What is the pathophysiology of physical child abuse-related burns?

Updated: Apr 24, 2017
  • Author: Angelo P Giardino, MD, MPH, PhD; Chief Editor: Caroly Pataki, MD  more...
  • Print
Answer

Burns arise from the application of heat energy to the child's skin. Various sources such as hot liquids (scalds), hot objects (contact or dry), flame (flash), chemicals, and electricity can generate heat. Three concentric zones of affected tissues have been identified. Coagulation is the most direct contact with the heat source in which the skin undergoes immediate coagulation necrosis as the proteins denature, and no cellular repair is possible. Stasis involves less heat energy exposure than with coagulation, and these cells, though injured, have some potential for repair. Hyperemia is the least direct injury, and these cells have the greatest potential for repair. All of these types and depth of burns can be encountered in both inflicted and accidental burns in children.

Human skin is composed of 3 layers: the epidermis, dermis, and subcutaneous tissue. Burns are classified clinically depending on the depth of the injury and the involvement of the various skin layers.

Superficial burns, which injure only the uppermost tissue of the epidermis, present as red, painful areas without blisters. Complete healing is expected from superficial burns. Deeper burns that extend through the epidermis into the upper levels of the dermis are referred to as partial thickness burns and present as painful blistering areas. Healing of partial-thickness burns varies, with various degrees of scarring depending on the level of tissue that is damaged. Finally, the deepest burns, full-thickness burns, extend past the epidermis and dermis and involve the subcutaneous tissue. These burns essentially have destroyed the overlying skin, blood vessels, and associated nerves and present as white, insensitive areas because of this destruction. A high degree of scarring and disfigurement result from full-thickness burns.

Evaluation of suspicious burns in children must include, as with any medical complaint, a detailed history from the caregiver and child, including a developmental history to ensure the child is capable of contributing to the injury (eg, "turned on the faucet"). Physical examination should include assessment of the burned area; critical assessment of the burned versus spared areas of skin can be helpful in determining the position of the child at the time of the burn. Note the image below.

Series of 3 photos of likely accidental hot water Series of 3 photos of likely accidental hot water scald burn on the leg of an infant. Sparing of skin-to-skin contact areas indicates child was flexed at the knee and ankle at the time of injury, which was consistent with being seated in the kitchen sink. Burn injuries require detailed scene investigation. In this case, investigators confirmed the ease of turning on the faucet and the high temperature of the water from it.

Careful gathering of information about what the child was wearing at the time, the time elapsed since the burn, symptom progression, and any topical treatments to the area is important in the determination of cause. Many childhood burns involve hot water in bathtubs or heated liquids in a kitchen setting. Scene investigations by child protective services and/or law enforcement can gather crucial information for determining whether the burn was inflicted or accidental burn (eg, temperature of tap water, height of faucets from floor, ease of turning handles, food residue on clothing or at the scene). Note the image below.

Pattern contact burn on buttocks of diapered child Pattern contact burn on buttocks of diapered child. The burn likely came from the metal grate surrounding heater.

Did this answer your question?
Additional feedback? (Optional)
Thank you for your feedback!