Case 85

A 19-month-old boy presented with bilateral burns in his hands. According to his father, the child was sitting at the dinner table. The father placed a cup of hot water on the table in front of the child to make some hot chocolate. The father stepped away for less than a minute and came back to the child screaming. The hot water was spilled on the table and he was shaking his hands in pain. The father washed the hands with cold water, noticed the burns and decided to seek medical care for his son. The photographs show the dorsum and palmer aspects of both hands (Images 85a through 85d). https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig85a.jpg"/> https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig85b.jpg"/> https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig85c.jpg"/> https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig85d.jpg"/>

Is the burn pattern consistent with the provided history?

What are some concerning features about this burn? What is your diagnosis?

192

There is a glove pattern and clear line of demarcation that is not consistent with the history provided by the father. When the Child Protective Services worker visited the home, the table was noticed to be small, the size of a corner coffee table. The cup was noted to be of a large size with a diameter of 20 cm. The child may have been able developmentally to reach the cup of hot water, however that would result in the water spilling and splashing the child and not in the burn pattern seen.

When assessing a child who sustained a burn, we need to consider the location and configuration, as well as the compatibility with the mechanism or history provided. ¹ This burn has many features concerning for abuse. It is bilateral, deep, symmetrical and with a clear line of demarcation separating the burned skin from the normal skin. There are also no splash marks. ² As in this case, burns become more concerning for abuse when unwitnessed or with a poor history of events. The palms are partially spared due to the skin being thicker in that area and possibly being in contact with a cooler surface when the hands were immersed. The line of demarcation suggests the child was restrained when the hands were immersed in the hot water and thus no splash marks. This glove pattern results from the hands forcibly held in hot water and is consistent with an immersion burn. The diagnosis is physical abuse.