Burns and Inflicted Trauma

Inflicted Burns - Scalding Suspicion

• Pattern: Sharp demarcation lines ("tide mark"), uniform depth. Absence of splash marks.
• Distribution:
  • Symmetrical burns on buttocks, perineum, or extremities.
  • "Glove" or "stocking" distribution on hands/feet.
  • "Donut" pattern on buttocks (spared area where skin touches cooler tub bottom).
  • Forced immersion: Flexion sparing in popliteal, antecubital fossae, groin.
• Depth: Often full-thickness, uniform depth due to prolonged contact.
• History: Inconsistent or changing history, delay in seeking care.

⭐ Forced immersion scalds often show a clear upper level of the burn (water line) and sparing of skin creases that are flexed and pressed together, preventing water contact.

• Differential: Accidental scalds (irregular margins, splash marks, variable depth, history consistent with injury).

Skeletal Trauma - Bones Don't Lie

• High Specificity Fractures (NAI indicators):
  • Metaphyseal Corner Fractures (MCF) / Bucket Handle Fractures (Classical Metaphyseal Lesions - CML).
  • Posterior Rib Fractures (due to squeezing/shaking).
  • Scapular, Sternal, Spinous Process Fractures (high force).
• Other Red Flags:
  • Multiple fractures in various stages of healing.
  • Any fracture in a non-ambulatory infant (e.g., femur, humerus <1 year old).
  • Complex skull fractures (e.g., depressed, diastatic, occipital, growing).
• Investigation:
  • Skeletal survey for all suspected NAI < 2 years.
  • Repeat survey in 2 weeks (detects occult/healing fractures).
  • 
• Differential Diagnosis: Osteogenesis Imperfecta (OI), Rickets. History often inconsistent with injury in NAI.

⭐ Metaphyseal corner fractures (CML) are virtually pathognomonic of non-accidental injury (NAI).

Head & Abdominal Trauma - Hidden Dangers

• Abusive Head Trauma (AHT) / Shaken Baby Syndrome:
  • Violent shaking +/- impact.
  • Triad: Subdural hematoma, retinal hemorrhages, encephalopathy.
  • Also: Posterior rib, metaphyseal fractures.
  • Signs: Irritability, lethargy, seizures, apnea.
  • ⚠️ History-injury mismatch is key.
• Skull Fractures (Suspicious):
  • Multiple, complex, bilateral, depressed, or crossing suture lines.
• Abdominal Trauma (Often occult):
  • 2nd leading cause of death in abuse.
  • Blunt force (punch, kick).
  • Injuries: Liver laceration (most common), pancreas, duodenal hematoma, bowel perforation.
  • Signs: Vomiting (bilious), pain, distension, shock.

  ⭐ Duodenal hematoma: specific inflicted injury; bilious vomiting, "double bubble" on X-ray. oka

Evaluation & Reporting - Spotting & Acting

• Initial Approach: Maintain high index of suspicion. Prioritize child's immediate safety.
• History Taking:
  • Inconsistent, vague, or changing explanations.
  • Delay in seeking medical care.
  • Mechanism of injury incompatible with developmental age.
• Physical Examination:
  • Complete head-to-toe exam (child undressed).
  • Note patterned injuries (e.g., belt marks, cigarette burns).
  • Multiple injuries in different stages of healing.
  • 📌 TEN-4 FACES-P bruising rule for concern:
    • Torso, Ears, Neck in children < 4 years.
    • Any bruise in an infant < 4 months old.
    • Frenulum, Angle of jaw, Cheek, Eyelids, Sclera; Patterned bruises.
• Key Investigations:
  • Skeletal survey: Mandatory for all suspected abuse cases < 2 years; repeat in 2 weeks.
  • CT/MRI head: If suspected head trauma, seizures, or altered sensorium.
  • Ophthalmology consultation: For retinal hemorrhages.
  • Coagulation profile: To rule out bleeding disorders.

⭐ Retinal hemorrhages, especially bilateral and extensive, are highly suggestive of Abusive Head Trauma (AHT) or Shaken Baby Syndrome.

• Medico-legal Responsibilities & Reporting:
  • Mandatory reporting to Child Welfare Committee (CWC) and local police (under JJ Act & POCSO Act).
  • Detailed, objective documentation. Register as a Medico-Legal Case (MLC).
  • Involve a multidisciplinary team (pediatrician, social worker, law enforcement).

High‑Yield Points - ⚡ Biggest Takeaways

• Patterned burns (cigarette, iron) and immersion scalds (glove/stocking, doughnut) strongly suggest inflicted trauma.
• Scalds with sharp demarcation, uniform depth, and flexural sparing are highly suspicious for abuse.
• Multiple fractures in varied healing stages are classic for Non-Accidental Injury (NAI).
• Metaphyseal corner fractures and posterior rib fractures are highly specific for child abuse.
• Abusive Head Trauma (Shaken Baby): subdural hematoma, extensive retinal hemorrhages, and encephalopathy.
• Inconsistent history, delayed presentation, or bruises in atypical sites/non-mobile infants are major red flags_