Certainly, 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