The recognition of child abuse in modern medicine began in the 19th century, with the work of the French forensic physician Ambroise Tardieu,, who described a wide array of physical and sexual injuries to children, including meningeal hemorrhage and brain injuries in fatally abused infants. More than 80 years later, American physicians began describing the clinical and radiologic manifestations of child abuse. Pediatrician and radiologist John Caffey, first described the association of chronic subdural hemorrhages and long-bone fractures in 1946, but it was not until 1972 that he published a seminal paper describing the radiologic and clinical features attributed to shaking injuries. Ludwig and Warman first published the term “shaken baby syndrome” in their review of 20 infants and young toddlers injured by shaking, none of whom showed evidence of impact injury to the head. In 1987, Duhaime et al reported that victims of fatal shaken baby syndrome, and many of those who survived their trauma, showed evidence of blunt impact to the head at the time of diagnosis. The importance of impact in acceleration/deceleration injury was supported by their basic biomechanical models, and they concluded that most serious abusive head injuries required an impact to the head. The relative importance of impact as a contributor to the head injury sustained by abused children became a source of controversy. Biomechanical modeling has since been used to both support and refute the contributions of shaking or impact to abusive head trauma (AHT)., In reality, all models and theories have known limitations, and many clinicians and researchers acknowledge that precise mechanisms for all abusive injuries remain incompletely understood. Efforts to better understand the mechanisms and causations of injury have improved the gathering of objective data in the clinical realm. Case investigations, including meticulous medical history taking, examinations, and medical workups, have expanded and improved. Medical diseases that can mimic the presentation of AHT are recognized, and screening is performed when indicated. Social welfare, law enforcement, and legal professionals have become better educated about AHT. Clinical research has expanded, and biomechanical modeling of injuries has improved.
Case histories clearly support the conclusion that shaking occurs in some injury scenarios. Shaking was the most commonly reported mechanism of injury described in a series of AHT cases in which perpetrators admitted abuse (68% of 81 cases). Shaking alone was described in 32 cases, and only 4 of the victims showed evidence of impact injury. Although this indicates incomplete admission to the injury mechanism in some cases, the commonality of a described shaking mechanism along with the infrequency of impact evidence supports shaking as an important mechanism of AHT. In addition, blunt impact trauma or impact combined with shaking can result in infant head injuries. In severe and fatal cases, concomitant cervical spine injury can sometimes be found. Secondary brain injury resulting from hypoxia, ischemia, and metabolic cascades contributes to poor outcomes., Shaken baby syndrome is a subset of AHT. Injuries induced by shaking and those caused by blunt trauma have the potential to result in death or permanent neurologic disability, including static encephalopathy, mental retardation, cerebral palsy, cortical blindness, seizure disorders, and learning disabilities. Medical and biomechanical research, clinical and pathologic experience, and radiologic advances have improved our understanding of the range of mechanisms that contribute to brain injury from AHT, yet controversy remains.
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