Pediatrics · Year 3 · from Pediatrics
Case 2: Inflicted Burns
Patient Demographics
- Age: 2-year-old female
- Sex: Female
Chief Complaint
"She burned herself in the bathtub."
History of Present Illness
A 2-year-old girl is brought to the emergency department by her mother with burns to her buttocks and feet. The mother states that the child climbed into the bathtub while the mother was answering the phone and turned on the hot water. She says she found the child in the tub screaming after "a few minutes." The burns were sustained yesterday, and the mother applied butter to the wounds and waited until today to seek medical care because she "thought it would get better." The child has had previous ED visits for a forearm fracture 6 months ago (attributed to a fall from a chair) and a head laceration 3 months ago (attributed to falling against a table).
Physical Examination
- Vital Signs: Temperature 37.5C, HR 125 bpm, RR 22/min
- General: Quiet, withdrawn toddler; avoids eye contact; minimal crying despite painful wounds
- Burns:
- Buttocks: Symmetric, full-thickness burns with clear lines of demarcation bilaterally; flexural creases (skin folds) are spared
- Feet: Circumferential "stocking" distribution burns to both feet up to the ankles with sharp demarcation; uniform depth
- No splash marks or drip patterns visible
- Skin (other): Fading linear bruise on right upper back; healing circular lesion (0.8 cm diameter) on left forearm
- Genitalia: Spared (protected in flexed position)
- Extremities: Old healing abrasions on shins
- Neurologic: Appropriate for age but very withdrawn
Diagnosis
Inflicted immersion burns (non-accidental trauma)
Clinical Reasoning
Several features indicate these are inflicted rather than accidental burns: (1) Symmetric, well-demarcated burns without splash marks indicate the child was forcibly held in hot water; accidental immersion would show irregular borders and splash patterns from struggling to escape; (2) Spared flexural creases suggest the child was held in a flexed position with skin folds protected; (3) Stocking-pattern burns to both feet with uniform depth and sharp demarcation are inconsistent with accidental contact; (4) The described mechanism is implausible - a 2-year-old cannot generate water hot enough for full-thickness burns from a standard water heater, and the distribution is inconsistent with the described accident; (5) Delay in seeking care is concerning; (6) History of multiple prior injuries raises concern for pattern of abuse; (7) The circular lesion on the arm may represent a cigarette burn.
Management
- Medical treatment of burns: Wound care, pain management, possible burn unit consultation
- Report to Child Protective Services: Mandatory; this is a medical emergency requiring immediate safety intervention
- Complete physical examination: Document all injuries with photographs and measurements
- Skeletal survey: Age-appropriate (child is under 2 years)
- Detailed documentation: Verbatim history from caregiver including timeline; document all inconsistencies
- Multidisciplinary team: Involve social work, child abuse pediatrician if available
- Safety planning: Child should NOT be discharged to the care of the perpetrator
- Law enforcement notification: Criminal investigation warranted
Clinical Image
Image Description: Characteristic immersion burn pattern showing stocking-distribution burns to the feet with clear lines of demarcation, uniform depth, and absence of splash marks, indicative of inflicted injury from forcible immersion.
Source: Radiopaedia - Child Abuse URL: https://radiopaedia.org/articles/child-abuse License: CC BY-NC-SA 3.0