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?)



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]

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Sean M. 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 renowned 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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  1. […] aspect of care in the Peds ED. We have covered several related topics (ex, Plantar Wounds, Road Rash, Fish hook FB, Absorbable Sutures). Aside from the initial assessment, irrigation, FB removal, […]

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