Road Rash

Road Rash Friction InjuryCertainly, pediatric rashes can be a challenge (and we have discussed my “Approach to the Pediatric Rash” previously).  One “rash,” however, deserves particular attention as it is not a Rash at all: it is a Burn!  Let’s remain vigilant for that benign sounding rash that may not be benign at all: Road Rash.

 

Road Rash : Basics

  • Accidental Injury is the leading cause of mortality for children.
    • See Childhood Injury
    • Motor Vehicle Accidents are the most common cause.
    • Fire/Burn is the 5th most common cause of injury.
  • “Road Rash” is a Friction Burn.
    • It is the most common non-thermal burn.
    • Patients 0-20 years of age account for 40% of cases. [Agrawal, 2008]
    • Often overlooked initially [Castana, 2009; Agrawal, 2008]
      • Many times associated with other injuries that may distract providers.
        • 35% had associated fractures
        • 10% had head injuries
      • Severity may be under-appreciated by providers – classifying it as “road rash” rather than burn.
  • “Road Rash” – difficult to know its true incidence.
    • Often embedded with diagnosis of abrasion or burn.
    • More minor versions may not even be documented.
    • Patients with minor versions may not seek medical attention.
    • Friction burns are not included in burns surveys. [Agrawal, 2008]

 

Road Rash: Physics Matters

  • Friction is a non-conservative, resistive force
  • Occurs when two surfaces move against each other
  • Is a function of the coefficient of friction of the objects
    • Skin moving against other surfaces has a high coefficient of friction
  • Frictional forces generate both:
    • Structural injury 
    • Thermal injury
  • Other influencers:
    • Velocity of the moving objects – the greater, the more severe the burn
    • Surface temperature – the hotter, then more severe (ex, asphalt in afternoon is hotter and generates more damage)

 

Road Rash: The Culprits

  • Most often occurs with motor vehicle accidents. [Agrawal, 2008]
    • Ejected passengers from car accidents
    • Motorcycle passengers
    • Bicycle riders
  • Other common causes:
    • Exercise Treadmills (fast moving belts) [Friedrich, 2007; Collier, 2004]
      • Many injuries reported and has lead to Injury Prevention strategies.
      • Can be severe injuries – one study had 46% with Full Thickness burns [Collier, 2004]
    • Sanders and Grinders (again, fast moving surfaces)
    • Domestic Vacuum cleaners (particularly those with rotating brushes) [Grob, 2003]

 

Road Rash: Severity

  • Road Rash / Friction Burn severity is determined by the depth (just like Thermal Burns):
    • Epidermal: Painful, red
    • Superficial Dermal: Painful, pink
    • Deep Dermal: Reduced pain, blotchy, No Cap Refill 
    • Full Thickness: No sensation, white or black, No cap refill
    • Deep Structures (Muscle, Tendon, Bone, etc) [Bailey, 2011]
  • Most of the cases in the literature are Superficial Dermal or deeper. [Castana, 2009]
    • Likely somewhat do to reporting bias, but still highlights the fact there is a lot of significant non-thermal burn.
    • Often had secondary infections and scar formation.
  • Can also be complicated by Traumatic Tattooing [Vrints, 2014]
    • Forceful impregnation of dirt, asphalt, gravel, glass into dermis.
    • After re-epithelization, becomes a permanently discolored area (black or blue).
    • Best strategy to prevent tattooing is to remove all of the foreign bodies before the region re-epithelializes.

 

Moral of the Morsel

  • Don’t be complacent with “road rash!”
  • Characterize and describe “road rash” like the burn that it is!
  • Treat “road rash” like a Burn! – because it is.
    • Assess the severity of the burn.
    • Don’t forget the fluid resuscitation!
    • Don’t forget the tetanus prophylaxis!
    • Consult your plastic surgeons or burn specialists to help determine best management (Close follow-up? Surgical debridement? Skin grafting?)

 

References

Vrints I1, Den Hondt M, Van Brussel M, Nanhekhan L. Immediate debridement of road rash injuries with Versajet® hydrosurgery: traumatic tattoo prevention? Aesthetic Plast Surg. 2014 Apr;38(2):467-70. PMID: 24584860. [PubMed] [Read by QxMD]

Menon S1, Ward D, Harvey JG, Hei EL, Holland AJ. Friction burns in children: does laser Doppler imaging have a role? J Burn Care Res. 2012 Nov-Dec;33(6):736-40. PMID: 22878493. [PubMed] [Read by QxMD]

Bailey JK1, Park C, Yakuboff KP. Fourth-degree burn of the brain from friction burn of scalp: an unusual injury from a golf cart. J Burn Care Res. 2011 Jul-Aug;32(4):e146-8. PMID: 21747331. [PubMed] [Read by QxMD]

Castana O1, Dagdelenis J, Rempelos G, Paneris P, Anagiotos G, Diplas D, Alexakis D. Traumatic injuries with deep abrasion: “a burn”. Ann Burns Fire Disasters. 2009 Mar 31;22(1):44-7. PMID: 21991151. [PubMed] [Read by QxMD]

Agrawal A1, Raibagkar SC, Vora HJ. Friction burns: epidemiology and prevention. Ann Burns Fire Disasters. 2008 Mar 31;21(1):3-6. PMID: 21991101. [PubMed] [Read by QxMD]

Friedrich JB1, Muzaffar AR, Hanel DP. Pediatric hand friction burns from treadmill contact. Hand (N Y). 2007 Dec;2(4):188-93. PMID: 18780051. [PubMed] [Read by QxMD]

Han T1, Han K, Kim J, Lee G, Choi J, Lee J, Jang Y, Oh S. Pediatric hand injury induced by treadmill. Burns. 2005 Nov;31(7):906-9. PMID: 15990237. [PubMed] [Read by QxMD]

Maguiña P1, Palmieri TL, Greenhalgh DG. Treadmills: a preventable source of pediatric friction burn injuries. J Burn Care Rehabil. 2004 Mar-Apr;25(2):201-4. PMID: 15091149. [PubMed] [Read by QxMD]

Collier ML1, Ward RS, Saffle JR, Edelman LS, Morris SE, Lundy C. Home treadmill friction injuries: a five-year review. J Burn Care Rehabil. 2004 Sep-Oct;25(5):441-4. PMID: 15353938. [PubMed] [Read by QxMD]

Grob M1, Josty IC, Soldin MG, Dickson WA. Paediatric friction hand injuries caused by domestic vacuum cleaners-a review from one unit. Burns. 2003 Nov;29(7):714-6. PMID: 14556731. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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