Frequency of skeletal injuries in children with inflicted burns

It is estimated that inflicted burn injuries in physically abused children occur with a prevalence of approximately 6-20%. Identification of burns of a nonaccidental nature is oftentimes difficult. Underlying skeletal injuries in abusive environments are often overshadowed by the acute burn injury.

We assessed the prevalence of inflicted burns and the frequency of associated skeletal injuries in a population from a large children's hospital.

From a database of nearly 3,000 children who were assessed for possible abuse from 1997 to 2012, we identified 142 children with burn injuries. We included only those who had undergone skeletal surveys as part of the diagnostic workup. The final diagnosis, based on the burn, was categorized as nonaccidental, accidental or indeterminate by a child abuse pediatrician. We excluded children with no skeletal survey (n = 18), children in whom the final diagnosis could not be found (n = 6), and other conditions misdiagnosed as burn (n = 6). The resulting cohort consisted of 112 children.

Of the 112 children with burns, 54 were girls and 58 boys with ages ranging from 1 month to 110 months, mean age of 15 months. Forty-five (40%) were determined to be nonaccidental, 36 (32%) were indeterminate and 31 (28%) accidental. The most common causative mechanism was scalding and the most common location was the perineum and lower extremity in all three diagnostic categories. Skeletal surveys were positive for fractures in 15/45 (33%) of the nonaccidental group; 2/36 (6%) in the indeterminate group, and 0/29 (0%) in the accidental group. Fractures in the nonaccidental group included healing rib fractures in seven, classic metaphyseal lesions in three, healing shaft fractures in six, skull fracture in one and clavicle fracture in two children. Fractures in the indeterminate group included shaft fractures in two, one of which was healing.

Intentional burns in children appear to be more common than previously known, occurring in 40% of the children in our series, a greater percentage than has been reported in the literature. In addition, nearly one-third of these children with inflicted burns had associated skeletal injuries, most commonly healing rib fractures. Thus young children with concern for nonaccidental burns should undergo a skeletal survey.