and videotaped the fall. She cried
when the snap came loose. The child fell from the
after the fall but was alert and talking. Her grand-
swing on its downstroke, striking her back and
mother walked/carried her into the kitchen, where
head on the grassy surface. She was immediately
her mother gave her a baby analgesic with some
unconscious and apneic but then started to breathe
water, which she drank. However, approximately 5
spontaneously. EMS took her to a pediatric hospi-
minutes later she vomited and became stuporous.
tal. A CT scan indicated a large left-sided sub-
EMS personnel airlifted her to a tertiary-care uni-
dural hematoma with extension to the interhemi-
versity hospital. A CT scan indicated a large right-
spheric fissure anteriorly and throughout the length
sided subdural hematoma with effacement of the
of the falx. The hematoma was surgically evacu-
right lateral ventricle and minimal subfalcine herni-
ated, but she developed malignant cerebral edema
ation. (The soft tissue windows for the scan could
and died the following day. A postmortem exami-
not be located and were unavailable for review.)
nation indicated symmetrical contusions on the
The hematoma was immediately evacuated. She re-
buttock and midline posterior thorax, consistent
mained comatose postoperatively, developed cere-
with impact against a fiat surface; a small residual
bral edema with herniation, and was removed from
left-sided subdural hematoma; cerebral edema
life support 36 hours after the fall. Bilateral retinal
with anoxic encephalopathy; and uncal and cere-
hemorrhage, not further described, was docu-
bellar tonsillar herniation. There were no cortical
mented in a funduscopic examination performed 24
contusions.
hours after admission. A postmortem examination
confirmed the right frontal scalp impact injury.
Case4 There was a small residual right subdural hema-
A 20-month-old was with other family members toma, a right parietal lobe contusion (secondary to
for a reunion at a public park. She was on the plat- the surgical intervention), and cerebral edema with
form portion of a jungle gym when she fell from cerebellar tonsillar herniation.
the side and struck her head on one of the support
posts. The platform was 1.7 meters (67 inches) Case6
above the ground and I.I meters (42 inches) above A 26-month-old was on a playground swing
the top of the support post that she struck. Only her being pushed by a 13-year-old cousin when he fell
father saw the actual fall, although there were a backward 0.9 to 1.8 meters (3--6 feet), striking his
number of other people in the immediate area. She head on hard-packed soil. The 13-year-old and sev-
was initially conscious and talking, but within•5 to eral other children saw the fall. He was immedi-
10 minutes became comatose. She was taken to a ately unconscious and was taken to a local emer-
nearby hospital, then transferred to a tertiary-care gency room, then transferred to a pediatric hospital.
facility. A CT scan indicated a right occipital skull A CT scan indicated acute ' cerebral edema and a
fracture with approximately 4-mm of depression small subdural hematoma adjacent to the anterior
and subarachnoid and subdural hemorrhage along interhemispheric falx. A funduscopic examination
the tentorium ·and posterior falx. Funduscopic ex- performed 4 hours after admission indicated exten-
amination indicated extensive bilateral retinal and sive bilat~ral retiqal hemorrhage, vitreous hemor-
preretinal hemorrhage. She died 2 days later be- rhage in the left eye, and papilledema. He had a
cause of uncontrollable increased intracranial pres- subsequent cardiopulmonary arrest and could not
sure. A limited postmortem examination indicated be resuscitated. A postmortem examination con-
an impact subgaleal hematoma overlying the frac- firmed the retinal hemorrhage and indicated a right
ture in the mid occiput. parietal scalp impact injury but no calvarial frac-
Am J Forensic Med Pathol, Vol. 22, No. I, March 2001
FATAL HEAD INJURIES WITH SHORT-DISTANCE FALLS 5
ture, a "film" of bilateral subdural hemorrhage, Case9
cerebral edema with herniation, and· focal hemor- A 4-year-old fell approximately 2.1 meters (7
rhage in the right posterior midbrain and pons. feet) from a playground slide at a state park, land'
. ing on the dirt ground on his buttock, then falling to
Case7 his left side, striking his head. T:ljere was no loss of
This 3-year-old with a history of TAR (thrombo- consciousness, but his family took him to a local
cytopenia-absent radius) syndrome was playing emergency facility, where an'. evaluation was nor-
with other children on playground equipment at his mal. However, be began vomiting and complained
school when he stepped through an opening in a of left neck and bead pain approximately 3 hours
platform. He fell 0.9 meters (3 feet) to the hard- later. He was taken to a second hospital, where a
packed ground, striking his face. A teacher wit- CT scan indicated a large left parietal epidural
nessed the incident. He was initially conscious and hematoma with a midline shift. He was transferred
able to walk. However, approximately 10 minutes to a pediatric hospital and the hematoma was evac-
later he had projectile vomiting and became co- uated, but he developed malignant cerebral edema
matose, was taken to a local hospital, and subse- with right occipital and left parietal infarcts and
quently transferred to a pediatric hospital. A CT was removed from the respirator 10 days later. A
scan indicated a small subdural hematoma and dif- postmortem examination indicated a small residual
fuse cerebral edema with uncal herniation, accord- epidural hematoma, marked cerebral edema, bilat-
ing to the admission history and physical examina- eral cerebellar tonsillar and uncal herniation, and
tion. (The original CT report and scan could not be hypoxic encephalopathy. There was no identifiable
located and were unavailable for review.) His skull fracture.
platelet count was 24,000/mm3 , and he was treated
empirically with platelet transfusions, although he Case 10
had no evidence for an expanding extra-axial mass. A 5-year-old was apparently walking across the
Resuscitation was discontinued in the emergency horizontal ladder of a "monkey bar," part of an in-
room. terconnecting system of homemade playground
equipment in his front yard, when his mother
Case8 looked out one of the windows and saw him laying
This 3-year-old was at a city park with an adult face down on the ground and not moving. The hor-
neighbor and four other children, ages 6 to 10. She izontal ladder was 2.1 meters (7 feet) above com-
was standing on the third step of a slide ladder 0.6 pacted dirt. EMS were called, be was taken to a
meters (22 inches) above the ground when she fell local hospital, and then transferred to a pediatric
forward onto compact dirt, striking her head. The hospital. A CT scan indicated a right posterior tem-
other children but not the adult saw the fall. She poral linear fracture with a small underlying
was crying but did not appear to be seriously in- epidural hematoma, a 5-mm thick acute subdural
jured, and the neighbor picked her up and brought hematoma along the right temporal and parietal
her to her parents' home. Approximately 15 min- lobes, and marked right-sided edema with a 10-mm
utes later she began to vomit, and her mother called midline shift. He was hyperventilated and treated
EMS. She was taken to a local emergency room, with mannitol, but the hematoma continued to en-
then transferred to a pediatric hospital. She was ini- large and was surgically evacuated. However, he
tially lethargic but responded to hyperventilation developed uncontrollable cerebral edema and was
and mannitol; she began to open her eyes with removed from life support 10 days after the fall.
stimulation and to spontaneously move all extre;ni-
ties and was extubated. However, she developed Case 11
malignant cerebral edema on the second hospital A 6-year-old was on a playground swing at a pri-
day and was reintubated and hyperventilated but vate lodge with his 14-year-old sister. His sister
died the following day. A postmortem examination heard a "thump,'' turned around, and saw him on
indicated a subgaleal hematoma at the vertex of the the grass-covered packed earth beneath the swing.
skull associated with a complex fracture involving The actual fall was not witnessed. The seat of the
the left frontal bone and bihiteral temporal bones. swing was 0.6 meters (2 feet) above the ground,
There were small epidural and subduraJ bematomas and the fall distance could have been from as high
(not identifiable on the CT scan), bilateral "contra- as 2.4 meters (8 feet). He was initially conscious
coup" contusions of the inferior surfaces of the and talking but within 10 minutes became co-
frontal and temporal lobes, and marked cerebral matose and was taken to a local emergency room,
eden1a with uncal herniation. then transferred to a tertiary-care hospital. A CT
Am J Forensic Nled Parhol, Vol. 22, No. 1, March 2001
6 J. PLUNKETT
scan indicated a large left frontoparietal subdural ture, subdural and subarachnoid hemorrhage, and a
hematoma with extension into the anterior inter- right cerebral hemisphere infarct. The infarct in-
hemispheric fissure and a significant midline shift cluded the posterior cerebral territory and was
with obliteration of the left lateral ventricle. There thought most consistent with thrombosis or dissec-
were no retinal hemorrhages. He was treated ag· tion of a right carotid artery that bad a persistent
gressively with dexamethasone and hyperventila- fetal origin of the posterior c'erebral artery. She
tion, but there was no surgical intervention. He died remained con1atose and was removed from the
the following day. respirator 6 days after admission. A postmortem
examination indicated superficial abrasions and
Case 12 contusions over the scapula, a prominent right pari-
This 6-year-old was at school and was sitting on etotemporal subgaleal bematoma, and a right pari-
the top crossbar of a "monkey bar" approximately 3 , eta! skull fracture. She bad a 50-ml subdural
meters (10 feet) above compacted clay soil when an bematoma and cerebral edema with global hypoxic
unrelated noncaretaker adult saw him fall from the or iscbemic injury ("respirator brain"), but the
crossbar to the ground. He landed flat on his back carotid vessels were normal.
and initially appeared to have the wind knocked out
of him but was conscious and alert. He was taken to Case 14
the school nurse who applied an ice pack to a con- A 7-year-old was on the playground during
tusion on the back of bis bead. He rested for ap- school hours playing on the horizontal ladder of a
proximately 30 minutes in the nurse's office and "monkey bar" when he slipped and fell 1.2 to 2.4
was being escorted back to class when be suddenly meters (4-8 feet). According to one witness, be
collapsed. EMS was called, and be was transported struck his forehead on the bars of the vertical lad-
to a pediatric hospital. He was comatose on admis- der; according to another eyewitness he struck the
sion, the fundi could not be visualized, and a bead rubber pad covering of the asphalt ground. There
CT scan was interpreted as normal. However, a CT are conflicting stories as to whether he had an ini-
scan performed the following morning approxi- tial loss of consciousness. However, he walked
mately 20 hours after the fall indicated diffuse cere- back to the school, and EMS was called because of
bral edema with effacement of the basilar cisterns the history of the fall. He was taken to a local hos-
and fourth ventricle. There was no identifiable sub- pital, where evaluation indicated a Glasgow coma
dural hemorrhage or cal varial fracture. He devel- score of 15 and a normal CT scan except for an oc-
oped transtentorial herniation and died 48 hours cipital subgaleal bematoma. He was kept overnight
after the fall. for observation because of the possible loss of con-
sciousness but was released the following day. He
Case 13 was doing homework at home 2 days after the fall
This 6-year-old was playing on a school play- when his grandmother noticed that he was stum-
ground with a 5th grade student/friend. She was bling and had slurred speech, and she took him
hand-over-hand traversing the crossbar of a "mon- back to the hospital. A second CT scan indicated a
key bar" 2.4 meters (7 feet 10 inches) above the left carotid artery occlusion and left temporal and
ground with her feet approximately 1 meter (40 parietal lobe infarcts. The infarcts and subsequent
inches) above the surface. She attempted to slide edema progressed; he had brainstem herniation;
down the pole when she reached the end of the and be was removed from life support 3 days later
crossbar but lost her grip and slid quickly to the (5 days after the initial fall). A postmortem exanli-
ground, striking the compacted dirt first with her nation indicated ischemic infarcts of the left pari-
feet, then her buttock and back, and finally 'her etal, temporal, and occipital lobes, acute cerebral
head. The friend inforn1ed the school principal of edema with herniation, and thrombosis of the left
the incident, but the child seemed fine and there vertebral artery. Occlusioli. of the carotid artery,
was no intervention. She went to a relative's home suspected premortem, could not be confirmed.
for after-school care approximately 30 minutes
after the fall, watched TV for a while, then com- Case 15
plained of a l\eadache and laid down for a nap. This 8-year-old was at a public playground near
When her parents arrived at the home later that her home· with se;,,eral friends her age. She was
evening, 6 hours after the incident, they discovered hanging by her hands from the horizontal ladder of
that she was incoherent and "drooling." EMS trans- a "monkey bar" with her feet approximately 1.1
ported her to a tertiary-care medical center. A CT meters (3.5 feet) above the ground when she at-
scan indicated a right parieto-occipital skull frac- tempted to swing from the bars to a nearby 0.9-
Am J Forensic Med Pathol, Vol. 22, No. J, March 2001
FATAL HEAD INJURIES WITH SHORT-DISTANCE FALLS 7
meter (34-inch) retaining wall. She landed on the lost her balance and fell 0.9 tol.8 )lleters (3-6 feet)
top of the wall but then lost her balance and fell to to the asphalt surface, striking her posterior thorax
the ground, either to a hard-packed surface (one and occipital scalp. She was inunediately uncon-
witness) or to a 5.1-cm (2-inGh) thick.resilient rub- scious and was taken to a tertiary-care hospital
ber mat (a second witness), striking her back and emergency room, where she was, pronounced dead.
head. She initially cried and complained of a A postmortem examination ii;idic'ated an occipital
headache but continued playing, then later went impact injury associated with an extensive com-
home. Her mother said that she seemed normal and minuted occipital fracture extending into both mid-
went to bed at her usual time. However, when her dle cranial fossa and "contra-coup" contusions of
mother tried to awaken her at approximately 8:30 both inferior frontal and temporal lobes.
the following morning (12 hours after the fall) she
complained of a headache and went back to sleep. Case 18
She awoke at 11 a.m. and complained of a severe This 13-year-old was at a public playground with
headache then became unresponsive and had a a friend. She was standing on the seat of a swing
seizure. EMS took her to a nearby hospital, but she with her friend seated between her legs when she
died in the emergency room. A postmortem exami- lost her grip and fell backwards 0.6 to 1.8 meters
nation indicated a right temporoparietal subdural (2-6 feet), striking either a concrete retaining wall
hematoma, extending to the base of the brain in the adjacent to the playground or a resilient 5.1-cm (2
middle and posterior fossae, with flattening of the inch) thick rubber mat covering the ground. She
gyri and narrowing of the sulci. (The presence or was immediately unconscious and was given emer-
absence of herniation is not described in the au- gency first aid by a physician who was nearby
topsy report.) There was no calvarial fracture, and when the fall occurred. She was taken to a nearby
there was no identifiable injury in the scalp or hospital and was purposefully moving all extremi-
galea. ties and had reactive pupils when initially evalu-
ated. A CT scan indicated interhemispheric sub-
Case 16 dural hemorrhage and generalized cerebral edema,
A 10-year-old was swinging on a swing at his which progressed rapidly to brain death. A post-
school's playground during recess when the seat de- mortem examination indicated a linear nonde-
tached from the chain and he fell 0.9 to 1.5 meters pressed midline occipital skull fracture, subdural
(3-5 feet) to the asphalt surface, striking the back of hemorrhage extending to the occiput, contusion of
his head. The other students but not the three adult the left cerebellar hemisphere, bifrontal "contra-
playground supervisors saw him fall. He remained coup" contusions, and cerebral edema.
conscious although groggy and was carried to the
school nurse's office, where an ice pack was placed
DISCUSSION
on an occipital contusion. He suddenly lost con-
sciousness approximately 10 minutes later. and General
EMS took him to a local hospital. He had decere- Traumatic brain injury (TBI) is caused by a force
brate posturing when initially evaluated. Fundus- resulting in either strain (deformation/unit length)
copic examination indicated extensive bilateral con- or stress (force/original cross-sectional area) of the
fluent and stellate, posterior and peripheral scalp, skull, and brain (35-37). The extent of injury
preretinal and subhyaloid hemorrhage. A CT scan depends not only on the level and duration of force
showed a large acute right frontoparietal subdural but also on the specific mechanical and geometric
hematoma with transtentorial herniation. i Trhe properties of the cranial system under loading
hematoma was surgically removed, but he devel- (38-40). Different parts of the skull and brain have
oped malignant cerebral edema and died 6 days later. distinct biophysical characteristics, and calculating
A postmortem examination indicated a right parietal deformation and stress is complex. However, an ap-
subarachnoid AV malformation, contiguous with a plied force causes the skull and brain to move, and
small amount of residual subdural hemorrhage, and acceleration, the time required to reach peak accel-
cerebral edema with anoxic encephalopathy and her- eration, and the duration of acceleration may be
niation. There was no calvarial fracture. measured at specific locations (36,41). These kine-
1natic parameters do not cause the . actual brain
Case 17 damage but are useful for analyzing TBI because
A 12-year-old was at a public playground with a they are easy to quantify. Research in TBI using
sister and another friend and was standing on the physical models and animal experiments has shown
seat of a swing when the swing began to twist. She that a force resulting in angular acceleration pro-
Am J Forensic Med Pathol, Vol. 22, No. I, March 2001
8 J PLUNKETT
duces primarily diffuse brain damage, whereas a ing surface is usually less than 5 milliseconds
force causing exclusively translational acceleration (39,59-61). Experimentally, impact duration longer
produces only focal brain damage (36). A fall from than 5 milliseconds will not cause a subdural
a countertop or table is often considered to be ex- hematoma unless the level of angular acceleration
clusively translational and therefore assumed inca- is above 1.75 X 105 rad/s 2 (61). A body in motion
pable of producing serious injury (3, 7-9). However, with an angular acceleration of 1.75 X 105 rad/s 2
sudden impact deceleration must have an angular has a tangential acceleration of 17 ,500 rn/s 2 at 0.1
vector unless the force is applied only through the meters (the distance from the midneck axis of rota-
center of mass (COM), and deformation of the tion to the midbrain COM in the Duhaime model).
skull during impact must be accompanied by a vol- A human cannot produce this level of acceleration
ume change (cavitation) in the subdural "space" by impulse ("shake") loading (62).
tangential to the applied force (41). The angular ' An injury resulting in a subdural hematoma in an
and deforn1ation factors produce tensile strains on infant may be caused by an accidental fall
the surface veins and mechanical distortions of the (43,44,64). A recent report documented the findings
brain during impact and may cause a subdural in seven children seen in a pediatric hospital emer-
hematoma without deep white matter injury or even gency room after an accidental fall of 0.6 to 1.5
unconsciousness (42-44). meters who had subdural hemon-hage, no Joss of
Many authors state that a fall from less than 3 consciousness, and no symptoms (44). The charac-
meters (10 feet) is rarely if ever fatal, especially if teristics of the hemon-hage, especially extension
the distance is Jess than 1.5 m~ters (5 feet) into the posterior interhemispheric fissure, have
(1-6,8,9). The few studies concluding that a short- been used to suggest if not confirm that the injury
distance fall may be fatal (22-24,26,27) have been was nonaccidental (9,62,65-68). The hemon-hage
criticized because the fall was not witnessed or was extended into the posterior interhemispheric fissure
seen only by the caretaker. However, isolated re- in 5 of the 10 children in this study (in whom the
ports of observed fatal falls and biomechanical blood was identifiable on CT or magnetic reso-
analysis using experimental animals, adult human nance scans and the scans were available for re-
volunteers, and models indicate the potential for se- view) and along the anterior falx or anterior inter-
rious head injury or death from as little as a 0.6- hemispheric fissure in an additional 2 of the 10.
meter (2-foot) fall (48-52). There are limited
experimental studies on infants (cadaver skull frac- Lucid Interval
ture) (53,54) and none on living subadult nonhu- Disruption of the diencephalic and midbrain por-
man primates, but the adult data have been extrap- tions of the reticular activating system (RAS)
olated to youngsters and used to develop the causes unconsciousness (36,69,70). "Shearing" or
Hybrid II/III and Child Restraint-Air Bag Interac- "diffuse axonal" injury (DAI) is thought to be the
tion (CRAB!) models (55) and to propose standards primary biophysical mechanism for immediate
for playground equipment (56,63). We simply do traumatic unconsciousness (36,71). Axonal injury
not know either kinematic or nonkinematic limits has been confirmed at autopsy in persons who had
in the pediatric population (57,58). a brief loss of consciousness after a head injury and
Each of the falls in this study exceeded estab- who later died from other causes, such as coronary
lished adult kinematic thresholds for traumatic artery disease (72). However, if unconsciousness is
brain injury (41,48-52). Casual analysis of the falls momentary or brief ("concussion") subsequent ~e
suggests that most were primarily translational. terioration must be due to a mechanism other than
However, deformation and internal angular acceler- DAI. Apnea and catecholamine release have been
ation of the skull and brain caused by the itnpact suggested as significant factors in the outcome fol-
produce the injury. What happens during the im- lowing head injury (73,74). In addition, the cen-
pact, not during the fall, determines the outcome. tripetal theory of traumatic unconsciousness states
that primary disruption of the RAS will not occur
Snbdural Hemorrhage in isolation and that structural brainstem damage
A "high strain" impact (short pulse duration and from inertial (impulse) or impact (contact) loading
high rate for deceleration onset) typical for a fall is must be accompanied by evidence for cortical and
more likely to cause subdural hemon-hage than a subcortical damage (36). This theory has been vali-
"low strain" in1pact (long pulse duration and low dated by magnetic resonance imaging and CT scans
rate for deceleration onset) that is typical of a in adults and children (75,76). Only one of the chil-
motor vehicle accident (42,61). The duration of de- dren in this study (case 6) had evidence for any
celeration for a head-impact fall against a nonyield- component of DAI. This child had focal hemor-
Am J Forensic Med Pathol, Vol. 22, No. 1, March 2001
FATAL HEAD INJURIES WITH SHORT-DISTANCE FALLS 9
rhage in the posterior midbrain and pons, thought amination and has been recommended as part of
by the pathologist to be primary, although there the evaluation of any pediatric patient with head
was no skull fracture, only "a film" of subdural trauma (89). None of the children in this study had
hemorrhage, no tears in thr:~corpus, _<;:allosum, and a formal retinal evaluation, and only six had fun-
no lacerations of the cerebral white matter (grossly duscopic examination .documented in the medical
or microscopically). record. Four of the six had bilateral retinal hemor-
The usual cause for delayed deterioration in in- rhage. '
fants and children is cerebral edema, whereas in
adults it is an expanding extra-axial hematoma Pre-existing Conditions
(77). If the mechanism for delayed deterioration One of these children (case 16) had a subarach-
(except for an expanding extra-axial mass) is ve- noid AV malformation that contributed to develop-
nospasm, cerebral edema may be the only morpho- ment of the subdural hematoma, causing his death.
logic marker. The "talk and die or deteriorate One (case 7) had-TAR syndrome (90), but his death
(TADD)" syndrome is well characterized in adults was thought to be caused by malignant cerebral
(78). Two reports in the pediatric literature discuss edema not an expanding extra-axial mass.
TADD, documenting 4 fatalities among 105 chil-
dren who had a lucid interval after head injury and Cerebrovascnlar Thrombosis
subsequently deteriorated (77,79). Many physicians Thrombosis or dissection of carotid or vertebral
believe that a lucid interval in an ultimately fatal arteries as a cause of delayed deterioration after
pediatric head injury is extremely unlikely or does head or neck injuries is documented in both adults
not occur unless there is an epidural hematoma and children (91,92). Case 14 is the first report of a
(7,8,11). Twelve children in this study had a lucid death due to traumatic cerebrovascular thrombosis
interval. A noncaretaker witnessed 9 of these 12 in an infant or child. Internal carotid artery throm-
z
0 falls. One child had an epidural hematoma. bosis was suggested radiographically in an addi-
-0
tional death (case 13) but could not be confirmed at
g autopsy. However, this child died 6 days after ad-
> Retinal Hemorrhage
mission to the hospital, and fibrinolysis may have
"
m The majority of published studies conclude that
retinal hemorrhage, especially if bilateral and pos- removed any evidence for thrombosis at the time
terior or associated with retinoschisis, is highly the autopsy was performed.
suggestive of, if not diagnostic for, nonaccidental
Limitations
injury (9,14-21). Rarely, retinal hemorrhage has
been associated with an accidental head injury, but 1. Six of the 18 falls were not witnessed or were
in these cases the bleeding was unilateral (80). It is seen only by the adult caretaker, and it is pos-
also stated that traumatic retinal hemorrhage may sible that another person caused the nonob-
be the direct mechanical effect of violent shaking served injuries.
(15). However, retinal hemorrhage may be caused 2. The exact height of the fall could be deter-
experimentally either by ligating the central retinal mined in only 10 cases. The others (7 swing
vein or its tributaries or by suddenly increasing in- and 1 stationary platform) could have been
tracranial pressure (81,82); retinoschisis is the re- from as little as 0.6 meters (2 feet) to as much
sult of breakthrough bleeding and venous stasis not as 2.4 meters (8 feet).
"violent shaking" (15,83). Any sudden increase in 3. A minimum impact velocity sufficient to
intracranial pressure may cause retinal hemorrhage cause fatal brain injury cannot be inferred
(84-87). Deformation of the skull coincident t& an from this study. Likewise, the probability that
impact nonselectively increases intracranial pres- an individual fall will have a fatal outcome
sure. Venospasm secondary to traumatic brain in- cannot be stated because the database depends
jury selectively increases venous pressure. Either on voluntary reporting and contractual agree-
mechanism may cause retinal hemorrhage irrespec- ments with selected U.S. state agencies. The
tive of whether the trauma was accidental or in- NEISS summaries for the study years esti-
flicted. Further, retinal and optic nerve sheath hem- mated that there were more than 250 deaths
orrhages associated with a ruptured vascular due to head and neck injuries associated with
malformation are due to an increase in venous pres- playground equipment, but there are only 114
sure not extension of blood along extravascular in the files. Further, this study does not in-
spaces (81-83,88). Dilated eye examination with an clude other nonplayground equipment-related
indirect ophthalmoscope is thought to be more sen- fatal falls, witnessed or not witnessed, in the
sitive for detecting retinal bleeding than routine ex- CPSC database (32).
Am J Forensic Med Pathol, Vol. 22, No. J, March 2001
10 J. PLUNKETT
CONCLUSIONS is not uniform (45). This analysis requires awareness
of the shape of the deceleration curve, knowledge of or
. fall is a complex event. There must be a
1. E very . . 'd . the mechanical properties and geometry of the cra- loc
biOme"chanical analysis for any inc1 ent 1n
nial system, and comprehension of the stress and cc
which the severity of the injnry appears .to be. strain characteristics for the specific part of the skull (n
lncOnsistent with the history. The question 1s
and brain that strikes the ground. A purely transla- (rr
not "Can an infant or child be seriously in-
tional fall requires that the body is rigid and that the ge
jured or killed from a short-distance fall?''. but
external forces acting on the body pass only through
rather "If a child falls (x) meters and strikes
the COM, i.e., there is no rotational component. A ! - L
a
his other head on nonyielding surface, what
meter-tall 3-year-old hanging by her knees from a
will happeu ?"
horizontal ladder with the vertex of her skull 0.5 me-
2. Retinal hemorrhage may occur whenever in-
ters above hard-packed earth approximates this
tracranial pressure exceeds venous pressure or
model. If she looses her grip and falls, striking the gL
whenever there is venous obstruction. The
occipital scalp, her impact velocity is 3.1 m/second. tic
characteristic of the bleeding cannot be used
An exclusively angular fall also requires that the
to determine the ultimate cause.
body is rigid. In addition, the rotation must be about
3. Axonal damage is unlikely to be the mecha-
a fixed axis or a given point internal or external to
nism for lethal injnry in a low-velocity impact
the body, and the applied moment and the inertial
such as from a fall. 2
moment must be at the identical point or axis. If this
4. Cerebrovascular thrombosis or dissection
same child has a 0.5-meter COM and has a "match-
must be considered in any injury with appar-
stick" fall while standing on the ground, again strik- 3
ent delayed deterioration, and especially in
ing her occiput, her angular velocity is 5.42 rad/sec-
one with a cerebral infarct or an unusual dis-
ond and tangential velocity 5.42 m/second at impact.
tribution for cerebral edema.
The impact velocity is higher than predicted for an 4
5. A fall from less than 3 meters (10 feet) in an in-
exclusively translational or external-axis angular fall
fant or child may cause fatal head injury and s
when the applied moment and the inertial moment
may not cause irrunediate syinptoms. The in-
are at a different fixed point (slip and fall) or when
jnry may be associated with bilateral retinal
the initial velocity is not zero (walking or running,
hemorrhage, and an associated subdural
then trip and fall), and the vectors are additive. How-
hematoma may extend into the interhemi-
ever, the head, neck, limbs, and torso do not move
spberic fissure. A history by the caretaker that
uniformly during a fall because relative motion oc-
the child may have fallen cannot be dismissed.
curs with different velocities and accelerations for
Acknowledgements: The author thanks the law en- each component. Calculation of the impact velocity
forcement, emergency medical services, and medical for an actual fall requires solutions of differential
professionals who willingly helped him obtain the origi- equations for each simultaneous translational and
nal source records and investigations; Ida Harper-Brown rotational motion (45). Fnrther, inertial or impulse
(Technical Information Specialist) and Jean Kennedy
(Senior Compliance Officer) from the U.S. CPSC, whose loading (whiplash) may cause head acceleration
enthusiastic assistance made this study possible; Ayub K. more than twice that of the midbody input force and
Ommaya. M.D., and Werner Goldsmith. Ph.D.• for criti- may be important in a fall where the initial impact is ](
cally reviewing the manuscript; Jan E. Leestrna, M.D., to the feet, buttock, back, or shoulder, and the final
and Faris A. Bandak, Ph.D., for helpful conunents; Mark impact is to the head (46,47).
E. Myers, M.D., and Michael B. Plunkett, M.D., for re-
view of the medical imaging studies; Jeanne Reuter and The translational motion of a rigid body at con-
Kathy Goranowski, for patience, humor, and completing stant gravitational acceleration (9.8 m/s 2 ) is calcu-
the manuscript; and all the families who shared ~e sto- lated from: 1:
ries of their sons and daughters and for whom this work
2
is dedicated. F =ma v = 2as v =at
where F = the sum of all forces acting on the body l
APPENDIX (newton), m = mass (kg), a = acceleration (rnls 2 ), [.
v =velocity (mis), s =distance (m), and t =time (s).
Newtonian mechanics involving constant acceler- The angular motion.of a rigid body about a fixed 1
ation may be used to determine the impact velocity axis at a given point of the body under constant
in a gravitational fall. However, c6nstant accelera- gravitational acceleration (9.8 m/s 2 ) is calculated
tion formulas cannot be used to calculate the rela- from:
tions among velocity, acceleration, and distance
traveled during an impact because the deceleration M =Ia
Am J Forensic Med Pathol, Vol. 22, No. 1, March 2001
FATAL HEAD INJURIES WITH SHORT-DISTANCE FALLS 11
!SS where M = the applied moment about the COM sociated systemic findings in suspected child abuse; a
necropsy study. Arch Opthalmol 1990;108:1094-101.
of or about the fixed point where the axis of rotation is 18. Williams DF, Swengel RM, Scbarre DW. Posterior seg-
~a located, I = the inertial moment about this same ment manifestations of ocular trauma. Retina 1990;10
nd COM or fixed point, a = angular acceleration (suppl):535-44.
19. Rosenberg NM, Singer J, Bolte R, et al. Retinal hemor-
111 (rad/s2 ), w = angular velocity. (radfs·), r = radius rhage. Pediatr Emerg Care 1994;10i303-5.
la- (m), v' = tangential velocity (mis), and a' = tan- 20. Swenson J, Levitt C. Shaken baby Syndrome: diagnosis
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21. Altman RL, Kutscher ML, Brand DA. The "shaken-baby
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a childhood falls. J Trauma 1989;29:1273--5.
lfI0 w2 = maL/2 I 0 = (1/3) rnL 2 23. Rieber GD. Fatal falls in childhood: how far must children
e- fall to sustain fatal head injury: report of cases and review
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60. Evans PG, Lissner HR, Lebow M. The relation of energy, rhage in an infant after cardiopulmonary resuscitation. Am
velocity, and acceleration to skull deformation and frac- J Forensic Med Pathol 1990;11:79-82.
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61. Gennarelli TA, Thibault LE. Blomechanics of acut6 sub- sociated with bungee jumping. Br J Ophthalmol 1994;78:
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62. Duhaime AC, Gennarelli TA. Thibault LE, et al. The 87. Jain BK, Talbot EM. Bungee jumping and intraoc.ular he-
shaken baby syndrome: a clinical, pathological and biome- morrhage. Br J Ophthalm·ot 1994;78:236-7,
chanical study. J Neurosurg 1987;66:409-15. 88, Edlow JA, Caplan LR. Avoiding pitfalls in the diagnosis of
63. Cory CZ. Assessing the severity of child head impacts onto subarachnoid hemorrhage. N Engl J Med 2000;342:29-36.
various domestic surface mixtures. :MPhil Thesis, School 89. Becker H, Gupta BK. Recognizing abusive head trauma in
of Engineering,' Cardiff University, Wales (UK). May children. JAMA 1999;282:1421.
1998. Avai1aple at: http://library.cf.ac.uk/ 90. Hall JG, Levin J, Kuhn JP, et al. Thrombocytopenia with
64. Howard MA, Bell BA, Uttley D. The pathophysiology of in- absent radius (TAR). Medicine (Baltitnore) 1969;48: 411-
fant subdural baematomas. BrJ Neurosurg 1993;7:355-65. 39.
65. Zimmerman RA, Bilaniuk LT, Bruce D, et al. Computed 9L Pozzati E, Giuliani G, Poppi M, FaenzaA. Blunt traumatic
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66. Merten DF, ·Osborne DRS. Craniocerebral trauma in the 92. Martin PJ, Enevoldson TP, Humphrey PRD. Causes of is-
child abuse syndrome. Pediatr Ann 1983;12:882-7. chaemic stroke in the young. PostgradMedJ 1997;73:8-16.
Am J Forensic Med Pathol, Vol. 22, No. J, March 2001
APPENDIX D
CASE REPORT
Delayed Sudden Death in an Infant Following an
Accidental Fall
A Case Report With Review of the Literature
Scott Denton, MD, and Darinka Mileusnic, MD, PhD
treated with nebulizer, was witnessed by his grandmother to
Abstract: Several controversies exist regarding ultimately lethal
head injuries in small children. Death from short falls, timing of fall backwards off the edge of a queen-sized bed, 30 inches
head injury, lucid intervals, presence of diffuse axonal inJUt)' (DAI), off the floor. The child was sitting on the edge of the bed as
and subdural hernatoma (SDH) as marker of DAI are the n1ost recent the grandmother dressed her 2-year-uld daughter. The child
controversial topics of debate in this evolving field of study. In this fell back vvards and rotated fron1 the sitting position, striking
area of debate, \Ve present a case of delayed death from a witnessed the 1nidback of his head on a vinyl-covered concrete floor at
fall backwards off a bed in a 9-month-old black male child who 8:00 AM. He i1n111ediately began crying, and the grandmother
struck his head on a concrete floor and was independently witnessed placed ice on a knot on the back of his head. He stopped
as "healthy" postfall for 72 hours until he was discovered dead in crying and was consolable within a few minutes. The child
bed. Grandn1other, babysitter, and mother all independently corrob-
was taken to the babysitter's residence, where the babysitter
orated under police investigation that the child "acted and behaved
normally" after the fall until death. Autopsy showed a linear non-
was told of the fall and to watch for any behavioral changes.
displaced parietal skull fracture, diastasis of adjacent occipital su- The tnother \Vas at work the tnorning when the fall occurred.
ture, subgaleal hemorrhage 'Nith evidence of aging, small posterior When the mother picked the child up at the babysitter's in the
clotting SDH, marked cerebral eden1a, and a sinall tear of the afternoon. he appeared 'Nell. The babysitter reported no
midsuperior body of the corpus calloswn consistent with focal problems and that he acted, ate, and behaved as usual. For the
axonal injury (F Al). No DAI was seen, and there \Vere no retinal next 2 days, the grandmother, mother, and babysitter did not
hemorrhages. All other causes of death were excluded upon thor- notice any abnormalities in either behavior or appearance of
ough police and medical examiner investigation. Although this the child.
seems to be a rare phenomenon, a delayed,, seemingly symptom-free
Approximately 72 hours after the fall off the bed, the
interval can occur between a clinically apparent mild head injury
child was found at the foot of the mother's bed, where he
and accidental death in a young child.
usually slept, prone, cold, and unresponsive. Paramedics were
(Am J Forensic Med Pathol 2003;24: 371-376) called, and in spite of resuscitative.: efforts, he was pro-
nounced dead upon arrival at the hospital. He \·vas last seen
alive 8 hours prior when he was fed by his mother and given
CASE REPORT
his usual albuterol breathing treahnent. No abnormalities on
I\ 9-rnonth-old black male child weighing 22 pounds (10 the child were seen in the emergency department. There was
/'"'\kg) and measuring 28 inches (71 crn), 80th percentile and no evidence of overlying or asphyxia.
50 1h percentile for age, respectively, with a history of asth1na Medical and family history revealed that the child was
born full-term weighing 7 pounds 4 ounces. He was diag-
nosed with asthma after complaints of \Vheezing episodes and
Manuscript received March 19, 2003; accepted May 29, 2003. was prescribed an a!buterol nebulizer twice daily. The child's
From the Cook County Office of the Medical Examiner, and Deparlmt'nt of father, who does not reside in the hon1e, bas asthma. The
Pathok1gy, Rush College of Medicine, Chicago, Illinois (J.S.D.), and
n1other and grandn1other reside together in a public housing
Knox County Office of the Medical Examiner. and Department of
Pathology, Graduate School of Medicine, Univt:rsity of Tt:nnessee, develop1nen1. Depart1nent of Child and Family Services
Knoxville, Tennessee (D.M.). records revealed no prior incidents concerning the deceased,
Reprints: Darinka Mih.msnic, MD, PhD, Regional Forensic Center, Univer- but the mother had I report of being a victitn of prior abuse.
sity of Tennessee Memorial Hospital, 1924 Alcoa Highway, Knoxville,
The grand1nother has a remote history of cocaine abuse. Her
1N 37920. E-mail: dmileusn@mc.utmck.edu
Copyright© 2003 by Lippincott Williams & Wilkins
2-year-old daughter is well and lives with her.
0195-7910/03/2404-037 l Autopsy revealed a well-developed and well-nourished
DOI: I 0.1097/0 ! .paf.0000097851.18478.16 black 111alc child appearing the stated age and without exter-
The American journal of Forensic Medicine and Pathology • Volume 24, Number 4, December 2003 371
Denton and Mileusnic The American journal of Forensic Medicine and Pathology • Volume 24, Number 4, December 2003
nal abnormality. There was no swelling or contusion of the
back of the head. Complete postmortem radiographs revealed
a linear, nondisplaced, posterior right parietal skull fracture.
Internal exa1nination confirmed the skull fracture, as well as
a patch or right posterior subgaleal hemorrhage that was
centrally red with yellow margins. The underlying right
posterior linear skull fracture was 3.0 inches (9.0 cm) long
and extended to the right parieto-occipital suture, causing
mild diastasis of the suture, 2.5 inches (7.5 cm) Jong (Fig. 1).
There was a thin adherent clotted SDH underlying the frac-
tme, 2.0 X 2.0 X 0.1 cm. The brain weighed 1035 g
(expected average weight for age, 750 g) and showed severe
edema with flattening of the gyri, loss of sulci, and notching
of both unci and cerebellar tonsils (Fig. 2). After formalin
fixation, serial sectioning of the brain revealed diffusely
dusky white matter and a focal tear of the midsuperior corpus
FIGURE 2. Severely edematous brain demonstrating flattening
of the gyri and narrowing of the sulci.
callosum, 1 1nrn, with surrounding hemorrhage, 2 n1m. There
were no other gross neuropathologic findings. The remaining
internal organs were unremarkable, without other new or old
fractures, petechiae, or gross asthma changes. Comprehen-
sive toxicologic screening using gas chromatography and
nlass spectrometry was negative. Microscopically, the corpus
callosum tear showed hemo1Thage with intact red blood cells,
PAI, and 1nicroglial activation without inflammation (Fig. 3).
Extensive sections of the brain showed only edema without
evidence of DAL Sections of the subgaleal hemorrhage
showed hen1orrhage of coalescing red blood cells with neu-
trophilic inflammation. Decalcified sections of the parietal
fracture showed an acute fracture with early periosteal reac-
tion at the fracture margin. Lung sections showed mild focal
FIGURE 1. View of the linear skull fracture Involving the pos- peribronchial lymphocytic aggregates consistent with bron-
terior right parietal bone1 after removal of the overlying sub- chitis without asthma changes. There were neither eosino-
galeal hemorrhage. phils nor 1nucus plugs. Sections of remaining organs were
372 © 2003 Lippincott Williams & Wilkins
The American journal of Forensic Medicine and Pathology 111 Volume 24, Number 4, December 2003 Delayed Sudden Death
in the majority of lethal events, are still controversial. One
\videly held belief is that short falls are almost never fatal.
Second, if a child is going to die follo\ving head trauma,
either accidental or abusive, he or she is severely impaired
and inost likely i1nmediately unconscious, without a lucid
interval. Finally, in severe injuries where children are im1ne-
diately comatose and die shortly after the incident from either
shaking and/or direct impact, it is believed that DAI is the
111echanism. Certain reviews have gone so far to identify
subdural hemorrhage, frequently present in certain forms of
early childhood abusive head traun1a, as a "marker" of unde-
tectable DAL 1 1f this were true, then reports describing
radiologically presen1 old and/or new subdural hemorrhages,
with or without focal shear hemorrhages in the white matter,
FIGURE 3. Coronal section of the corpus callosum showing in living children would be a rarity rather than a com1non
wedge-shaped laceration (right upper corner) surrounded by a place. 2
rim of hemorrhage, FAI and activated microglia (1 OOX, hema- In this present case, we discuss the death of a 9-month-
toxylin-eosin). old child who died 3 days after a witnessed backward fall
from a bed on a concrete floor. Main pathologic findings
consisted of a linear nondisplaced skull fracture, minimal
clotting subdural hemorrhage, severe brain swelling with
without pathologic changes. The eyes were examined by an
tonsillary herniation, and a small tear in the body of the
ophthalmic pathologist consultant and were normal. A foren-
corpus callosu1n, which appeared histologically as FAL Anal-
sic radiologist consultant also reviewed postmortem radio-
ysis of the fall revealed a rotational component of the body
graphs and repo1ted no additional findings.
and head movement, 1.vhich could account for the described
injuries. The location and appearance of the prin1at)' injury
Follow-up Investigation was consistent viith flipping backward and striking the back
Prior to the autopsy, Chicago police detectives \Vere
of the head. There was no diffuse axonal da1nage or retinal
notified of the skull fracture and attended the examination.
hemorrhage. Thorough workup, including scene investigation
After autopsy, police re1nanded the grandmother and mother
and independent police questioning of all individuals in-
to the police station, where they were interviewed separately
volved in the care of the infant, prior to, during, and after the
about the injuries. Upon extensive questioning about any
accident, were unanin1ous. There were no inconsistencies,
possibility of inflicted trauma and abuse that the baby could have
and the stories have never varied from the beginning to the
sustained, they both spontaneously gave the similar story of the conclusion of the investigation. There were no other instances
fall 3 days prior. The babysitter was questioned and confinned
of trau1na to the head observed by the caretakers. Based on
the accounts and timing of the reported events. Police detectives
several independent accounts, the infant's behavior following
and evidence technicians accompanied the mother and grand-
the head trauma up to his sudden death was ordinary and did
mother back to their residence and verified the scene and
not require medical attention, qualifying as a lucid or symp-
reenactment of the fall. A week later, the prosector patholo-
tom-free interval.
gist (JSD) and a specialist child death scene investigator of
Deciding whether head injury in a very young child is
the Medical Exa1niner's Office went to the residence and
accidental or nonaccidental has always been proble1natic for
again inspected the residence, interviewed the grandmother
clinicians and forensic pathologists alike. 3 ·4 We realize that a
and 1notber. and reenactcJ. the fi.lll. As with the police detec-
number of child abuse experts would have a problem with the
tives, all felt the grandmother and mother to be truthful and
accidental detenninlltion of the manner of death in the present
grieving appropriately for the circumstances. After consider-
case. We do not argue the widely noted observation that
ation of the autopsy, toxicologic, histologic, consultative, and
simple falls from low heights rarely result in significant
investigative findings, the death was certified as craniocere-
prin1ary brain injury. 5 However, every fall is different, as well
bral injuries due to a fall fron1 the bed backwards onto a
as the individual reaction to the pri tnary insult. Son1e experts
concrete floor. The manner was determined accidental.
in head trauma consider the term minor head injury an
oxymoron. 6 We believe that a series of secondary injuries,
DISCUSSION known to occur after a primary insult, resulted in the extreme
Ce1tain issues in pediatric head trauma, such as lethal- swelling of the brain and death of the child. What is widely
ity of short falls, timing of head injury, and presence of DAI understated and so1ncti1nes forgotten about is secondary brain
© 2003 Lippincott Williams & Wilkins 373
Copyright Lippincott
Denton and Mileusnic The American journal of Forensic Medicine and Pathology • Volume 24, Number 4, December 2003
injury, which occasionally may be the principal force deter- ists involved in the care of abused children accept as true that
mining the outco1ne after a see1ningly trivial head injury. 7- 12 all children who eventually die, regardless of the type of the
Another frequently forgotten factor is the influence of age and head injury, must be severely disabled, usually comatose
sex on the presentation and the outco1ne of head injury. The from the ve1y moment the injury occurred. 23 From personal
grouping together of different pathologies such as subdural experience and based on the literature review, this tenet is not
hemorrhages, cerebral contusions, FAI, and DAI, as well as necessarily true. 24 '25 Although there are clearly scenarios in
lumping together of infants, toddlers, and preschool children, which this principle could be applicable, there is undoubtedly
needs to be addressed. It has been shown that infants and a subpopulation of infants and especially toddlers with a
young toddlers lose consciousness less frequently, and a completely different constellation of injuries and a dissitnilar
smaller proportion of their head injuries lead to immediate presentation. Occasionally, these children have nonspecific
coma in comparison to other children with the same grades of symptoms for several hours to a day prior to the onset of
traumatic energy. 13 Pohl et a1 9 demonstrated that evolution of either coma or seizure followed by coma. Common observa-
posttraumatic brain da1nage after head trauma in developing tions include reduced physical activity, lethargy, drowsiness,
rodents is a highly dynamic process exhibiting age-dependent irritability, temperature irregularities, poor feeding, and gas-
excitotoxic and distant apoptotic cell death. trointestinal symptoms. 232627 Careful analysis of the history
Reviewing the literature on childhood head trauma, one and the events leading to the critical symptoms indicate that
can clearly see that a gradual sideway drift or evolution of there was a certain progression of symptomatology.
findings and conclusions of the original reports, research, and Occult intracranial injury in infants younger than 12
data had taken place. One of them, also frequently encoun- months of age is not uncommon. 28 Clinical symptoms and
tered in cou1t, is that ve1y young children, especially infants, signs are insensitive indicators of intracranial inju1y in in-
are auton1atically assu1ned to be the victi1ns of "shaken baby fants.29 Radiologic observations can so1netimes be of litnited
syndrome." 14 - 16 However, fro1n the literature and from per- value as well. 30 Also, slow deterioration following mild head
sonal experience, findings of direct impact to the head pre- injuries in children have been reported. 31 Furthermore) l of
vail. The problem is not only se1nantic in nature but has 1najor the most frequently cited articles on restricting the time of
and far-reaching consequences since the character, location, injury in fatal inflicted head injuries draws its pediatric
and clinical presentation of the injuries arc different from the population mainly from motor vehicle accidents, with the
rare purely shaken babies. 17 ·18 average age of the study group patients being 8.5 years, with
Another encountered fallacy is that the children who a SD of 4.0 yearsn
die of head trau1na, especially abusive head trau1na, sustain Although many studies have offered guidelines for
DAL Going back to some of the original research, it is clear determining the age of cerebral injuries, various factors limit
that the authors explicitly stated that the 2 worst types of head the reliability of these 1nethods; for example, reduced cere-
injury are SDH and DAI. These 2 have different mechanisms bral blood flow n1ay impede the ceilular response. Not infre-
of causation: SDH occurs much more commonly in nonve- quently, injured children survive in the hospital for additional
hicular injuries, such as falls and abusive head trauma, while 2 to 3 days or even longer, sometimes undergoing craniot-
DAI is caused almost exclusively by vehicular mecha- omy, rendering timing of the injuries based on the autopsy
nisms.19-22 Although both injuries frequently share a com- findings, including histologic examination of the cerebral
mon mechanical cause such as angular acceleration, they injuries, extre1nely difficult. 8-23 -33- 35
differ in degree. SDH usually occurs with a rotational injury DAI is most likely a rarity in nonaccidental head
of short duration and a high rate of acceleration. Conversely, trauma, and the term is misleading. 17 • 18 ' 36 Coma may be more
motor vehicle accidents tend to cause longer-duration, lower- of a reflection of the severity of axonal damage in particular
acceleration-rate injuries leading to DAI rather than SDH. 8·21 regions of the brain, most notably the brainstem, rather than
SDHs occur in a greater number in children with inflicted the total su1n of axonal injury distributed throughout the
versus noninflicted traumatic brain inju1y, whereas shear brain. Furthermore, the plane of head rotational acceleration
injuries are commonly visualized in the noninflicted inju1y plays an important role in determining both the distribution of
group. 22 Therefore, current supposition that the presence of axonal damage and the production of coma. 36 The localized
SDH is a marker of DAI is likely inaccurate. axonal damage demonstrated in corticospinal tracts in the
A frequently asked question is whether delayed 1nental lower brainstem and rostral cervical cord, presumably caused
status deterioration can occur following head injury in chil- by stretch to the neuroaxis produced by cervical hyperexten-
dren. This is critically important in unwitnessed circu1n- sion, may be more significant This finding also provides an
stances such as child abuse. A widely held dogma is that if a explanation for the frequent occurrence of apnea at presen-
child becomes unresponsive while in the care of an individual tation. Tn many of the cases reported by Geddes et al, 18 the
who is reporting the onset of unconsciousness, that same axonal damage at the craniocervical junction was survivable;
individual must be the perpetrator. Currently, some special- what was life-threatening was the subsequent hypoxic injury
374 © 2003 Lippincott Williams & Wilkins
The American journal of Forensic Medicine and Pathology • Volume 24, Number 41 December 2003 Delayed Sudden Death
and brain swelling. In addition, true contusional tears, which 9. Pohl D, Bittigau P, Ishimaru MJ, et al. N-methyl-D-aspartate antagonists
are peculiar to the brains of young infants, represent localized and apoptotic cell death by head trauma in developing rat brain. Proc
Natl Acad Sci. USA. 1999;96:2508-2513.
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27. Haviland J, Ross Russe
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