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Chapter 1

BURN INJURIES

Matt Young, MD

Terra N. Frazier, DO

Aaron J. Miller, MD, MPA

Donna Londergan Evans, MD, FAAP

Children who are burned abusively are marked or branded with the outward manifestation of parental violence, emotional imbalance, impulsivity, educational and cultural deprivation, and poverty. Intentionally burning a child is controlled and premeditated.

Abusive burns cause both physical and emotional trauma at the time of the incident, and often produce long-term physical and psychological scarring. Individuals who burn children typically are educationally deprived; abuse women (if male); and may be isolated, suspicious, rigid, dependent, or immature. They often display more concern for themselves than the child, frequently show little remorse, and are evasive and contradictory. They generally do not volunteer information, seldom visit the child in the hospital, and rarely ask questions about the child’s condition. By contrast, parents whose child is unintentionally burned usually blame themselves for a lack of supervision and may display a profound sense of guilt.

Burn injuries can be divided into 6 categories: flame, scald, contact, electrical, chemical, and radiation, eg, sunburn from ultraviolet radiation. Abusive burns generally cluster in the scald and contact categories, although there are reports of other types of burns. Children’s skin is much thinner than adult skin, so serious burning occurs more rapidly and at lower temperatures. Electrical burns can be deceptive since trauma may not always be outwardly apparent. Electricity follows the path of least resistance, and skin is a natural resistor to electrical flow. Nerves, muscles, and blood vessels, however, are good conductors and, therefore, are more susceptible to electrical trauma. Electrical flash burns are caused when the current is shorted, producing a very brief, high-intensity fireball that causes thermal injury. Flash burns char the superficial layers of skin but usually do not cause destruction of deep tissues.

The first priority for the burned victim is to medically treat the injury. Once accomplished, efforts can then be directed toward obtaining an accurate history from witnesses and family members, specifically, the timing, nature, extent, and location of the burn. Medical personnel must document the exact shape, depth, and margins of all wounds and include all affected body parts. Immediate attention to these details may prove invaluable when ascertaining whether the burn resulted from an abusive or unintentional injury.

Medical providers may choose to interview the child victim. It is important that the child’s safety is assured and that they will not be longer be harmed. General open-ended questions are preferred, eg, “How did you get hurt?” More detailed, specific questions may be asked after the child victim has had the opportunity to tell their story. It is also important to ascertain whether the child has been coached or threatened, if they tell.

Figure 1-1. Length of time required for second- and third-degree burns to occur when exposed to liquids of varying temperatures, reinforcing the relative importance of time and surface temperature in the causation of cutaneous burns.

Other important factors to consider when examining a burn victim, is the length of time it takes for a second- or third-degree burn to occur relative to the temperature of a given liquid (Figure 1-1), the surface temperature, and the location of the burn on the child’s body (Figure 1-2). The head and thoracoabdominal region are more likely to be involved in unintentional burns, whereas buttocks, genitalia, bilateral hand, and bilateral feet burns are much more likely to be related to abuse. Unintentional scald burns of the trunk usually involve the anterior surface of the body. In most cases, a child pulls a tablecloth edge, causing a hot liquid to spill over and burn them from the table. Gravity causes an inverted triangle burn pattern. Clothing may affect the burn pattern and severity as it insulates the skin. Hot liquid may pool in the diaper area resulting in an unusual burn pattern. The most common indicators of abuse are burns to the genitalia and buttocks, and mirror image burns to the extremities. Bruises, welts, or fractures may also be present. The most important factor in distinguishing abusive from unintentional burns is determining whether the burn pattern is consistent with the history given by caregivers.

A medical provider should consider abuse when the following are present:

1. Multiple hematomas or scars in various stages of healing

2. Concurrent injuries or evidence of neglect, such as malnutrition and failure to thrive (Especially suspicious are old rib fractures and distal femoral or tibial metaphyseal, or transverse fractures.)

Figure 1-2. Diagram of anterior and posterior body surfaces with the results of the Grossman Burn Center Study that was presented at the American Burn Association Annual Meeting in 1999. It represents the frequency of involvement of different body parts with a comparison between unintentional and abusive burns.

3. History of multiple prior hospitalizations for “unintentional” traumas

4. An inexplicable delay between time of injury and first attempt to obtain medical attention (In some cases, a caregiver with medical training may delay as they initially tried to treat the injury themselves.)

5. Burns which appear older than the alleged day of the incident, similarly indicating ambivalence about seeking care due to the possibility of the true etiology of the burn being revealed

6. An account of the incident which is not consistent with the age or developmental ability of the child

7. Allegations by the responsible caregivers that there were no witnesses to the incident and the child was merely discovered to be burned

8. History of relatives other than the parents bringing the injured child to the hospital or a nonrelated caregiver bringing the child (excepting a proper explanation, such as a babysitter caring for a child while the parents are out of town)

9. Burns attributed to the action of a sibling or other child (Although this is often an explanation from parents or other caregivers for abusive burns, it should also be noted that siblings can be abusive.)

10. An injured child who is excessively withdrawn, submissive, overly polite, or does not cry during painful procedures

11. Scalds of the hands or feet, often symmetrical, that appear to be full thickness in depth, suggesting that the extremities were forcibly immersed and held in hot liquid

12. Isolated burns of the buttocks or perineum and genitalia, or the characteristic doughnut-shaped burn of the buttocks

13. Conflicting or changing explanations offered by the responsible caregivers

The burns presented in this chapter illustrate patterns found in abusive burns as well as unintentional burns. The inability to match the caregivers’ description to the patterns observed usually reveals the abusive nature of these intentional burns. The young ages of these victims are typically seen with abusive burns.

IMMERSION BURNS

STOCKING-GLOVE PATTERN

Case Study 1-3

This 11-month-old male presented with bilateral submersion burns of the hands. The initial history given by the mother was that the child had been burned when he spilled hot coffee on himself. The injury was not consistent with a spill and indicated an inflicted submersion burn. The child’s hands were immersed in a pot of scalding water.

Figure 1-3-a. Note the distinct line of demarcation between the burned and unburned areas.

Figure 1-3-b. Note that all digits of both hands are burned.

Case Study 1-4

This 20-month-old girl was in the care of her mother’s boyfriend. He stated that she was sitting in about 4 inches of bathwater when he left the room momentarily. He returned to the bathroom when he heard the child cry and noted that the hot water had been turned on. His explanation was inconsistent with her injuries, which were clearly caused by submersion. The abusive nature of the injuries was evidenced by the stocking-glove pattern and the spared portion of skin in the popliteal area of the left leg, which was protected by either the girl flexing her leg or the boyfriend’s hand as he dipped her into the water.

Figures 1-4-a, b, and c. Stocking-glove pattern burns on both legs of the infant.

Case Study 1-5

The caregivers of this 18-month-old boy stated that the child sustained these burns when he turned on the hot water in the bathroom sink. The bilateral stocking-glove pattern, however, was indicative of immersion burns. The caregivers later admitted to intentionally immersing the boy’s hands in hot water as a form of punishment.

Figure 1-5-a. Bilateral stocking-glove pattern burns on the boy’s hands and forearms.

Figures 1-5-b and c. The palms of each of the boy’s hands are severely burned.

Case Study 1-6

This 20-month-old boy was seen for a healed immersion burn. The caregiver stated that it was caused by splashing hot water. However, the stocking-glove pattern was indicative of an immersion burn.

Figure 1-6. Stocking-glove pattern burn 3 weeks after the injury took place. The skin has been grafted and is healing.

Case Study 1-7

This 6-year-old girl was held in a bathtub of scalding water by her mother’s boyfriend while the mother was away from home. The mother’s boyfriend stated that the child had slipped on some soap in the bathtub. In the presence of her mother and the boyfriend, the child initially corroborated the boyfriend’s history. Once separated from them for an interview, the child made the following disclosures.

When asked “When you were in the bathtub, did it hurt?” the child replied, “Yes.” When asked “Did you cry?” she replied, “No.” When asked why not, she said, “Because I had tape on my mouth.” The child stated that the boyfriend used electrical tape to cover her mouth and bind her wrists and ankles prior to being submerged in the scalding water.

The boyfriend was later convicted and sentenced to a life term.

Figure 1-7-a. The child’s legs at the time of admission, less than 8 hours after the incident, revealing blistering and redness. The full severity of the scald burn may not become apparent until 24 to 48 hours after the event.

Figure 1-7-b. Note the initial appearance of the doughnut-shaped pattern, the circular areas of unburned skin on the child’s buttocks. This is the result of the buttocks being held forcibly against the cooler surface of the bathtub bottom. This doughnut pattern is an important indicator of abuse; however, it may not be present in all abusive burn injuries. A child can be held in scalding water without being forced to the bottom of the tub, which would produce burns to the entire buttocks.

Figure 1-7-c. After 24 hours, the burns show evidence of much more necrotic skin, represented by the white areas.

Figure 1-7-d. The burns at 48 hours become better demarcated. Note the area of the left ankle that is not burned; this supports the child’s statement that her ankles were covered with electrical tape.

IMMERSION BURNS

MULTIPLE INJURIES

Case Study 1-8

This 18-month-old boy was examined for contact burns to the chin caused by a cigarette lighter. Additionally, he had immersion burns to his lower trunk and bilateral lower extremities. His mother held him in a bathtub of scalding water.

Figure 1-8-a. Contact burn to the chin.

Figure 1-8-b. The distribution of the burn can be used to approximate the position in which the child was held in the water. The sharp line of demarcation demonstrates that the child’s knees were above the water level.

Figure 1-8-c. The doughnut-shaped pattern on the right buttock is consistent with the lack of burns to the knees. The right buttock would be deeper in the water and against the cooler surface of the tub, whereas the left buttock would have been in the water and received burns to the entire surface. The distinct line of demarcation on the back trunk indicates the water level in the tub.

Case Study 1-9

This 6-year-old girl was abused by a childcare employee as punishment for soiling herself. The child was slapped across the face, whipped with an electric cord, and then immersed in scalding water from the waist down.

Figure 1-9-a. Patterned bruises on the girl’s back caused by being whipped with an electrical cord.

Figure 1-9-b. Patterned bruises on the girl’s right cheek caused by an open-handed slap.

Figure 1-9-c. Note the distinct line of demarcation between the burned and unburned skin.

Figures 1-9-d and e. The child’s extremities were flexed during submersion; therefore, there is an absence of injury in the flexion creases of her groin. This is also seen in the popliteal areas.

Figure 1-9-f. Note the circumferential nature of the immersion burns.

Case Study 1-10

This 9-year-old boy was held in scalding water by his mother. His initial description of the incident indicated that he fell into the bathtub. Once he felt safe after learning of his mother’s incarceration, he revealed the true etiology of his burns to his health care providers. He described being held in the water “until his skin was floating off in the water.” He also described his exact position in the bathtub as leaning more to the right side. The child’s mother was tried for abuse and torture. She was released with time served.

Figures 1-10-a and b. The child’s description of his position in the bathtub is consistent with his injuries. His right thigh has more severe burns than on the anterior surface of his left thigh. There are also unburned areas in the popliteal and inguinal flexion creases.

Case Study 1-11

This 18-month-old boy had second-and third-degree immersion burns to both lower extremities. He was originally admitted to another hospital and was transferred with the diagnosis of “scalded skin syndrome” that was caused by an infectious process.

Figures 1-11-a and b. This burn, which shows a combination of thermal and chemical burn characteristics, appears more like an intentional immersion burn. Body radiographs revealed a healing tibial plateau fracture. As a result of progressive swelling, the child developed a compartment syndrome in the affected leg necessitating a fasciotomy. Thorough investigation revealed that this child was one of several being cared for by a particular caregiver. The child soiled his diaper. As the caregiver had run out of clean diapers, she dipped him in a mixture of hot water, ammonia, and disinfecting cleaning detergent. Reportedly, to both cleanse and punish him for soiling.

Case Study 1-12

This 33-month-old girl was taken to the ER by her parents who reported that they first noted the burns to her back after returning from a trip. The child was in the backseat of the car. They stated that although she was restless, she did not give them any reason to suspect that she was injured. They initially did not know how the injury had occurred.

Figure 1-12-a. Second-degree burns of the back to the gluteal crease on her left side, including the left buttock.

Figures 1-12-b and c. The burns extend laterally on the torso to the midchest of her right side and to a higher level on her left side.

Figure 1-12-d. Her right arm has a small area of burn medially and at the elbow. After the child’s examination, the parents suggested the injury resulted from a sunburn or that it was caused by the sun heating the back of the carseat. They also reported that she was wearing a bathing suit. The burns involved multiple surface areas. The patterns were not consistent with sunburn, since there were no clothing lines. Also, contact burns demonstrate contouring on the host surface. This child’s burns were more consistent with immersion burns caused by a hot liquid, and subsequently reported as abuse. The child was placed in foster care for 6 months, and then returned to her parents. One month later, she returned with a similar burn without any explanation.

Case Study 1-13

This 18-month-old girl was examined for second- and third-degree burns on both legs. She was also malnourished requiring nutritional support before skin grafting could be done. Investigation by social services determined that the burns were most likely unintentional.

Figures 1-13-a and b. Sustained second- and third-degree burns of both legs from hot water immersion.

The child was readmitted 6 months later with a large third-degree burn on her back. Her mother and stepfather stated that she was asleep in the back seat of their car when battery acid spilled onto her. According to their account, the child did not awaken when she was burned and they only noted the burn after they arrived home and were getting her ready for bed. After a thorough investigation, it was determined that her stepfather inflicted the burns. The child was initially placed in foster care and subsequently adopted.

Figure 1-13-c. Third-degree burn to this child’s back that occurred 6 months after the initial burns on her legs.

Case Study 1-14

This child was first seen when he was 26 months old. While in the care of a 14-year-old babysitter, he burned his right hand on a space heater. Initially, the burn was determined to be an unintentional injury. Four months later he returned to the ER with another burn. His mother reported that she had given him a bath the evening before and had not see the burns until the following day when she noticed that the skin on his buttocks was coming off. It was later revealed that the child was burned as a form of punishment.

Figure 1-14-a. Contact burn on this 26-month-old child’s right hand resulting from a space heater.

Figures 1-14-b, c, and d. This child has a large bruise on his lower back and a smaller one on his left thigh. These are confluent linear marks.

Case Study 1-15

This 3-year-old girl was taken to the ER for second- and third-degree burns of her hands. It was alleged that the child stuck her hands under running hot water. The child later stated that “mommy was mad at me and put my hands in the water.”

Figures 1-15-a and b. Compare these injuries with typical immersion injuries. There is no stocking-glove sign. The palms are relatively spared. In addition to the child’s history, the temperature of the water, as measured by the investigator, confirmed that it was not hot enough to cause an instantaneous burn.

IMMERSION BURNS

DELAY IN CARE

Case Study 1-16

After a considerable delay, this 9-month-old boy was brought for medical attention for burns. An older sibling reportedly burned him in a bathtub. Caregivers did not seek medical care initially as they did not appreciate the severity of the burns.

Figure 1-16-a. Immersion burn at least partial thickness deep. Note considerable burns on the buttocks bilaterally with burns extending onto the posterior legs. Depth of the water was relatively shallow.

Figure 1-16-b. On closer inspection, the burn reveals evidence of healing with granulation tissue as well as areas of secondary infection.

Figure 1-16-c. Burn to the knee appears to be full thickness. Other burns to the legs reveal a pattern more complex than a simple immersion burn—possibly due to hot water being poured from above.

This case represents medical neglect, supervisory neglect, and possible physical abuse, depending on who burned the infant. Delay in seeking medical care for a substantial burn can lead to further disfigurement, scarring, sepsis, and an increased risk of death.

IMMERSION BURNS

EXTENSIVE BATHTUB BURNS

Case Study 1-17

This 15-month-old boy was brought to the ER for burns that reportedly occurred in a bathtub. The mother stated that she left the child for just a couple of seconds after she had placed him in the bath. She stated that he turned on the hot water and burned himself. Extensive partial thickness burns resulted.

Figure 1-17-a. Burns to the right foot and lower leg.

Figure 1-17-b. Very painful partial thickness burns to the perineum, buttocks, and scrotum.

Figure 1-17-c. The position of this child is similar to the position when burned, but he would have been sitting more upright. The foot is forward into the deeper water with the knee only slightly bent.

Figure 1-17-d. Pattern reveals that the right foot was in the water more than the left.

Figure 1-17-e. The heel of the left foot is burned but the dorsum spared, indicating the left foot was held up, perhaps as the child was being placed into the hot water.

Figure 1-17-f. The thicker skin of the soles is relatively spared. The burn pattern indicates that the right leg was only slightly bent.

If there was no water in the bathtub initially, it would have taken a long time to get water to the depth indicated by the burns. If the water had already been in the tub, the mother would be neglectful for leaving the child alone; however, incoming hot water would take a long time to heat the existing water to a temperature that could cause such burns, and the screams of the child would have alerted the mother. Also, it is doubtful that this child would have stayed relatively still in this position. He would have moved away from the painful stimulus and prevented these burns. Thus, these burns represent immersion into very hot water that would have already been in the bathtub to this depth. It was determined that this was a case of physical abuse and not neglect—the mother’s history was false.

Case Study 1-18

3-year-old male reportedly placed in the bathtub with existing water in the tub and water running from the faucet. The mother’s boyfriend reportedly pulled the lever to turn on the mobile shower head. He then pulled it down and moved the spray over the child to rinse child off. This child also had multiple other bruises, including genital bruising. The child stated, “Father hurt me.”

Figures 1-18-a, b, and c. Burns on the boy’s face, shoulder, and back.

IMMERSION BURNS

SAME BURN, DIFFERENT MANNER

Case Study 1-19

22-month-old male with immersion burns. The mother reported that, initially, the water running from the faucet was cold. She then adjusted the faucet but did not check the water temperature again. The mother sat the child on the edge of the tub with his feet outside the tub. Her hands were placed under his axilla, and while holding him, she slid him backwards off the edge of the tub into the water. His buttocks entered the water first while she was still holding him. His feet were still over the edge of the tub. He screamed immediately when he entered the water. His mother was uncertain how far his buttock entered the water but reported she removed him immediately once he screamed. She noted that his skin was red and peeling. Although it is difficult to determine if the etiology of his burn was unintentional, the history offered was plausible.

Figures 1-19-a and b. Immersion burns on the child’s buttocks and scrotum.

Case Study 1-20

2-year-old with immersion burns. This mother stated that she placed the child in an empty bathtub, facing the faucet. She then turned the water on and left it running, while she left the room for approximately 5-10 minutes. Although she heard the child crying, she assumed the child was upset about having to take a bath. When the mother returned, the child appeared frightened, and immediately stood up in the tub gesturing to be removed. The mother noted that the water was still running and steam was rising from the bath water. She immediately removed the child from the tub and estimated that there was approximately 5-6 inches of water remaining in the tub. The mother later confessed that the child “went potty” and that she held her under the tub faucet. The feet should have been burned had the child stood in the water, as initially stated by the mother.

Figures 1-20-a and b. Immersion burns on the child’s buttocks.

IMMERSION BURNS

PERINEAL BURNS

Case Study 1-21

This toddler suffered an abusive bathtub burn.

Figure 1-21-a. Note the perineal burns with sparing of the buttock areas that were pressed against the cooler bathtub.

Figure 1-21-b. With spreading of the labia majora, urethral prolapse can be seen. Urethral prolapse most commonly presents as painful genital bleeding in prepubertal African-American girls. It is not an indication of concomitant sexual abuse.

IMMERSION BURNS

STOCKING-GLOVE PATTERN BURNS

Case Study 1-22

A toddler was brought to the ER with a burned foot. The mother stated this child stood in the bathtub and turned on the hot water.

Figure 1-22-a. Deep partial thickness burn to the inner aspect of the left foot. Note blisters on the toes corresponding to less severe burning.

Figure 1-22-b. Deep partial thickness burn to the right foot. If the history offered were true, the stream of water would have to have fallen symmetrically between both feet; however, it is evident that the child was immersed in several inches of water of a lesser temperature. A further inconsistency is that the child would have reacted by moving away from the stream of hot water.

Case Study 1-23

21-month-old female with bilateral glove-stocking pattern scald burns. A cousin was running water for a bath when the child reportedly put her hands under the hot water. If this child had leaned over and fallen on her hands, there would not be a clean line of demarcation for the burn, especially while the water was still running.

Figure 1-23. Glove stocking pattern scald burn on child’s right hand.

IMMERSION BURNS

HEALING IMMERSION BURNS

Case Study 1-24

This 3-year-old child was brought to the outpatient department of a childrens hospital.

He was found to have burns that were healing. He reportedly burned himself in a bathtub. There were no burns to the hands or feet, indicating that this was an immersion burn. This child was lowered into hot water.

Figure 1-24-a. Bilateral burn to the buttocks consistent with an immersion burn.

Figure 1-24-b. Splash mark on the right flank.

In addition to physical abuse, this child was also neglected as the caregivers did not seek immediate medical attention. This child suffered additional pain, had an increased risk of infection, and had an injury that resulted in scarring.

IMMERSION BURNS

IMMERSION BURN SCAR

Case Study 1-25

This 3-year-old was brought to the outpatient department due to allegations of sexual abuse. No physical evidence of sexual abuse was seen. Examination revealed completely healed immersion burns to the buttocks. The mother reported that this child burned herself in the bathtub. No burns were seen on the feet or hands. This is presumptive evidence of physical abuse as the history offered was not consistent with this burn pattern. The child was also neglected as medical care was not sought for the burn.

Figure 1-25. Immersion-burn scar along the right buttock.

IMMERSION BURNS

“DOUGHNUT” BURN PATTERN

Case Study 1-26

This preschooler reportedly burned herself in the bathtub.

Figure 1-26-a. Note the “doughnut” distribution whereby the buttock areas against the cooler bathtub are spared, but the skin above is burned.

Figure 1-26-b. Closer view of the buttocks burn shows symmetry not expected when the injury is unintentional.

IMMERSION BURNS

WATER LINES SHOWN BY BURNS

Case Study 1-27