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Let’s look at a few aspects of fractures that may or may not make you more or less concerned about abuse. There has been a pervasive thought that the more complex the skull fracture, the more concerning for abuse. And in some regards this makes sense, in that a more complex fracture requires more force. Hobbs, in his 1984 article on skull fractures, suggests that “in young children where a minor fall is alleged, it is possible to recognize abuse by considerations of the fracture alone.” He noted single, narrow (width no more than 3.0 mm), parietal fractures with no associated intracranial injury to be the greatest predictors of accident while more complex fractures were more indicative of abuse. When we looked at this question, with the advantage of 3D CT and higher resolution imaging rather than x-rays, we noted that complex fractures are fairly common in children with accidental injuries. And that really, in isolation, there is only a 7% positive predictive value of a complex skull fracture for abuse. What this tells me, is that we can’t tell abuse from accident based on fracture type alone, not that we ever would use this in isolation from all other findings or lack there of. It suggests that we need to look at the whole picture and not necessarily make decisions based on the type of skull fracture.,