# Situation: A nurse works in the pediatric outpatient department, emergency room, and pediatric ward of a district hospital. The nurse examines several children in the outpatient department today. Which finding MOST strongly suggests physical abuse?

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> subject: Nursing Practice II — Maternal and Child Health Nursing

## 문제

Situation: A nurse works in the pediatric outpatient department, emergency room, and pediatric ward of a district hospital.

The nurse examines several children in the outpatient department today. Which finding MOST strongly suggests physical abuse?

## 보기

1. A walking 20-month-old with bruises of different colors on both shins
2. A 4-year-old with a buckle fracture of the wrist after falling from a chair
3. A 2-year-old with burns on both feet ending in a sharp line at the ankles **✔ 정답**
4. A 3-year-old with a healing scrape on the chin after tripping while running

**정답: 3**

## 해설

Burns on both feet with a sharp, uniform upper line (a stocking pattern) indicate forced immersion in hot water. Bruises over bony prominences such as the shins, a buckle fracture from a fall, and a chin scrape from tripping fit normal toddler and preschool mobility and the histories given.

## 심화 해설

Core clinical reasoning

The finding that most strongly suggests physical abuse is burns on both feet ending in a sharp line at the ankles. This pattern is called a stocking immersion burn. When a child’s feet are forcibly held in hot water, the burn margin forms a sharp, uniform, circumferential upper border because the water level is the same on both sides. Accidental burns from a child stepping into hot liquid usually produce irregular, splash-like edges and asymmetric depth.

Watch out! A sharp line at the ankles means the feet were held still in the water. A child who accidentally steps into hot water will reflexively withdraw the foot, creating splash marks and an uneven upper border. The sharp line is therefore a red flag for forced immersion, not an accident.

Why the other findings fit normal childhood injury

The remaining options describe injuries that match the developmental mobility of toddlers and preschoolers and the histories provided.

| Finding | Why it is less concerning for abuse | Key distinguishing feature |
| --- | --- | --- |
| Bruises of different colors on both shins in a walking 20-month-old | Bruises over bony prominences such as the shins are common in ambulatory toddlers who bump into furniture and fall while learning to walk. Different colors reflect bruises at different stages of healing, which is expected with repeated minor trauma over days. | Location is developmentally normal; shins are a typical impact site for a walking child. |
| Buckle fracture of the wrist after falling from a chair in a 4-year-old | A buckle (torus) fracture is an incomplete compression fracture of the metaphysis. It commonly results from a fall onto an outstretched hand and is consistent with the reported mechanism. The history is plausible and the fracture type matches low-energy trauma. | Mechanism and injury are biomechanically consistent. |
| Healing scrape on the chin after tripping while running in a 3-year-old | Facial abrasions from falls are frequent in active preschoolers. A healing scrape indicates the injury occurred days earlier, which aligns with the child’s ongoing mobility and the described tripping event. | Minor soft-tissue injury in a common fall location for the age. |

Pathophysiology and injury-pattern recognition

In suspected physical abuse, the clinician evaluates whether the injury pattern matches the stated mechanism and the child’s developmental stage. Abusive injuries tend to occur in locations that are protected during normal play or in patterns that cannot be produced by the described accident. Burns with a sharp demarcation line, especially in a stocking or glove distribution, are highly specific for immersion abuse because accidental scald injuries rarely produce such uniform borders.

The AAP clinical report emphasizes that certain burn patterns—including forced immersion burns with clear upper margins—should prompt a full evaluation for child physical abuse, including a skeletal survey and consideration of occult injury.  A systematic review of clinical signs in primary care similarly identifies patterned burns and bruises in non-ambulatory or protected areas as indicators that raise concern.

Key point! For licensure exams, remember the triad of patterned injury, implausible history, and developmental mismatch. The stocking burn has all three: a recognizable pattern, a history that would not produce it, and an injury distribution inconsistent with a child’s own actions.

Clinical and legal priority

When abuse is suspected, the nurse’s immediate responsibilities are to ensure the child’s safety, document findings objectively using precise descriptions and measurements, and report the suspicion to the appropriate child protection agency according to local law. Documentation should describe the burn’s location, size, depth, and the exact character of the upper border without using diagnostic labels such as “abuse” in the medical record.  The finding of a stocking-pattern burn in a 2-year-old is a sentinel injury that warrants protection and further investigation, because many children who later suffer fatal abuse have had prior abusive injuries that were not recognized.

## 임상 시나리오

Immersion Burn Red FlagRecognizing forced hot-water immersion in children
A stocking immersion burn with a sharp, uniform upper border at the ankles strongly suggests forced immersion in hot water. Accidental burns typically show irregular edges and splash marks because the child reflexively withdraws.

Bruises over bony prominences such as the shins, buckle fractures from low-height falls, and minor scrapes from running are common in toddlers and preschoolers and usually fit the reported mechanism.

CautionA sharp line at the ankles means the feet were held still in the water. Document the burn pattern precisely and follow mandatory reporting protocols when abuse is suspected.

## 핵심 개념

- **Stocking immersion burn** — A burn pattern on the feet or lower legs with a sharp, uniform upper border caused by forcibly holding the body part in hot liquid.
- **Buckle fracture** — An incomplete compression fracture of bone, common in children after low-energy falls.
- **Bony prominence bruising** — Bruises over areas such as shins, forehead, or elbows that commonly occur from normal childhood falls and activity.
- **Red flag for abuse** — A clinical finding or pattern that raises strong suspicion for non-accidental trauma.
- **Accidental burn pattern** — Irregular, asymmetric burn edges with splash marks typically seen when a child steps into hot liquid and withdraws reflexively.

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