Fatal traumatic brain injuries in children showed a marked split by age and recorded mechanism in the analysis. Traffic accidents and falls mainly involved adolescents, while abusive head trauma was concentrated in very young children. The findings may help forensic teams assess unclear deaths, but they show associations rather than proving that one mechanism causes a particular injury pattern.
The study examined 96 fatal traumatic brain injury cases among 13,941 pediatric autopsies. The children were aged from 0 to 18 years, and the records were collected between 2005 and 2024. The analysis included cases in which external force directly caused the death and traumatic brain injury was the primary cause identified at autopsy; cases with non-traumatic causes, pre-existing intracranial pathology or incomplete records were excluded.
A two-peak age pattern
The ages in the cohort formed a bimodal pattern, with one peak in infancy and another in late adolescence. The largest single age group was 18-year-olds, with 18 cases, followed by infants recorded as age 0, with 12 cases. Among children younger than two, cases clustered largely in the first six to eight months of life; the median age in that group was 6.24 months, with the middle half ranging from 3.24 to 9.48 months.
Across the full cohort, the median age was 11 years, and the middle half of the cases ranged from 2.25 to 17 years. The sex split was close, although males made up 52.1% of the cases. The study did not find a statistically significant association between sex and mechanism.
Mechanisms separated by age
Traffic accidents accounted for 47.9% of the cases, making them the most common recorded mechanism. Falls accounted for 12.5% and abusive head trauma for 10.4%. Most deaths were classified as unintentional, at 83.3%, while suicide accounted for 6.3%. Within the abusive-head-trauma group, two cases involved impact and eight did not.
The median age was 16.5 years in traffic accidents and 15.5 years in falls, compared with 1.92 years in abusive head trauma. The differences between traffic accidents and abusive head trauma, and between falls and abusive head trauma, were statistically significant. Traffic accidents and falls did not differ significantly from each other in age.
Eight of the 10 abusive-head-trauma cases involved children aged two years or younger. In the subgroup without an identified impact, seven of eight cases were in that age range. The age concentration was statistically significant, although the subgroup was small.
What the autopsies recorded
Cerebral edema, or brain swelling, was recorded in 91.7% of all cases. Intracranial hemorrhage, meaning bleeding inside the skull, was recorded in 82.3%. Subarachnoid hemorrhage was the most frequent hemorrhage subtype, appearing in 61.5% of the cohort. These findings could occur together, so the injury categories were not mutually exclusive.
Some bleeding patterns varied across the three main mechanism groups. Subarachnoid hemorrhage appeared in 37 traffic-accident cases, five fall cases and one abusive-head-trauma case, a statistically significant difference. Intraventricular hemorrhage appeared in 23 traffic-accident cases, three fall cases and no abusive-head-trauma cases, also a statistically significant difference. The comparisons for any hemorrhage, subdural hemorrhage and epidural hemorrhage were not statistically significant.
Bone injuries also showed the broadest pattern in traffic accidents. Skull injury was recorded in 37 traffic-accident cases, five fall cases and two abusive-head-trauma cases, a statistically significant difference. Facial bone injury appeared in 28 traffic-accident cases and four fall cases, but in none of the abusive-head-trauma cases, also a statistically significant difference. Several more specific skull and facial fracture categories also favored traffic accidents.
Why the pattern needs caution
The researchers describe the age- and mechanism-linked patterns as potentially useful in distinguishing unclear fatal cases and informing prevention. But the study was observational and retrospective, so it cannot establish a causal link between a mechanism and an injury pattern. The mechanism-pattern comparisons were not adjusted for age, meaning age-related confounding cannot be ruled out.
The evidence comes from fatal cases selected through pediatric autopsies, so the mechanism distribution is not a population incidence estimate. The injury-pattern pairwise comparisons were exploratory and were not corrected for multiple comparisons. That means the observed differences need confirmation in larger analyses before they are treated as reliable general patterns.
Mechanisms were assigned from the cause and context recorded in autopsy reports. For abusive head trauma, the classification used autopsy findings only. The study therefore offers a way to organize forensic observations, not an independent test that can by itself establish how an injury occurred.
Study status and access
The front matter labels the article RESEARCH and reports that it was received on 27 March 2026 and accepted on 1 July 2026. Open-access funding was enabled and organized by Projekt DEAL, but no funding was received to conduct the study. The authors declared no competing interests.
The anonymized retrospective analysis received a waiver of ethical approval, and informed consent and a clinical trial number were not applicable. The underlying dataset is not publicly available because of ethical and legal restrictions surrounding sensitive forensic data.
Paper data and sources
Original title: Traumatic brain injury in children and adolescents: a retrospective analysis of age- and mechanism-specific injury patterns.
Authors: Teresa Knüppel, Katharina Feld, Sibylle Banaschak
Journal/Repository: International journal of legal medicine
Status: Peer-reviewed
First online: 2026-08-21
DOI: 10.1007/s00414-026-03953-4
Original paper · Full text