CORRESPONDENCE

aneuploidy
has
been
seen.4
Cytogenetic investigation, preimplantation and post-implantation, in
the
placentas
and
fetuses
of
pregnancies achieved by extracorporeal fertilisation can provide
important insight on this issue. Most
data on human reproduction point
towards a very efficient qualitative
system in which selection for the most
appropriate genetic set takes place
very early in gestation, rather than an
inefficient quantitative system that
brings to term many fetuses that
would not survive postnatally.
Looking
at
these
selective
mechanisms may provide a better
understanding
of
the
sexual
reproductive
system.
Such
an
understanding is now needed because
of the increased use of extracorporeal
fertilisation methods, and gamete
micromanipulation.
With
this
information at hand, we can then
decide whether to abandon the
concept that human reproduction is a
remarkably inefficient process.
*Augusto E Semprini, Giuseppe Simoni
Department of Obstetrics and Gynaecology,
L Sacco Hospital, Milan, Italy; Department of
Human Genetics, San Paolo Hospital,
University of Milan Medical School; and *Via
Carlo Crivelli 20, 20122 Milan, Italy
(e-mail: e.semprini@libero.it)
1
2

Lockwood CJ. Prediction of pregnancy

loss. Lancet 2000; 355: 129293.
St John J, Sakkas D, Dimitriadi K, et al.
Failure of elimination of paternal
mitochondrial DNA in abnormal embryos.
Lancet 2000; 355: 200.
Wolstenholme J, Rooney DE, Davison EV.
Confined placental mosaicism, IUGR,
and adverse pregnancy outcome: a
controlled retrospective UK
Collaborative Survey. Prenat Diagn 1994;
14: 34561.
Sirchia SM, Garagiola L, Colucci C, et al.
Trisomic zygote rescue revealed by DNA
polymorphism analysis in confined
placental mosaicism. Prenat Diagn 1998;
18: 20106.

Skull fracturechild
abuse or an accident?
SirIn
November,
1999,
a
Bangladeshi boy aged 8 months was
admitted to hospital with a linear
parietal fracture. The mother had
noticed a haematoma on the right side
of his head and had consulted her
general practitioner who arranged a
skull radiograph. There were no
retinal haemorrhages or other injuries.
A skeletal survey was normal.
The parents, both unemployed,
were the childs only carers. They also
had a daughter aged 18 months. The
parents were unable to provide an
explanation for the injury. They were

258

Toy aeroplane (above) believed to have

caused linear parietal fracture (arrow)
(radiograph below)

adamant that the boy had not fallen or

been dropped. On the day before
admission his mother was alone with
the two children, when she heard him
scream. At the time she was in the
kitchen adjoining the lounge, where
the children were playing with a toy
aeroplane. When she left the room the
boy had been sitting on a carpeted
floor. After the scream she found him
lying on his side and his sister who was
holding the aeroplane was standing
next to him.
The child was admitted to hospital
for 3 weeks, after which the local
authority obtained an interim care
order. Both children were removed
from the parents and initially placed in
foster care before being moved to their
grandparents home. Eventually, after
social-worker assessment they were
reunited with their parents.
A linear parietal fracture is a
common accidental injury in infants.
It usually occurs when children are
dropped or fall from a height. It is
because this explanation is so
plausible that many inflicted injuries
are said to have been caused
accidentally. These parents, who
claimed not to know the cause,
insisted that he had not fallen or been
dropped despite their awareness of the
probability that he would be removed
from their care. Such behaviour would
be unusual had the injury been
inflicted. The likely cause of the

fracture was a freak accident, which

could not be explained, because it was
not witnessed. The aeroplane (480 g)
probably landed on the boys head
after it had been dropped or tossed in
the air by his sister, who was 79 cm in
height. She did not have sufficient
strength to forcefully bang it against
his head.
There is evidence that shows that
on impact the momentum resulting
from short falls can cause skull
fracture. Still-born babies allowed to
fall 41 cm head down onto a paved
surface sustained skull fractures.1
Weber showed that skull fractures
occurred when cadaver infants were
dropped 82 cm onto a firm surface.2 In
a survey of children under age 3 years,
who presented to an emergency
department a third had parietal
fractures after falling from a height
less than 60 cm (beds and chairs).3
There is a report of a child of 7
months who sustained a depressed
fracture after falling out of bed into a
toy car.4 In the literature there are
reports of fractures from falling
domestic objects such as television
sets, but no reports of fractures caused
by falling toys.5
This case report shows that a heavy
toy falling a short distance onto an
infants head can cause a fracture. As
toys become more complex and
heavier this message should not be
lost on toy manufacturers. The report
also highlights the plight of some
innocent families that arises from our
desire to protect children.
Ivan Blumenthal
Department of Paediatrics, The Royal Oldham
Hospital, Oldham OL1 2JH, UK
(e-mail: ivan.blumenthal@norford.demon.co.uk)
1

Taylor AS. Medical jurisprudence.

Philadelphia: Blanchard and Lee,
1856.
Weber W. Zur biomechanischen Fragilitat
des Sauglingsschadels. Zeitschrift fur
Rechtsmedizin 1985; 94: 93101.
Levethal JM, Thomas SA, Rosenfield NS,
Makowitz RI. Fractures in young children,
distinguishing child abuse from
unintentional injuries. AJDC 1993; 147:
8792.
Wheeler DS, Shope TR. Depressed skull
fracture in 7-month old who fell from bed.
Pediatrics 1997; 100: 103334.
Bernard PA, Johnston C, Curtiss SE,
King WD. Toppled television sets cause
significant pediatric morbidity and
mortality Paediatrics 1998; 102: e32.

DEPARTMENT OF ERROR
Hospital admission and mortality rates for
venous thromboembolism in Oxford region,
UK, 197598In this Research letter by
M J Goldacre and colleagues (June 3, p 1968),
the figures (but not the legends) should be
transposed.

THE LANCET Vol 356 July 15, 2000

For personal use only. Not to be reproduced without permission of The Lancet.