LITMIR.BIZ

      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

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