A Unique Type of Birth Trauma Mistaken for Abuse

Pediatric abusive head trauma is a challenging subject across many disciplines. Of particular importance is the identification of mimics of abuse, so cause and manner of death can be properly assigned. We present the case of suspected child abuse involving an infant who presented unresponsive to the hospital with hypoglycemia, hypothermia, and bilateral parietal fractures. An autopsy revealed fractures associated with organizing scalp hemorrhage and gross leptomeningeal congestion and hemorrhage. The fractures were circular with external displacement, rounded margins, and subperiosteal new bone formation indicative of healing. Birth records revealed vacuum assist and cesarean section delivery. Although vacuum extraction-related injuries are typically cephalohematomas and/or linear fractures, the outbending and circular morphology of the fractures are consistent with vacuum extraction. Moreover, microscopic neuropathological examination revealed hemorrhagic purulent leptomeningitis. This unique case demonstrates the importance of considering birth trauma in the determination of cause and manner of death of an infant.