Introduction

Fatal head injury in infants and young children represents a critical area of forensic investigation, requiring meticulous postmortem examination and objective documentation of traumatic findings. The forensic pathologist plays a central role in identifying, describing, and interpreting injuries of the central nervous system and associated structures, particularly when deaths are referred under circumstances raising concern for inflicted trauma.

Early descriptions of inflicted injury, including physical abuse and infanticide, emphasized the importance of careful postmortem evaluation in distinguishing traumatic findings from natural disease or accidental injury [1, 2]. The publication of “The Battered Child Syndrome” by Henry Kempe in the 1960s marked a pivotal moment in highlighting the diagnostic value of detailed injury assessment, particularly in fatal cases involving young children [3]. These developments contributed to the establishment of coordinated medico-legal frameworks, including the Child Abuse Prevention and Treatment Act (CAPTA) of 1974 in the United States, which standardized investigative approaches across healthcare and legal systems [4].

Within this evolving context, injuries involving the head and brain emerged as the most frequent and consequential findings in fatal pediatric cases referred for forensic investigation. During the 1970s, the term shaken baby syndrome was introduced to describe characteristic intracranial and ocular findings observed in infants with fatal or severe head injury in the absence of prominent external trauma [5, 6]. These observations were classically summarized as a frequently reported combination of subdural hemorrhage, retinal hemorrhages, and hypoxic-ischemic encephalopathy, with proposed diagnostic criteria based on autopsy and clinical correlations [7–9]. When skull fractures or focal intracranial hemorrhages were present, alternative terminology was used to describe head injury associated with direct impact.

As understanding evolved, emphasis shifted toward descriptive terminology that encompassed a range of traumatic findings without reliance on a single inferred mechanism. In 2009, the American Academy of Pediatrics introduced the term abusive head trauma to describe inflicted head injuries in infants and children, encompassing intracranial findings such as subdural hematomas, retinal hemorrhages, skull fractures, and diffuse axonal injury (DAI) [10]. More recently, additional descriptive entities, including the so-called “Compressed Baby Head”, have been proposed based on specific constellations of cranial findings observed at autopsy [11].

Numerous studies have examined injury distributions, autopsy findings, and proposed mechanisms in pediatric fatal head injury cases investigated under circumstances of suspected maltreatment [12–14]. Although biomechanical interpretations remain debated, head injury remains the leading cause of death in children investigated for physical abuse [15, 16] and may be associated with injuries to the cervical spine and associated nerve roots that can be incompletely assessed with routine autopsy techniques.

The present study retrospectively reviews autopsy findings in fatal pediatric head injury cases involving individuals under one year of age examined at a large metropolitan medical examiner’s office over a nine-year period, with particular attention to intracranial, cervical spinal cord, and associated soft tissue findings. The observed findings are compared with existing literature. In addition, based on recurrent anatomic observations, an alternative en bloc cervical spine dissection technique is described as a technical approach to enhance postmortem evaluation of the cranio-cervical region in pediatric fatal head injury cases.