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. 2022 Nov 4;68(1):315–326. doi: 10.1111/1556-4029.15168

An unusual blunt force trauma pattern and mechanism to the cranial vault: Investigation of an atypical infant homicide

Carolyn V Isaac 1,✉, Jered B Cornelison 2, Clara J Devota 1, Brandy L Shattuck 3, Rudolph J Castellani 4
PMCID: PMC10098721  PMID: 36331044

Abstract

This case report presents an unusual fracture pattern in the cranium of a four‐month‐old infant indicative of child abuse. Upon postmortem examination, the infant presented with numerous bilateral linear cranial fractures running perpendicular to the sagittal suture with depressed and curvilinear fractures apparent on the supra‐auricular surfaces of the cranium. Histological evidence indicates multiple traumatic events to the cranium. In addition, the stair‐step pattern of a parietal fracture may represent multiple contiguous fractures from repeated loading of the head at different times with variation of the focal points of compressive force. Additionally, the left humerus, left radius, and left ulna have healing metaphyseal fractures, and the left ulna also has an antemortem diaphyseal fracture which resulted in the distal metaphysis being rotated 45 degrees medially. Integration of autopsy, anthropological, and neuropathological reports for this case suggest multiple inflicted injury episodes with a repeated atypical mechanism(s) to the cranial vault of the infant. During investigative interviews, the caretaker admitted to squeezing the infant's head and neck on multiple occasions to quiet the child. This reported abusive mechanism is consistent with the pattern of symmetric cranial fractures and soft tissue injuries indicating asphyxiation. This case report provides forensic investigators with a potential trauma mechanism to explore in cases when a similar pattern of cranial trauma is observed and highlights the need for greater research on fracture propagation and fracture healing in the infant cranium.

Keywords: abusive head trauma, asphyxiation, child abuse, classic metaphyseal lesions, forensic anthropology, forensic pathology, inflicted injury, metaphyseal fractures, non‐accidental injury, skull fracture

Highlights.

  • Multiple cranial and postcranial, including metaphyseal, fractures indicative of abuse.

  • Gross and histological analyses revealed multiple stages of cranial fracture healing.

  • Perpetrator admits to manually compressing the infant's head and neck on multiple occasions.

  • Bilateral cranial fractures perpendicular to the sagittal suture are consistent with compression.

  • Stair‐step pattern of parietal fracture may indicate multiple contiguous fractures from different traumatic events.

1. INTRODUCTION

Differentiating accidental from inflicted injury is a principal element of medico‐legal death investigations in cases of infant mortality and suspected child abuse. Non‐ambulatory infants with unexplained fracture(s) upon postmortem examination often prompt suspicions of inflicted injury. Fractures in these cases require a differential diagnosis between child abuse, accidental injury, birth trauma, and natural disease. Determination of abuse rarely hinges upon the presence of a single fracture or fracture type, rather, in cases of suspected inflicted injury, forensic investigators must consider contextual information to understand the proximate cause.

Clinical literature provides guidelines for evaluating suspected cases of child abuse including assessing the developmental stage of the child, the full scope of injuries, their severity, relative degrees of healing, and medical history including the reported mechanism of injury [1, 2, 3]. Suspicions for child maltreatment are raised if the child is a preambulatory infant with any injury, there are injuries to multiple organ systems, different stages of healing are present, patterned injuries are observed, there are injuries to unusual locations like the torso, ears, face, neck or upper arm, there are unexplained serious injuries, or there is evidence of neglect [1, 2]. Additionally, if no explanation or only a vague explanation of the cause of the injury is provided, a history which is implausible for the child's physical or developmental stage, a delay in seeking medical care, inconsistencies in caretaker or witness accounts of the injury event, or an explanation that is inconsistent with the pattern, severity, or age of the injury could also be indicators of child abuse [1, 2].

An important part of the investigation is determining whether the caretaker's explanation of the traumatic event is consistent with the injuries observed. This requires an evaluation of the fracture pattern to estimate the trauma mechanism or the correlation of the fracture pattern with a known injury mechanism. The injury context and fracture pattern interpretation are especially important for cranial fractures as they are common injuries in children for both accidental and non‐accidental circumstances and have a lower specificity for abuse than other injuries, such as rib fractures and metaphyseal fractures [1, 4, 5, 6, 7]. The percentage of pediatric cranial fractures attributed to abuse is relatively low compared to cranial fractures resulting from accidental injury [1, 7, 8, 9]. However, the association between a cranial fracture and abuse dramatically increases in infants and young children. According to clinical studies, approximately one in three infants and toddlers with cranial fractures are victims of inflicted injury [10, 11, 12]. These studies largely reflect patterns of abusive cranial trauma in living children. The frequency of cranial fractures in cases where the child died due to abusive activity remains unknown; however, it is estimated that abusive head trauma in children less than a year old has an annual incidence of 33 to 38 cases per 100,000 children and nearly 25% of those cases result in death [13, 14]. Several studies have found that the presence of multiple cranial fractures and variable degrees of healing is more suggestive of abuse [4, 8, 10, 12, 15], rather than the complexity of the fracture as was previously thought [6, 16].

Understanding fracture patterns in forensic cases is difficult as few controlled studies of cranial impacts have been completed for human skeletal material. While there are some experimental studies on fracture initiation and propagation in the human cranium [17, 18, 19, 20, 21, 22, 23, 24, 25, 26], few address the structural or biomechanical differences of the developing infant head [27, 28] while others have utilized immature porcine models as a proxy for the infant cranium [29, 30, 31, 32, 33]. These studies have demonstrated significant differences in the biomechanical properties of infant bone and sutures compared to adults [27, 28] and have shown that the age of the child [29, 30], impact energy [30], impact surface [29, 30, 32, 34, 35], head entrapment [31], and impact shape [33] all influence the degree and pattern of fracturing. To supplement the limited number of controlled experiments, retrospective clinical studies and case reports are often used to inform fracture pattern interpretation in subadult individuals. Unfortunately, in cases of suspected abuse, the trauma mechanism is often unknown or unsubstantiated [1, 2, 36, 37].

This report presents a case of an infant who died with acute and remote injuries indicative of an abusive history, including evidence of asphyxia, an unusual pattern of multiple cranial fractures, and multiple metaphyseal and diaphyseal fractures of the left arm. Subsequently, the perpetrator admitted to a trauma mechanism which may explain the atypical cranial fracture pattern. The findings of this case expand the spectrum of abusive head trauma mechanisms in infants, provide a pattern of skeletal trauma indicative of abuse potentially resulting from bilateral compression of the cranium, and provide radiographic, gross, and histological evidence of the fractures resulting from inflicted injury. Furthermore, this case report highlights the need for further research into patterns of blunt force trauma in the infant cranium and the development of methods for fracture age estimation.

2. CASE REPORT

A four‐month‐old male infant was found unresponsive in a crib in the early morning by the infant's mother. The mother attempted cardiopulmonary resuscitation (CPR) and law enforcement were called to the residence. Upon arrival, police continued CPR while the infant was transported to the hospital where he subsequently died.

2.1. Medical history

The infant was born vaginally at 33‐weeks gestational age with no recorded complications or medical interventions associated with the delivery. The child was hospitalized for prematurity. Both the infant and the mother tested positive for tetrahydrocannabinol (THC) following birth and a caseworker with Child Protective Services (CPS) was assigned to the family. A cranial ultrasound was performed 11 days after birth and was normal with no evidence for traumatic brain injury or cranial fractures. The infant was released from the hospital 25 days after birth and was under the care of his parents for 3 months until his death.

2.2. Autopsy findings

The postmortem radiographic skeletal survey revealed multiple fractures to the neurocranium and radiographic evidence consistent with metaphyseal fractures of the left humerus, ulna, and radius (Figure 1). External examination of the remains indicated florid petechial hemorrhage of the conjunctiva and face, most notable around the right eye. Two blue‐purple contusions, measuring 1.2 and 0.8 centimeters, were observed on the left arm. According to World Health Organization growth charts, the infant's body weight at the time of postmortem examination was less than the 5th percentile, the crown‐heel length was in the 10th percentile, and the head circumference was less than the 5th percentile for a 10‐week adjusted age male.

FIGURE 1.

FIGURE 1

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Radiographic series taken prior to postmortem examination indicating (A) multiple fractures of the cranial vault, (B) a metaphyseal fracture of the left humerus (circled), and (C) metaphyseal injuries of the left radius and ulna (circled).

Internal examination revealed hemorrhagic cerebrospinal fluid, two areas of hemorrhage in the soft tissues of the left and right fronto‐parietal regions of the scalp, and corresponding hemorrhages in the soft‐tissues adherent to the skull underlying the scalp hemorrhages (Figure 2). Multiple cranial fractures extending from the areas of soft tissue hemorrhage were also observed. Scant amounts of subarachnoid hemorrhage were noted on the brain. The brain was retained for neuropathological analysis. The skull cap and elements of the left arm were resected and submitted for anthropological analysis.

FIGURE 2.

FIGURE 2

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An image of the scalp reflected showing a soft tissue hemorrhage (arrow) and skull fractures (arrowheads). [Color figure can be viewed at wileyonlinelibrary.com]

2.3. Neuropathology findings

Consistent with the forensic pathology findings, neuropathological analysis revealed focal subacute subarachnoid hemorrhages in the right frontal parasagittal region and left inferior parietal lobule of the brain, approximately 1 centimeter in diameter and less than 1 centimeter in diameter, respectively. There were no other observed abnormalities, pathological conditions of the brain tissues, or retinal hemorrhages.

2.4. Anthropological examination

The skull cap was radiographed (Figure 3) and photographed (Figure 4A,D,G) prior to histological sampling and maceration, revealing numerous fractures. Histological samples were resected from three cranial fractures prior to processing (Figure 4B). The calvarium, left humerus, left radius, and left ulna were macerated in an incubator over a two‐week period with manual removal of the soft tissues.

FIGURE 3.

FIGURE 3

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Superior radiograph of the calvarium prior to maceration showing fractures in the right and left parietals (anterior is oriented at the top of the image).

FIGURE 4.

FIGURE 4

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Cranial fractures identified in the calvarium from the superior (A–C), left lateral (D–F), and right lateral (G–I) views. The first photo in each orientation (A, D, and G) shows the skull cap after resection with some fractures visible. The second set of photos (B, E, and H) are of the cranial vault following histologic sampling, maceration, and soft tissue removal and highlights the fractures, several with open margins. Cranial vault diagrams (C, F, and I) show the 14 fractures identified and areas of histological sampling indicated by the gray‐shaded rectangles. [Color figure can be viewed at wileyonlinelibrary.com]

The left parietal demonstrated a comminuted, slightly depressed defect (Fracture 1) with four associated simple, linear, radiating fractures (Fractures 2 through 5), all with rounded fracture margins and extensive subperiosteal new bone formation (Figure 4D–F). The majority of the Fracture 1 defect had no remaining fracture gap and the inferior margin was nearly obliterated. While Fracture 2 extended between Fracture 1 and the anterior left parietal, Fractures 3 through 5 extended to the sagittal suture. Also evident in the left parietal region was a curvilinear fracture (Fracture 6) and linear fracture (Fracture 7) adjacent to the craniotomy cut (Figure 4D–F). Since only the cranial vault was available for anthropological evaluation, the extent, number, and location of terminal points of these fractures could not be evaluated, but rounded fracture margins and subperiosteal new bone formation associated with Fracture 7 provided evidence of healing.

The right parietal exhibited a simple fracture (Fracture 8) with an unusual morphology, changing direction multiple times in a stair‐step pattern that extended between the sagittal suture and the craniotomy cut. Fracture 9, a complex linear fracture with branching (Fracture 10) extended between the sagittal suture with its other terminus in the right parietal. A simple, linear fracture (Fracture 11) connected Fractures 8 and 9. Fracture 12 is a simple curvilinear fracture which extends between Fracture 8 and the intersection of the lambdoid suture and craniotomy cut (Figure 4G–I). Fracture 13 is a simple, curvilinear fracture that extends between Fracture 12 and the lambdoid suture (Figure 4G–I). The final cranial fracture observed (Fracture 14) was a simple, linear fracture of the left lateral occipital, extending between the lambdoid suture and the craniotomy cut (Figure 4D–F).

In total, 14 fractures were identified in the cranial vault. In the left parietal, Fractures 2 through 5 all communicated with Fracture 1. Fractures 6 and 7 did not intersect with any other fractures in the portion of the cranial vault that was evaluated. The right parietal presented a complicated fracture pattern with all identified fractures [8, 9, 10, 11, 12, 13] intersecting with at least one other fracture. Fracture 14 was the only fracture observed in the occipital. All fractures exhibited evidence of healing indicating they occurred antemortem and were consistent with blunt force trauma to the head. There was no evidence of perimortem trauma. It is important to note that each fracture does not represent an individual impact as multiple fractures may have occurred from the same traumatic event.

The left arm exhibited multiple healing osseous injuries. A metaphyseal fracture was observed radiographically (Figure 5A,B) and grossly (Figure 5C,D) in the proximal humerus extending along the supero‐posterior and supero‐lateral metaphyseal margin and across the physeal surface (Figure 5E). Subperiosteal new bone formation was present along the margin. The metaphyseal fracture was largely healed in the lateral aspect with no visible fracture line, while the fracture line was visible posteriorly.

FIGURE 5.

FIGURE 5

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Radiographic and gross evidence of skeletal trauma of the left humerus. (A) Anterior–posterior radiograph; (B) lateral radiograph; (C) anterior view; (D) posterior view; and (E) detailed superior view of the physeal surface of the proximal humerus. Arrows indicate the radiographic and grossly observed evidence of a healing metaphyseal fracture. [Color figure can be viewed at wileyonlinelibrary.com]

Healing trauma was also identified in both the left radius and ulna. The left radius had subperiosteal new bone formation along the shaft, proximally at the radial tuberosity and distally at the metaphysis (Figure 6). There was also a healing metaphyseal fracture of the anterior distal metaphysis (Figure 6B,C) that extends to the physeal surface of the metaphysis (Figure 6E). The left ulna exhibited evidence of a healed fracture in the distal one‐third of the diaphysis with the distal metaphysis rotated approximately 45 degrees medially relative to the proximal two‐thirds of the diaphysis (Figure 7B,C). Due to extensive remodeling, the fracture type was indeterminate, but the rotation of the distal ulnar metaphysis suggests an oblique or spiral fracture. There was also a metaphyseal fracture of the distal metaphysis of the ulna observed radiographically (Figure 7A) and grossly on the physeal surface (Figure 7E). The metaphyseal fractures of the humerus, radius, and ulna, and the fracture of the distal ulnar diaphysis suggest at least one traumatic event to the left arm.

FIGURE 6.

FIGURE 6

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Radiographic and gross evidence of skeletal trauma of the left radius. (A) Anterior–posterior radiograph showing a region of subperiosteal new bone formation along the lateral margin, indicated by the white arrowhead; (B) lateral radiograph showing a healing metaphyseal fracture in the anterior distal aspect indicated by the white arrow; (C) anterior view demonstrating subperiosteal new bone formation at the radial tuberosity and distal metaphysis indicated by black arrowheads; (D) posterior view demonstrating subperiosteal new bone formation indicated by black arrowheads along the shaft; and (E) detailed inferior view of the distal physeal surface of the radius showing the healing metaphyseal fracture. [Color figure can be viewed at wileyonlinelibrary.com]

FIGURE 7.

FIGURE 7

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Radiographic and gross evidence of skeletal trauma of the left ulna. (A) Anterior–posterior radiograph showing a healing metaphyseal fracture of the anterior distal metaphysis indicated by white arrow; (B) anterior view showing the healing metaphyseal fracture indicated by the arrowhead and medial rotation of distal shaft; (C) lateral view showing a healed fracture between the white arrowheads; (D) articulated ulna and radius demonstrating the medial rotation of the distal ulna; and (E) detailed inferior view of the distal ulnar physeal surface showing the healing metaphyseal fracture. [Color figure can be viewed at wileyonlinelibrary.com]

2.5. Histological examination

Three cranial fractures were excised for histological analysis prior to maceration to further investigate differential levels of healing. Fracture 4 grossly appeared to have rounded fracture margins and subperiosteal new bone formation. When observed histologically (Figure 8); however, the fracture gap was resolving on the ectocranial and endocranial surfaces with bone formation and the gap was infiltrated with fibrous connective tissue and areas of cartilage formation. In addition, the healing fracture exhibited blurred fracture margins, numerous new capillaries, and new woven bone formation along and within the fracture gap.

FIGURE 8.

FIGURE 8

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Histology of fracture 4 (H&E stain) overall fracture (top, scale 400 μm) and detailed view of the fracture gap (bottom, scale 200 μm) highlighting cartilage (Ca), fibrous connective tissue (FCT), and capillaries (C). [Color figure can be viewed at wileyonlinelibrary.com]

The unusual stair‐step fracture (Fracture 8) presented grossly with a wide fracture gap, rounded margins, and profuse subperiosteal new bone formation along the margins. Histological assessment indicated minimal bone resorption, moderate fibrous connective tissue that bridged the ectocranial fracture gap, and minimal new capillary formation (Figure 9). The fracture margins were also misaligned, with the right side displaced inferiorly.

FIGURE 9.

FIGURE 9

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Histology of fracture 8 (H&E stain) overall fracture (top, scale 400 μm) and detailed view (bottom, scale 200 μm) highlighting dense fibrous connective tissue (FCT) and capillaries (C). [Color figure can be viewed at wileyonlinelibrary.com]

Visual examination of Fracture 9 near the sagittal suture exhibited rounded margins and a distinct fracture gap while the area sampled, located inferiorly, presented less distinct evidence of healing. Histologically the sample did not exhibit a marked tissue response compared to the other histological samples. There was minimal fibrous connective tissue within the fracture gap, minimal new capillaries, and minimal evidence of bone resorption of the fracture margins (Figure 10).

FIGURE 10.

FIGURE 10

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Histology of fracture 9 (H&E stain) overall (top, scale 400 μm) and detailed view (bottom, scale 200 μm) highlighting fibrous connective tissue (FCT) and capillaries (C). [Color figure can be viewed at wileyonlinelibrary.com]

Histological and gross examination of the cranial fractures indicated the presence of different degrees of fracture repair, providing evidence of at least three levels of healing in the calvarium. These different stages of healing include (1) an early stage in which the fracture margin was open with rounded fracture margins, minimal to moderate fibrous connective tissue, minimal new capillaries, and minimal evidence of bone resorption; (2) a reparative stage with complete infiltration of the fracture gap with extensive fibrous connective tissue and cartilaginous tissue, numerous new capillaries, and new woven bone along and within the fracture gap, and; (3) a remodeling stage in which the fracture margin was completely obliterated with persistent subperiosteal new bone formation as observed grossly in Fracture 1.

2.6. Additional investigative information

Interviews with the infant's parents were prompted after it was discovered at autopsy that the infant had multiple fractures. Initially, the father claimed he accidentally hit the infant's head on a wall corner, but later admitted to repeatedly hitting the infant the night the child was found unresponsive; however, it was unclear how many times the child was struck as the father was under the influence of alcohol and marijuana. Eventually, the father admitted to repeated episodes of abuse in the attempt to quiet the infant, including routinely striking the infant's head, tipping the chin back and squeezing down on the neck, squeezing the infant's neck and skull while pushing back on the chin and squeezing his skull while covering the face. These mechanisms are modeled in Figure 11.

FIGURE 11.

FIGURE 11

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Three confessed mechanisms of abuse used by the caretaker to quiet the child. (A) Tipping the infant's chin back while compressing the neck; (B) squeezing the infant's neck and skull while pushing back the chin; and (C and D) compressing both sides of the cranium while covering the infant's face. [Color figure can be viewed at wileyonlinelibrary.com]

3. DISCUSSION

In this report, we detail the postmortem examination of a four‐month‐old infant who presented with petechiae of the face and eyes, scalp and subarachnoid hematomas, fourteen calvarial fractures, three metaphyseal fractures and subperiosteal new bone formation on the left arm, and a healed fracture in the left distal ulna diaphysis. In the differential diagnosis process, birth trauma or fractures due to prematurity in the cranium were ruled out based on the normal results of the cranial ultrasound performed during the infant's hospitalization after birth. In addition, there was no evidence of natural disease or accidental injury in the infant's history nor on examination. Based on the results of the autopsy, neuropathological, and anthropological analyses, the medical examiner concluded the death was a homicide. The cause of death was deemed asphyxia due to obstruction of the airways as evidenced by the multiple petechiae on the face and conjunctivae. The blunt force injuries to the head, evidenced by multiple skull fractures at varied states of healing, bloody cerebrospinal fluid, and scalp and subarachnoid hemorrhages, were recorded as contributory causes of death.

While the pattern of skeletal injuries presented in this case example are consistent with clinical studies and forensic reports of child abuse, the cranial fracture pattern and purported mechanism of abuse are unusual. The infant in this case presented with multiple bilateral fractures in the parietals, consistent with Meservy and colleagues’ [12] characterization of pediatric cranial fractures observed radiographically where multiple skull fractures, bilateral fractures, and fractures crossing sutures were more common in cases of abuse. Theoretical consideration of the pattern of linear fractures running perpendicularly to the sagittal suture appears to be consistent with low velocity bilateral compression applied to the lateral aspects of cranial vault. This is supported by the findings of a study by Hiss and Kahana [38] who reported bilateral temporoparietal fractures were only observed in infants who experienced bilateral compression of the head. A slow loading compression force is also congruent with the abusive mechanism described by the suspect whereby the palm of the hand covers the face of the child, and the fingers squeeze the lateral aspects of the cranium (Figure 11). Furthermore, the curvilinear fractures (Fractures 6 and 12), and the depressed fracture on the left parietal (Fracture 1) may represent focal trauma from the fingers and thumb to the supra‐auricular sides of the head.

All of the cranial fractures were antemortem with evidence of healing. Fracture 1 was the most advanced in fracture repair with nearly obliterated fracture margins indicating remodeling. Histological analysis revealed two potential additional stages of healing at the microscopic level evidenced by the progression from soft‐tissue response to woven bone formation. Using the histological method published by Naqvi and colleagues [39] to estimate the age of fractures in infants, Fractures 8 and 9 with fibrin formation and fibrous connective tissue/granulation tissue would most likely occur between 12 hours and 3 days after injury. Fracture 4 with granulation tissue, cartilage, and woven bone would be consistent with an injury that is 5 to 7 days old. Although there was no histological sample taken of the fracture with the most advanced gross healing (Fracture 1), Naqvi and colleagues indicate fracture union occurred in most fractures in their sample 22 to 28 days after injury [39].

However, Naqvi et al. [39] do not identify the skeletal elements utilized to develop the method nor has the method been independently validated on a sample of infant cranial fractures where the time elapsed since injury is known. The lack of research and methods for the accurate estimation of infant cranial fracture age limits the ability to correlate the histologic differences between the fractures in this case with different traumatic events. Additional factors such as differences in the extent of the fracture gaps and reinjury of a pre‐existing fracture further convolute determination of multiple traumatic events. The stair‐step morphology of Fracture 8 was also atypical in this case example, as this type of fracture has not previously been reported in the literature except in cases of thermal fracturing [40]. Considering the reported abuse mechanism, the stair‐step pattern of Fracture 8 could represent multiple contiguous fractures from repeated loading of the skull at different times with variation of the focal points of compressive force (i.e., the placement of the hand and fingers). As Berryman and colleagues [41] describe, antemortem fractures may lengthen as the result of a new traumatic event if the energy imparted cannot be dissipated by the preexisting fracture. However, the morphology of Fracture 8 is not observed elsewhere in the literature nor have there been controlled fractography studies demonstrating the pattern. As fractures initiate, they are expected to be straight, propagating perpendicular to the maximum tensile stresses, but the propagation path is influenced by intrinsic and extrinsic conditions [42]. The conditions under which the stair‐step pattern will occur remain unknown.

Provided the current lack of controlled experiments on cranial fracture patterns and healing, the fracture pattern of the cranium cannot solely indicate repeated traumatic events and a history of abuse; however, clarity as to the circumstances in which these injuries occurred is provided by the postcranial injuries which are highly correlated with physical abuse. Metaphyseal fractures in infants are due to the greater susceptibility of the developing trabeculae in the primary spongiosa of long bone metaphysis to planar failure near the bone's proximal or distal end and are highly correlated with inflicted injury in young children – particularly non‐ambulatory infants [1, 43, 44, 45]. Kleinman and colleagues [43, 44] have suggested metaphyseal injuries are produced when forces of torsion and/or tension are exerted on an infants' extremities. These forces are associated with yanking or twisting of the arms and legs or the uncontrolled flailing of the limbs during shaking episodes [43, 44, 46]. The medial rotation of the distal ulnar head also indicates a torsional force applied over the left extremity causing a fracture.

4. CONCLUSION

The interpretation of fracture pattern and timing is of utmost importance in the differential diagnosis of trauma, particularly if the injuries could be the result of either an accident or from an inflicted injury and not from documented birth trauma or due to an underlying health condition. Often, these determinations are contingent upon the type and location of fractures, the age and developmental status of the child, and the history provided by the caretaker. This report is illustrative of an infant with multiple injuries sustained over time. In this case, the perpetrator's admission is consistent with the observed cranial fracture patterns. However, the mechanism of the injuries should be approached with caution since there is no appropriate research to support the specific injury patterns. Furthermore, this case provides radiographic, gross, and histological evidence of healing cranial and postcranial fractures. The limitations imposed on the interpretation of the fracture pattern and histological data in this case demonstrate the need for increased research into fracture propagation under variable intrinsic and extrinsic factors and the progression of histomorphological repair in the pediatric cranium.

FUNDING INFORMATION

The histological component of this work was supported by the National Institute of Justice [award number 2017‐DN‐BX‐0166]. The opinions, findings, and conclusions or recommendations expressed in this publication are those of the authors and do not necessarily reflect those of the U.S. Department of Justice.

CONFLICT OF INTEREST

The authors declare there are no conflicts of interest.

ACKNOWLEDGMENTS

The authors would like to thank Kristi Bailey, H.T.L. and Jon Langworthy, H.T.L. of Western Michigan University Homer Stryker M.D. School of Medicine, Research Histology Laboratory, for their work in creating the histological slides for this case. The authors would also like to thank the two reviewers for their thoughtful evaluations which helped to improve this manuscript.

Isaac CV, Cornelison JB, Devota CJ, Shattuck BL, Castellani RJ. An unusual blunt force trauma pattern and mechanism to the cranial vault: Investigation of an atypical infant homicide. J Forensic Sci. 2023;68:315–326. 10.1111/1556-4029.15168

Presented at the American Academy of Forensic Sciences 68th Annual Meeting, February 22–27, 2016, in Las Vegas, NV.

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