26 cm fall caught on video causing subdural hemorrhages and extensive retinal hemorrhages in an 8‐month‐old infant

Key Clinical Message Severe, too many to count retinal hemorrhages (RH) in infants have been associated with abusive head trauma, but can occur in short falls. An 8‐month‐old male fell backward from a height of 26 cm, landing on his buttocks then hitting the back of his head on a vinyl floor. The fall was videotaped. Acute subdural hemorrhages were found along with extensive, too many to count intra‐RH in both eyes. Falls from small heights on to the occiput can lead to extensive RH of the type often associated with abusive head trauma.


| INTRODUCTION
Since the seminal publication of Plunket, 1 case studies [2][3][4][5][6][7][8][9][10][11] have continued to demonstrate that short falls can cause subdural hemorrhages (SDH) and extensive retinal hemorrhages (RH).While cases with independently witnessed short falls are important sources of evidence, falls caught on video are even more compelling.Because filmed cases are rare, it is important that they are documented in the literature.Here we report on the videotaped short fall of an alert, healthy and active infant from a low sofa that led to seizures, acute SDH and extensive RH.

| CASE HISTORY
The male infant was 8 months old, born via normal vaginal delivery at 39 + 4 weeks gestation, weighing 3.6 kg.Vitamin K and hepatitis B injections were given at birth.One month prior to the fall, the mother took the infant to hospital reporting twitching of one shoulder and arm.The infant was assessed and sent home with no investigations or treatment.Roseola was diagnosed 2 weeks prior to hospitalization, which had resulted in fever and rash.
The head circumference was 47 cm (99th percentile) 1 month prior to the fall, and 47.6 cm (99th centile) 1 day after the fall.
Two days prior to the fall, the infant had vomited and was eating less than usual.The mother reported that the infant was learning to walk and "furniture surf" so had falls most days.The infant had fallen forward off a low trampoline 15 cm off the ground onto concrete resulting in an abrasion of his nose a few days prior to the videotaped fall.
On the day of the fall, the mother left the infant at a gym creche, at which time he was alert, active, fully responsive, and (at least outwardly) healthy.The infant sat on his bottom on the edge of the couch and fell backward, with his bottom hitting the floor and his occiput hitting the floor immediately thereafter.The distance from the ground to the seat of the couch is 26 cm, while head to ground height is approximately 65-70 cm prior to the fall.The fall was caught on the surveillance video of the creche (see Video S1).There is a rotational component to the accident, with the buttocks hitting first and acting as a pivot point.The body then rotates around an axis passing through the hips, as the infant falls backward until the back of head hits the floor.
After the fall the mother collected the infant, at which time he was drowsy, "a bit floppy" and unresponsive.Once taken to the car, the mother reported a 5 s episode of arm and leg stiffening, back arching and eye deviations upwards and to the right.She took him to the local hospital from where he was transferred to a children's hospital.

| Clinical presentation
A CT brain on the day of the accident showed bilateral small volume acute, high density, SDH on a background of chronic, low density, collections (Figure 1).The child was kept in hospital and monitored.Seven days later, an MRI showed bilateral subdural collections measuring up to 5 mm thick without significant mass effect (Figure 2).The extra axial CSF spaces and lateral ventricles were judged to be normal.No parenchymal diffusion abnormalities were identified.Midline structures and craniocervical junction were normal.
It was noted that dating the SDHs was inaccurate due to dilution of blood products.The acute SDHs were attributed to the fall.
Less than 24 h after the fall, eye examination was performed without ocular manipulation.Binocular indirect ophthalmoscope with 30D lens found multiple RH in both eyes, too numerous to count (at least >30 in each eye), large intra-retinal macular hemorrhages extending to retinal periphery in all quadrants in each eye and a retinal fold along the inferior arcade of the right eye.Almost all RHs in both eyes were intra-retinal dot/blot as well as preretinal.The optic nerves in each eye were mildly swollen.No RetCam images were taken, but the ophthalmologist made sketches (Figure 3).
Seven days after the fall, the ophthalmology team reexamined the eyes and noted bilateral intra-retinal/ large preretinal diffuse hemorrhages.The RH were resolving slowly, as expected.
3][14] Too numerous to count (>20) IRHs can resolve in a matter of days. 14n this case, there were too numerous to count IRHs at first examination, <24 h after the fall.The IRHs resolved slowly, still present 1 week later.This indicates that the RHs occurred around the time of the fall and, given the changes to the state of the infant caused by the fall, it is reasonable to attribute the RHs to the fall.
There were no external signs of injury: no bruising and a skeletal survey and nuclear medicine bone scans demonstrated no evidence of fractures.
No abnormality was demonstrated at cranio-cervical junction.The spinal cord appeared normal in signal and in contour.No structural abnormality of the spinal cord was identified.
There was a small subdural collection in the lumbosacral spine that was isointense on T1 and hypointense on T2 (Figure 4).There were no signal changes within the vertebral bodies to suggest occult compression fracture and no other abnormality was detected (no soft tissue edema).
The infant improved rapidly and was neurologically normal the day after the fall.

| Outcome
The child was removed from the parents, along with two siblings, based on the advice of a child abuse pediatrician that the findings were due to abusive head trauma.
After an investigation it was determined that the fall caused the hemorrhages, and no charges were laid.After 12 months separation, the children were returned to the family.This highlights the potential harm resulting from determinations of child abuse based on findings that can have non-abusive origins.The trauma caused by parentchild separation, which has been shown to be harmful to infants, 15 is also traumatic for parents.

| DISCUSSION
This case adds to previous studies that have shown that short falls can result in SDHs and RHs.Low level falls onto the occiput have been associated with extensive RHs and SDH. 6,11It is of note that most babies in the Atkinson series, like the present case, had large heads circumference (>90th percentile).
Mattheij 16 also found that infants with a large head circumference could be predisposed to RH or SDH.In a study of 29 babies with RHs, of whom 6 had no suspicion of abusive head trauma, they found "no differences between the groups concerning the location, distribution, or size of the RH" leading the authors to conclude that "there is no pathognomonic size, distribution, or location of RH seen only in AHT". 16I G U R E 2 T1 weighted sagittal MRI 7 days after the fall injury.There is a holohemispheric isointense subdural collection present on the left.There is a smaller collection on the right (not shown).

F I G U R E 3 Drawing of the retinal hemorrhages.
Recently, Sokoloff et al. 17 categorized cases with loss of consciousness (LOC) and/or bilateral/interhemispheric SDH (bihSDH) as involving inertial forces, linking them to extensive RHs.While they cited studies suggesting that inertial forces can cause LOC and/or bi-hSDH, that does not rule out other causes like contact injury.Thus, it remains unclear whether contact injuries alone can cause LOC and/or bihSDH and hence be associated with extensive RHs, or whether intertial forces are required.
In this context, it is interesting that the fall in the current case involved both contact and intertial (rotational) forces, and that both contact and intertial forces were also identified in another recent short fall case that was videotaped, 10 and which also had SDH and extensive RHs.
It is also worth noting that the mother reported prior low height falls in this infant.Prior traumatic brain injury has been shown to be a predisposition to more severe subsequent traumatic brain injury. 18,19

| CONCLUSION
A short, low impact, occipital fall on a vinyl floor was captured on video.The fall, which involved both contact and rotational forces, resulted in a changed state of consciousness, acute SDHs and extensive, too many to count RH that extended to the periphery in both eyes.The baby had macrocrania and possible chronic SDH which may have accounted for the severe RH rather than the fall, or may have made the infant particularly vulnerable to trauma. 16

F I G U R E 1
Axial image non-contrast CT brain showing hyperdense (acute) linear subdural collection on the left with associated hypodense subdural fluid (chronic collection).There is a smaller hyperdense collection on the right.