Title


Burn Management

1. CASE PRESENTATION

2. INTRODUCTION

2.1. Etiology and epidemiology

2.2. Prevention

3. PATHOPHYSIOLOGY OF BURNS

4. INITIAL MANAGEMENT

 

4.1. Primary Survey

 

4.2. Assessment of injury

 

4.3. Patient Selection

 

4.4. Fluid resuscitation

 

4.5. Escharotomy

5. INHALATION INJURY

6. WOUND CARE

7. MEDICAL MANAGEMENT

 

7.1. Nutritional support

 

7.2. Anemia

 

7.3. HIV

8. SURGICAL MANAGEMENT

 

8.1. General surgical principles

 

8.2. Specific anatomic considerations

9. REHABILITATION

 

9.1. Hypertrophic scarring

 

9.2. Contractures

 

9.3. Splinting

10. SURGICAL RELEASE

 

10.1. Neck contractures

 

10.2. Hands

 

10.3. Axilla

 

10.4. Deep structures

 

10.5. Face

11. CONCLUSIONS

12. RECOMMENDATIONS

13. REFERENCES

 

 

1. CASE PRESENTATION

 

Pepita, 6 years old, was thrown into a fire by another child two years earlier and sustained an 8% burn of her lower back. The burn was initially thought to be superficial, but, months later, the wound is still open and has never been grafted. Pepita cannot stand upright because she has flexion contractures of both hips and one knee. Instead, she has to crawl. Her groin was not burned, and the burn on her knee was only a minor one. Her contractures are the result of failing to ensure that she used her unburnt and minimally burnt limbs during the acute stage of her injury. She has now been abandoned by her family [1].

 


2. INTRODUCTION

 

The devastating effects of burns are long lasting at both an individual and societal level.  These impacts are compounded in resource-poor settings, where the human and material resources necessary to deal with this complex public health problem are lacking.  Developing nations are disproportionately affected - 95% of the 322,000 global fire-related deaths in 2002 occurred in low to middle-resource countries [2]. A structured and comprehensive approach to burn care must be applied to resource-poor settings in order to improve outcomes.


A combination of improved management and prevention strategies has resulted in important declines in morbidity and mortality in the developed world.  A recent
US study demonstrated a 50% decline in burn-related mortality and hospital admissions over a 20 year period [3].  Patients are frequently surviving even the most devastating burns due to advances in infection control, antimicrobial and biologic wound coverings, as well as a better understanding of resuscitation and the systemic effects of burn physiology and associated lung injury in burn patients.  However, a stark contrast is seen when comparing the burn related mortality rates in high and low-income countries.  For example, the WHO Global Burden of disease database has reported an over 10 fold difference between mortality rates in South East Asia and Europe (11.6 vs 0.7 per 100 000 population respectively) [2]. 

Unfortunately, without adequate resources in first-aid, acute surgical management and rehabilitation facilities, patients that do survive their burn injuries in developing countries often have poor, disfiguring and disabling long term outcomes. A Ghanaian study found that 18 % of childhood burns patients had suffered a physical impairment or disability [4].

As surgeons working in or supporting those who work in resource-poor countries, it is imperative that we understand the region-specific risk factors associated with burns, support preventative measures and provide rapid and appropriate resuscitation, surgical treatment and rehabilitation.


2.1. Etiology and epidemiology

In order to understand and overcome the challenges in the management and prevention of burns in low-income countries, a close look at the epidemiology and causal factors involved is required.  It is also necessary to understand the local economic constraints and the available health-care infrastructure.


There exist numerous hospital or clinic-based studies describing epidemiological characteristics of their burn population.  Forjuoh has published a review of 117 articles from 34 low and middle-income countries [5].  The majority of these studies dealt with the pediatric population, with the highest incidence of burns occurring in infants and toddlers (ages 0-4 years) who are dependant on others for their care.  In a study from
Angola which looked at all age groups, the pediatric population accounted for as much as one third of all burn victims [6].  A comprehensive population-based study in Ghana identified and calculated the strength of specific risk factors found in childhood burns; the presence of a pre-existing impairment such as epilepsy was associated with 6.7 greater odds of a burn, a finding supported by many other studies [7]. Other risk factors identified in case-control studies include history of a burn or burn-death in a sibling, low income, illiteracy, poor living conditions (overcrowding, lack of water supply) and careless practices (cooking equipment within reach of children) [7, 8, 9, 10]. All these reflect the importance of identifying and developing prevention strategies that reach marginalized populations.


In many countries in
Africa and Asia, young women are also at particular risk.  A reversal of gender distribution is seen compared to most other injury mechanisms. Women in East Asia account for 26% of the burn deaths worldwide, the highest burn mortality rates of any population (16.9 per 100 000 population per year) [5, 11]. This risk is attributed to the domestic role of women cooking in the home, using unsafe ground-level stoves oil-lanterns or open-fires and frequently wearing highly flammable (yet inexpensive) synthetic, loose clothing [12]. Some authors have found that violence against women is a frequent underlying causal factor in fatal burns, often billed as suicide in newlywed young women [13].


Most burns occur in the home, commonly in the cooking area, accounting for the high proportion of scald burns, followed by flame burns. Combined, they account for over 80% of all burns seen in low-income countries [4]. Electrical burns are also frequently seen in low-income areas where building codes may be less stringent and homes may be built near high tension wires. Although most studies report higher burn rates in urban settings, this could be due to a publication bias, with few district hospitals having the means to carry out and publish results [14]  Given the lack of first-aid resources and longer distances to travel to medical care in rural settings, it is not surprising that outcomes are worse in these locations. This is intuitively understood and is illustrated in a South African study showing that the average pre-hospital delay was 42 hrs in rural
South Africa, with high rates of wound infection (22%), contractures (6%) and prolonged length of stay [15].


2.2. Prevention

At a population health level, the true magnitude of the problem is not well defined with few standardized comprehensive statistical collection systems in many low-income countries. Some authors suggest that the global estimated death rate is a gross underestimation [14]. It is widely accepted that the social and economic costs of burn injuries to low-income populations are great and efforts to develop, evaluate, and implement prevention strategies specific to the local cultural and economic settings are urgently needed. Successful examples have been shown to work in developed countries such as Norway, where with a community-based prevention program, the rate of burn-related hospital admissions was reduced by 52% [5]. 


With over 2 billion people worldwide preparing meals using rudimentary traditional stoves or open fires [5], much interest has been directed toward developing safer domestic appliances and energy sources [14]. An example of such a strategy is the inexpensive redesigned flat kerosene lamp, designed by burn surgeon Dr. Wijaya Godakumbura of Sri Lanka’s Safe Bottle Lamp Project [16]. Although outcome studies have not formally been performed, with over 600 000 lamps distributed and accompanying community based education addressing basic fire-safety, this project is anticipated to have a major impact on the incidence of lamp-related accidents.


Recognizing the complexity of the issue and its regional challenges, the WHO, in collaboration with international partner agencies, developed in 2008 an evidence-based global strategy for burn prevention and care [5].

 


3. PATHOPHYSIOLOGY OF BURNS


There are several processes involved in the local tissue responses after a burn. An increase in vascular permeability leads to the loss of water, electrolytes, proteins and heat [11]. The complement and coagulation cascades are activated and this results in thrombosis and the release of histamine and bradykinin. These mediators cause an increase in capillary leak and interstitial edema in distant organs and soft tissue. In addition, the activation of the inflammatory cascade can lead to immune dysfunction. All of these responses increase the patient’s susceptibility to sepsis and multiple organ failure [17]. These systemic responses are significant once a burn exceeds 20 percent of the patient’s body surface. Hypovolemia, immunosuppression, bacterial translocation from the gut, and Acute Respiratory Distress Syndrome (ARDS) can ensue [11].

 


4. INITIAL MANAGEMENT


4.1. Primary Survey

The rapid implementation of the ABCs of trauma management (airway, breathing, circulation) also applies to burns. The initial physical examination of the burn victim should focus on assessing the airway and the patient’s hemodynamic status, as well as estimating the size and depth of the burn. Airway edema can result in airway obstruction and death. One hundred percent oxygen should be administered from the outset. If there are any concerns about the adequacy of the airway, prompt endotracheal intubation is mandated [18].  In addition, signs of inhalational injuries should be quickly recognized. 


If there are concerns of cervical spine injuries, nasotracheal intubation can be performed because it has the advantages of decreased cervical spine manipulation and the tube can be easily secured by suturing it to the nasal septum. The disadvantage of nasotracheal tubes is that they tend to be of smaller caliber, which are not as good for suctioning, and may increase the risk of sinusitis. In difficult cases, fiber-optic bronchoscopy (if available) can prove to be an invaluable tool in securing the airway. Vocal cords, directly injured from smoke, may be resistant to usual topical anesthesia and care must be exercised to avoid laryngospasm.  Consideration should be given to securing the tube to the teeth with wires (or heavy sutures), rather than risking further damage to burned facial skin with tie-tapes.


Once the airway has been addressed, the next step is to place two large-bore (at least 14 gauge) peripheral intravenous catheters through non-burned viable tissue. If necessary, these catheters can be placed through burned skin because the eschar is still sterile in the acute phase and more importantly, death can result from delays in fluid resuscitation. A Foley catheter should be placed to monitor urine output because this is the most straightforward and reliable indicator of intravascular volume status in the majority of these patients. Associated life-threatening injuries such as cardiac tamponade, pneumothorax, hemothorax, and flail chest must be identified and treated quickly [18]  Tetanus toxoid should also be administered routinely to all burn patients, depending on immune status .


4.2. Assessment of injury

Quantifying the extent (figures 1&2) of the burn is crucial in determining subsequent management. Burns are dynamic injuries, and damage to the skin can continue for 24 to 48 hours after the initial injury due to edema, coagulation of small vessels, pressure, desiccation, and infection.  Thus daily evaluation is of paramount importance in reassessing burn depth and success of excision [17].


Superficial burns (1st degree) are generally red, painful, and involve the most superficial aspect of the skin; as such, they are not included in the calculation of total body surface area (TBSA). These blanch to the touch [19] and have an intact epidermal barrier. Examples include sunburn or a minor scald from a kitchen accident. These burns will heal spontaneously, will not require operative treatment, and will not result in scarring. Treatment is aimed at comfort with the use of soothing topical salves with or without aloe and oral non-steroidal anti-inflammatory agents. Surgery is not required for these patients [20].

 

 


Figure 1:  Burn Depth Burns are usually classified into superficial, superficial partial thickness, deep partial thickness and full thickness. Here we have given then letters A, B, C, D and E. [1]

 

Partial-thickness (2nd degree) burns involve the dermis and the epidermis. Partial-thickness injuries classified into two types: superficial and deep. All second-degree injuries involve some amount of dermal damage, and the division is based on the depth of injury into this structure. 

Superficial dermal burns are erythematous, painful, may blanch to touch, and often blister.


Examples include scald injuries from overheated bathtub water and flash flame burns from open carburetors. These wounds will spontaneously re-epithelialize from retained epidermal structures in the rete ridges, hair follicles, and sweat glands in 7–14 days. The injury will cause some slight skin discoloration.

Deep dermal burns into the reticular dermis will appear more pale and mottled, will not blanch to touch, but will remain painful to pinprick. These burns will usually heal in 14–28 days by re-epithelialization from hair follicles and sweat gland keratinocytes, often with severe scarring. Some of these will require surgical treatment [20]. 


A full-thickness (3rd degree) burn generally is identified by a dry and leathery appearance, although a plastic-like texture and a hemorrhagic or purpuric pattern may also be seen.  Classically, full-thickness burn wounds have been described as insensate, although there is often  mixed distribution patterns  which make sensation determination less reliable as a defining characteristic [19]. 


Deep dermal and full-thickness burns require excision and grafting with autograft skin to heal the wounds in a timely fashion[19], thus minimizing morbidity from protein loss, sepsis, and contracture.  Since all the elements of the epidermis have been obliterated in full-thickness wounds, healing can occur only through wound contraction and/or spreading epithelialization from the wound edges. In a sizable wound, this process will take weeks to months to years to complete. [21]. 

Fourth-degree burns involve other organs beneath the skin, such as fat, muscle, bone, and the brain.  

Figure 2
In adults, the rule of nines can be used to quickly estimate the size of a burn. The anterior and posterior trunk is each l8%, each of the lower extremities is l8%, each upper extremity is 9%, and the head is 9%. This is depicted clearly in Figure 2. Unfortunately, the rule of nines is somewhat inaccurate in children and may overestimate burn size because the head accounts for a greater portion of the body surface area (BSA). In a 2-year-old child, this is 19% of the TBSA Diagrams such as the Lund and Browder charts (Figure 3) are more accurate and should be used for calculating the burn size in children[18].  In small burns, the surface of the patient’s hand can be used to estimate the extent of the burn; it represents approximately 1% of the TBSA (from fingertips to wrist).


4.3. Patient Selection

Patient selection is the key to improving the outcomes of burn injury within the resource constraints of a given environment.  The mortality of a given size of burn injury increases in infants and the elderly. It is difficult to cite what size of burn constitutes a lethal injury as mortality varies so much around the world, but local experience will suggest what magnitude of injury is likely to be survivable given the treatments available.  For patients with clearly lethal burn/inhalation injury it is humane to withhold fluid resuscitation and airway intervention and provide palliation with dressings and generous amounts of intravenous morphine.  Depending on circumstances it may be prudent to ask a colleague to examine the patient and note their

 

 

Figure 3: Lund and Browder chart [11]

 

concurrence with the lethality of the prognosis.  Patients with severe, but not clearly lethal burn injuries pose a difficult problem: they can consume an inordinate amount of scarce hospital resources (ICU days, total length of stay, dressing supplies,  nursing and operating room time), and still die or have dreadful outcomes.  Consultation and possible referral to a burn centre is helpful.  Treatment with pain control, dressings, prevention of infection, nutritional support, good splinting and early mobilization of affected joints, and careful selection of patients for surgical intervention is a sound policy.  Small but potentially disabling burns, especially in children, should be the main focus of surgical attention.  It is in this group of patients that early surgery, meticulous graft care, splinting, pressure garments and aggressive physiotherapy will produce the most gratifying (and cost effective) outcomes.


4.4. Fluid resuscitation

The most commonly used formula for adults, for fluid resuscitation after a burn, is the Parkland formula. To calculate daily fluid requirements, a crystalloid solution at the rate of 4 mL/kg/%TBSA burn is given intravenously. The first half of the calculated amount of fluid is administered within the first 8 hours after the burn, and the remaining is given over the next 16 hours. In the first 24 hours post-burn, the initial resuscitation fluid is Lactated Ringers, which is isotonic to plasma.


In children, maintenance requirements must be added to the resuscitation formula, and should be provide as a dextrose containing solution for infants due to the risk of hypoglycemia if they are not drinking. The addition of maintenance is less important in adults due to the large volumes and low risk of hypoglycemia.  One formula that accounts for the maintenance requirements is the Shiners Burns Hospital SBH-Galveston Formula, which calls for initial resuscitation with 5000 mL/m2 BSA burn/d + 2000 mL/m2 BSA/d of Lactated Ringers solution [18]. See http://www.halls.md/body-surface-area/bsa.htm to express BSA in M2.  Again, the first half is administered within the first 8 hours post-burn, and the remaining is given over the next 16 hours.


Another option to intravenous fluids, in cases of less severe burns or where intravenous solutions are at a premium, includes oral rehydration solution. The WHO describes a method for preparation of an electrolyte-balanced solution [62]. Although very time consuming, IV fluids may also be prepared on site at low cost [63].

It is important to remember that these are only guidelines, and the infusion volumes must be titrated on a regular basis. Urine output is the usual indicator of adequate resuscitation. Urine output in a child should be maintained at 1 mL/kg/h. In an adult, 0.5 mL/kg/h is sufficient (unless myoglobinuria is suspected in which case it should be over 2 mL/kg/h).  It is essential to avoid over-aggressive resuscitation, which may lead to increased extravascular hydrostatic pressure and pulmonary edema. This is especially important in patients who have a cardiac history, as well as patients with a concomitant inhalation injury, because they will also have increased pulmonary vascular permeability. Administration of colloid or hypertonic solutions decreases the total amount of fluid requirements in the first 24 hours post-injury; however, no clear advantages in long-term outcomes over isotonic crystalloid resuscitations have been clinically documented. In general, crystalloid resuscitation with isotonic Lactated Ringers is the best option in the acute phase [18].


If a patient is having increased fluid requirements, it should raise suspicion of concomitant inhalation injury, a delay in resuscitation, or another associated injury. It must be reiterated that the most important thing is to begin resuscitation as soon as possible after the time of injury. Unfortunately, delays in adequate resuscitation are common and lead to increased fluid requirements because of additive perfusion-reperfusion injury, which lead to unnecessary loss of life [18].


4.5. Escharotomy

With circumferential full thickness, or deep partial thickness burns, there must be a high index of suspicion for compartment syndrome. The decreased skin compliance does not accommodate the extreme edema from the inflammatory response.  Swelling increases with fluid resuscitation and it is much better to release a limb with early escharotomies than to discover too late that compartment syndrome and myonecrosis have set in. The diagnosis of compartment syndrome in a burned patient is challenging. Pallor is difficult to determine because the eschar often is discolored, soot stained and can be pale and leathery or red and plastic-like to the touch. Most burn wounds are painful to the touch, unless an area of pure full thickness exists. Paresthesia and paralysis are late findings of compartment syndrome and are impossible to address in a patient that may be paralyzed or sedated. The absence of a pulse is similarly too late of a finding. Delayed escharotomies can lead to muscle necrosis and limb loss. Sufficient release can usually be noted as soon as the dermis is released, as the wound opens and subcutaneous tissue bulges out.  Escharotomies may need to be done on any limb. (Figure 4) Escharotomy may be done with a scalpel or diathermy blade. While it is true that full thickness burns are usually insensate, it is not true that escharotomy can routinely be performed without some kind of pain control.  Ketamine or fentanyl and versed are safe and effective.  The incision should go through skin but not into fascia or muscle. The mid-medial and mid-lateral lines of each limb are incised.  A small “T” where the incision meets normal skin will ease constriction at the end of the incision.

 

 

 


Thoracic escharotomies are also occasionally required for improving chest-wall compliance and facilitate ventilation. This may require multiple incisions across the chest, both longitudinally and transversely to allow full chest expansion. Figure 4 shows possible thoracic escharotomy lines, but more lines may be required for very deep constricting burns. 


In electrical injury, the final extent of tissue injury can be difficult to predict. Frequent assessments and surgical debridements are required often in the face of progressive myonecrosis. With any high voltage electrical injury, the index of suspicion for a deep injury should be high. The skin wound is not a reliable indicator of the underlying damage. These injuries will require a fasciotomy, with release of all muscle compartments to minimize muscle damage.  Patients should also be monitored for myoglobinuria which will require treatment with increasing urine output, alkalinization of the urine, and sometimes with very cautious use of diuretics. Untreated myoglobinuria can lead to deposition in the glomerular tubules and renal failure. 

 


5. INHALATION INJURY


Inhalation injuries are associated with severe burns and poor outcomes. A retrospective review in Cape Town, South Africa found that inhalation injury was  present in 63% of severe burn patients (>30% TBSA), which resulted in a mortality rate of 76% [21]. However, it is believed that inhalation injuries are more frequently seen in high income countries due to the high prevalence of house burns, where victims are confined to enclosed spaces. Alcohol and smoking account for over half the deaths in developing countries, so prolonged exposure to smoke may occur as a result of intoxication. The prevalence of inhalational injury in low to middle income countries is unknown, but suspected to be lower. The reason for differences in prevalence is unclear, whether due to under diagnosis [20] or a true difference given that the vast majority of burns occur outdoors. Researchers have found prevalence rates of inhalational injury in South Africa of 2.2 % of pediatric burn patients [19] and 14.5% of  adult burn patients [21].


Successful management of inhalation injuries relies on early suspicion and resuscitation, as well as minimizing post-injury complications such as bronchopneumonia and acute respiratory distress syndrome (ARDS).


In the early resuscitation phase (< 36hrs), it is key to suspect inhalation injury, consider early intubation and empirically oxygenate these patients. Patients who have had prolonged exposure to smoke (ie. trapped indoors), loss of consciousness, flash burns with singed facial hair, carbonaceous sputum, hoarseness should all be closely observed for impending airway obstruction. Suspicion should also be high in patient with facial scald injuries, where airway compromise is often misdiagnosed. Scald burns can be associated with direct thermal injury to the upper airway from ingestion of hot liquids or steam inhalation[19]. Intubation with a large endotracheal tube (to enable suctioning) should be done in patients with stridor, increased work to breathing, respiratory distress, hypoxia, hypercapnea, deep burns to the face or edema/erythema of the oropharynx on laryngoscopic exam. Respiratory distress may not develop for several hours, and intubation should be performed in the case of transfer in high risk patients even in absence of stridor as obstruction may progress quickly as a result of airway inflammation from injury or edema from resuscitation [22].


Smoke inhalation injury is often associated with significant carbon monoxide exposure, resulting in carboxyhemoglobinemia. Carbon monoxide poisonings account for the majority of deaths, which occur at the scene or early in the pre-hospital phase. Asphyxia or anoxic brain injury develop quickly; as the oxygen-carrying capacity of the blood is decreased. The clinical manifestations of carbon monoxide poisoning are non-specific and can include headache, malaise, confusion, dyspnea, seizures and loss of consciousness. The diagnosis of carbon monoxide poisoning may be hard to confirm, given its imprecise presentation, unavailable carboxyhemoglobin levels, and misleading O2 saturation measurement. Conventional pulse oxymetry monitors are unable to distinguish O2 saturation from CO saturation, and therefore the patient may have a falsely normal O2 saturation reading. Patients may also appear pink/red and well-perfused, classically described as “cherry red”. PaO2 should be confirmed by blood gas if possible. Clinical suspicion is the mainstay for diagnosis and treatment.  Given poor outcomes associated with neurologic findings or loss of consciousness in the setting of carbon monoxide poisoning [23], administration of high flow oxygen should be used liberally to reverse tissue hypoxia and to accelerate the displacement of carbon monoxide (as well as cyanide) from their binding sites. The half-life of carboxyhemoglobin can be decreased from 240 minutes to 75-80 minutes by using 100% FiO2 instead of room air (21% FiO2) [24].


In the post-resuscitation phase (2-5 days) many competing factors can contribute to exacerbate pulmonary insufficiency. Direct thermal injury or exposure to bronchopulmonary toxins from smoke exposure can lead to airway edema, inflammatory changes and activation of systemic inflammatory response, as well as disruption of the muco-ciliary transport, increased capillary permeability, mucosal necrosis and sloughing. As a result subsequent distal airway obstruction, from atelectasis, edema and inflammatory debris, leads to a high risk of bronchopneumonia; the most frequent complication seen in a cohort of children with inhalational injuries in South Africa, seen in 32% of patients [19]. Other compounding factors include non-cardiogenic pulmonary edema secondary to aggressive fluid resuscitation in burn patients, poor lung compliance and chest wall rigidity in the setting of trunk burns, secondary ventilatory-associated
lung injury from aggressive high tidal volume, ventilator associated pneumonia, relative immunosuppression and the emergence of multi-drug resistance [25]. 


Recent recommendations to minimize respiratory complications in burn patients have been shown to improve outcomes in high income countries [25, 26]. These include using low tidal volume ventilation with PEEP (positive end expiratory pressure) to maintain alveolar patency and minimize baro-trauma, humidified oxygenation and elevating the head of the bed to improve pulmonary toilet and judicious use of antibiotics based on bronchoalveolar lavage cultures.  Other interventions and treatments remain controversial including early tracheostomy [27], adjunct inhalational therapies (heparin or N-acetylcysteine) or other modes of ventilation.  Corticosteroids have been shown to be harmful in this patient population [28].


The final inflammatory-inflammation phase of injury (5 days and beyond) persists until complete lung healing and burn wound closure, during which time patients remain at risk for infectious complications.


Most patients do not suffer from long-term respiratory complications as a result of their lung injury, with evidence of normal lung function seen in a study at 4 years post-injury [29].  Rarely, complications such as fibrosis and tracheal stenosis have been seen and should be managed independently of the causal etiology.

 


6. WOUND CARE


Wound care is a fundamental pillar in the care of the burn patient, and an area of evolution partially responsible for improved survival seen since the 1960s. As a result of loss of dermal integrity, the burn wound loses its protective barrier against invasion by micro-organisms and against evaporative losses. Therefore, until complete re-epitheliazation occurs, the burn dressing serves a number of functions: protection against micro-organism invasion, minimizing metabolic losses, limiting the pain of exposed burn surfaces, containing messy wound secretions, and hiding the burn to help prevent adverse psychological responses [30].
Most of the practices used in modern burn units are based on anecdotal or uncontrolled clinical observations. However, with the introduction of topical antimicrobial prophylaxis, occlusive dressing, and improved sterility as well as a goal of early wound closure, the incidence of burn wound infections have steadily declined [31, 32].


Burn wound care requires an experienced eye and knowledge of the dressing options available.  Surgeons often lack the time to examine wounds as often as they should so developing expertise in the nursing staff is important.  If dressings are changed each day by a nurse experienced in burns many problems will be averted and if staff understand well the importance of both splinting and early mobilization to prevent contracture functional results will improve. The routine inspection of wounds by a knowledgeable person is at least as important as the selection of the dressing material itself. This is the advantage of a burn team.


Exposure Method: 
Leaving a burn open is a poor option but where dressings are not possible it may be the only option.  The patients is washed daily and kept of clean dry sheets with another sheet or mosquito net draped over a frame to reduce the pain from air currents and to reduce contamination from the environment.  Ambient temperature control is important to maintain normothermia. Exposure is less painful for full-thickness burns than for partial thickness burns but has little else to recommend it.


Tubbing:
Most modern burn units avoid the regular immersion of patients in water both because they practice early excision and grafting and because of the high risks developing resistant strains of bacteria in the tub environment and of patient cross-infection.  That said, tubbing can be helpful to clean the wounds and gently remove eschar as it separates.  When early wound infections develop suspect the tub! Avoid the routine immersion of infected patients in filthy bathtubs of cold water on the basis of ignorance and tradition.


Bland Dressings:
  These provide a clean, moist wound healing environment, absorb exudates protect from contamination and provide comfort at a fraction of the cost of antibiotic dressings.  Where antibiotic dressings are scarce bland dressings are a very acceptable solution for burns.  Expensive topical antibiotic dressings may be reserved for infected wounds. Paraffin gauze is widely available and can be manufactured locally. Honey and ghee dressings were first advocated in Ayurvedic texts two thousand years ago and remain an excellent choice for bland burn dressings. Mix two parts honey with one part ghee (clarified butter) and pour over a stack of gauze dressings in a tray.  Cover and store.  Vegetable oil or mineral oil may be substituted for Ghee. Gauze sheets can be applied directly to the wound in a single layer and covered with plain dry gauze to absorb exudates, then wrapped.  Dressings should be changed at least ever second day, or when soiled.


Antimicrobial dressing:
There exist numerous topical antimicrobial agents that are effective in delaying the onset of invasive wound infections, but none prevent them entirely. This is why they must be used in conjunction with a goal of early surgical wound closure when possible. A brief review of the agents most likely to be available to low and middle income countries will follow. There are also alternative synthetic wound coverings and newer silver-ionized agents that can be used; however they are often very costly and inaccessible in low-income countries. A more detailed review, as well as instructions for preparation, can be found in these references [11, 33].


Table 1:  Burn Wound Dressings [Modified from Sabiston, 33]

Antimicrobial Salves

Silver sulfadiazine (Flamazine, Silvadene)

Broad-spectrum antimicrobial; painless and easy to use; does not penetrate eschar; deeply may leave black tattoos from silver ion; mild inhibition of epithelialization

Mafenide acetate (Sulfamylon)

Broad-spectrum antimicrobial; penetrates eschar well; may cause pain in sensate skin; wide application causes metabolic acidosis, therefore only suitable for small areas; mild inhibition of epithelialization.

Bacitracin

Ease of application; painless; antimicrobial spectrum not as wide as above agents

Neomycin

Ease of application; painless; antimicrobial spectrum not as wide

Polymyxin B

Ease of application; painless; antimicrobial spectrum not as wide

Nystatin (Mycostatin)

Effective in inhibiting most fungal growth; cannot be used in combination with mafenide acetate

Mupirocin (Bactroban)

More effective staphylococcal coverage; does not inhibit epithelialization; expensive

Antimicrobial Soaks

0.5% Silver nitrate

Effective against all microorganisms; stains contacted areas; leaches sodium from wounds; may cause methemoglobinemia

5% Mafenide acetate

Wide antibacterial coverage; no fungal coverage; painful on application to sensate wound; wide application associated with metabolic acidosis, and therefore generally used for small high-risk areas such as cartilage coverage in nose and ears.

0.025% Sodium hypochlorite (Dakin solution)

Effective against almost all microbes, particularly gram-positive organisms; mildly inhibits epithelialization

0.25% Acetic acid

Effective against most organisms, particularly gram-negative ones; mildly inhibits epithelialization

Synthetic Coverings

OpSite

Provides a moisture barrier; inexpensive; decreased wound pain; use complicated by accumulation of transudate and exudate requiring removal; no antimicrobial properties

Biobrane

Provides a wound barrier; associated with decreased pain; use complicated by accumulation of exudate risking invasive wound infection; no antimicrobial properties

Transcyte

Provides a wound barrier; decreased pain; accelerated wound healing; use complicated by accumulation of exudate; no antimicrobial properties

Integra

Provides complete wound closure and leaves a dermal equivalent; sporadic take rates; no antimicrobial properties.  Allows for coverage with a very thin skin graft with no dermis.  Very expensive product

Biologic Coverings

Xenograft (pig skin)

Completely closes the wound; provides some immunologic benefits; must be removed or allowed to slough

Allograft (homograft, cadaver skin)

Provides all the normal functions of skin; can leave a dermal equivalent; epithelium must be removed or allowed to slough

 

Silver sulfadiazine (SSD, Flamazine), is by far the most frequently used agent, given its broad antimicrobial coverage, painless application and minimal toxicity. It is better to apply the SSD to large gauze squares and to apply these to the wound than to attempt to cover the burn in an even coat of cream before applying the gauze. A very loose plastic or surgical glove containing silver sulfadiazine and gently secured with tape around the wrists is a simple and excellent hand dressing. Splints can be applied outside the bag and the fingers can easily be mobilized to reduce swelling and prevent stiffening.


There exist many other less expensive options worthy of mention. Honey has well established antimicrobial properties, and has demonstrated effectiveness in limited studies [34]. Tannins, as found in tea leaves, have also been shown to have antibacterial properties and may reduce the incidence of hypertrophic scarring [64, 65]. Amniotic membrane, used as a biologic wound coverage has also been shown to be more effective than nitrofurazone in decreasing the incidence of wound infection [35], as well as being cost-effective in reducing the length of stay and increasing epithelialization [36]. Obvious caution regarding the risk of disease transmission with the use of human tissue should be used and comprehensive donor viral screening performed prior to wide-spread adoption of this technique. Another innovative way to minimize cost yet still provide an occlusive dressing  to prevent dehydration has been demonstrated in India with the use of Banana leaves [37]. Gore et al have shown an acceptable level of patient acceptance, in comparison to potato peels. Both options provide wound protection and healing at a fraction of the cost of conventional dressings.


If despite vigilance, an invasive wound infection becomes evident on serial observations, one must consider altering the current treatment protocol. An invasive wound infection can be determined by clinical expertise or suggestive by wound cultures showing > 105 organism per gram or invasion seen on tissue biopsy. Invasion of microorganism into viable tissues may lead to progression of the burn or systemic sepsis. It should be noted that elevated temperatures per se are not necessarily indicative of sepsis, but are common secondary to the inflammatory component of the burn wound process. The same organisms have been identified in serial wound cultures in both low and middle income countries, with Staph aureaus, Proteus, Klebsiella, E.coli and Pseudomonas being the most common. The problem of drug resistance is not confined to high income countries [38]. A recent Nigerian study, looking at serial wound cultures, concluded that systemic prophylactic antibiotics did not reduce invasive infection, but may in fact select more virulent, resistant strains of bacteria [39], a notion which has gained wide spread acceptance. We should therefore guide our antimicrobial use by evidence of invasive infection, organism culture and sensitivities when these are known. Prophylactic antibiotics at the time of initial admission are not routinely advised.

 


7. MEDICAL MANAGEMENT


Severe burn wounds are known to induce systemic inflammatory response syndrome (SIRS) through the release of a series of pro-inflammatory endotoxins, exotoxins from infectious sources or from the wound itself. Although the exact mechanism is not well understood, it is clear that there is a systemic response which can lead to progressive infection, immuno-suppression, sepsis and eventually multi-organ failure. Supportive measures are needed early in the care of the severely burned patient to minimize the progression and attenuate the hypermetabolic response to burn injury.


7.1. Nutritional Support

Early nutritional support is essential in burn patients, even more so in low-middle income countries where many patients present malnourished. Burn patients demonstrate levels of metabolism that can be as high as 200% normal and that are proportional to the severity of the burn. The metabolic rate does not return to normal until wound closure. Supporting this high metabolic rate with diets rich in carbohydrate and protein without overfeeding patients can decrease muscle wasting, and poor wound healing consequences of chronic malnutrition. Early feeding also avoids mucosal atrophy and bacterial translocation [40]. This is particularly important for intubated patients, for whom feeding is often not initiated at presentation, increasing the risk of bacterial sepsis. Strategies to achieve this goal include tube feeding, which should begin within 6 hours, weekly monitoring patients’ weights, and the creation of high protein high-caloric feeds from locally available produce. The frequency of the feeds should be adjusted to the severity of the burn (%TBSA) and the patient’s pre-existing nutritional status [11].


7.2. Anemia

Unfortunately the prevalence of underlying disease in burn patients is common in low to middle income countries and may influence treatment options. A Liberian study found that 61% of their patients had underlying medical co-morbidities, including epilepsy, anemia as a result of malaria, or iron deficiency and malnutrition [41]. Anemia and malnutrition contribute to infectious complications in these burn patients; however grafting was possible, albeit delayed, in this study, with surgery being performed between 5-96 days (average 29.8 days) with reasonable graft take (mean 81%). There is no question that the benefits of early excision must be weighted against the risk of blood loss and physiological needs of these specific patients. However, new understanding of the potentially infectious complications of blood transfusion is emerging as a result of large prospective multi-centered ICU trials [42]. A recent multicenter retrospective cohort study that has shown an associated 13% rise in infectious complications per unit of blood transfused and an associated increased mortality rate even when accounting for burn severity [43]. This study underlined the importance of further research to establish appropriate transfusion guidelines. Strategies should be undertaken to minimize blood loss during surgery.  Some techniques for minimizing blood loss are discussed in the surgical management. 


7.3. HIV

Another important consideration in many low-income countries is the burn patient who is HIV positive. Until recently, little was known regarding clinical outcomes in this specific patient population. James et al conducted a study in a burn unit in Malawi [44], showing a 31% HIV prevalence rate in their adult burn population (34 of 112 patients) and in 3% of the pediatric burn patients (6 of 231 patients under the age of 15). The researchers found that HIV status was an independent risk factor for death, mostly from infectious complications with more marked immunosuppression, as indicated by a lower mean CD 4 count (383mm3 vs. 937 mm3 in HIV negative patients). They found no differences in bacterial cultures, need or outcome of skin grafting, transfusion or antibiotic requirements or length of stay. In a case-controlled study out of South Africa [45], no differences in mortality or morbidity was found when comparing 33 patients with and without HIV, when matched for age, sex, burn severity and inhalational injury.  Two patients with clinical AIDS died of infectious complications leading the authors to conclude that HIV positive patients, without the stigmata of AIDS should be treated in the same manner with similar outcomes expected. Further research is needed to understand the effect of HIV on immunosuppression in its early stages of disease.

 


8. SURGICAL MANAGEMENT


After hemodynamic stabilization, a burned patient’s priority of treatment shifts to ‘burn-wound-management’[46]. Preoperatively, several factors can pose a challenge to surgical patient care.  In the developing world, many of the burns present late, already infected, or the poor general health of the patients makes them unfit for anesthesia. In addition, blood loss can be significant in burn wound excision, especially since inflamed and infected wounds tend to bleed more during tangential excision. Thus, burn surgery can be dangerous in high risk patients where blood transfusion facilities are not readily available.


The options for the surgical management of burns includes early tangential excision and grafting for deep dermal burns and delayed escharectomy skin grafting for full thickness skin loss [47]
.  Tangential excision describes the sequential and layered excisions of devitalized tissues to a vital bed, generally recognized by punctuate bleeding. An inadequately excised wound is more likely to become infected and is unsuitable for graft take, necessitating further surgery [19]. The use of tumescence (discussed below) is good for decreasing blood loss from the burn site; however it makes judgment of adequacy of excision and of hemostasis more difficult. It can decrease blood loss to a minimal amount. Adequate debridement must instead be determined by tissue quality, and not by punctuate bleeding. 

The exact timing for wound excision is debatable. It is often suggested that burn wounds should be excised and grafted if they are not expected to heal within 21 days of injury. This is especially true for key functional and esthetic locations such as the hands and face.[19]. The decision to perform extensive excisions in a single setting versus staged procedures is dependent upon the hemodynamic stability of the patient, the availability of resources, and the coordination of all parties involved in the care of the patient [19]. Conservative treatment of burn wounds, with silver sulfadiazine, followed by serial excision of the burn wound is currently the standard of care in many burn centers throughout the world. Burns are excised in areas of as much as 20% TBSA in one operative setting, and performing the entire excision of the burn wound in 10 days post-injury is the goal. All full-thickness burns can be excised first, so that deep dermal and indeterminate depth wounds are addressed later, preventing excision of potentially viable tissue.  Early excision and grafting is the treatment of choice to potentially reduce scar contractures and hypopigmentation [47]. The disadvantages to serial excision are that the patient needs to return many times to the operative room, so that episodes of bacterial translocation, bacteremia, and cardiovascular instability are repeated. Other disadvantages include exaggerated blood losses, prolongation of the hypermetabolic response, and increased risk of infection and sepsis from remaining eschar in which bacteria proliferate.


Near-total wound excision has been advocated as an alternative to serial debridement in massive burns. In near-total excision, all full-thickness and partial-thickness burns are excised within 24 hours of admission, and the excised wounds are covered with autografts and skin substitutes are used if the burn exceeds the donor-site supply. Areas of the face are normally not excised in the first operation. Near-total burn excision has dramatically improved survival in massive burns [18].  However, it has been postulated that the surgical trauma of immediate burn wound excision, especially given the hemodynamic instability of burn patients during the first 72 h after the injury, may aggravate the inflammatory and catabolic responses, leading to potentially fatal postoperative complications [18][47]. It should be clear that near-total wound excision is only meant for massive burns, and allograft/autograft/xenograft must be available for coverage, or the wounds would only have been converted to full thickness open wounds. 


8.1. General Surgical Principles

The intent of burn wound operations is twofold: to remove devitalized tissue and restore skin continuity.  For this process to take place and for the skin graft to take, four things are required:

  • A viable wound bed
  • No accumulation of fluid between the graft and the wound bed
  • No shear stresses on the wound
  • Avoidance of massive micro-organism proliferation


Surgical debridement is performed using a Goulian blade for small areas or those with multiple irregular contours (e.g., hand or knee) and a Watson or Humby blade for larger areas. Inexpensive alternatives have been proposed for harvesting and debriding blades [48]. Burned tissue is excised tangentially and sequentially until the wound has been excised down to healthy dermis, fat, muscle, peritenon, or periosteum. The wound may then be covered with an autograft, allograft, or synthetic skin substitute.


Graft depth should be adjusted in pediatric and geriatric populations for their thinner reticular dermis layer. If using a powered dermatome, it should be set at less than 10/1000th inch.  The meshing pattern used for wound closure depends on burn surface area and donor site availability.  Meshing of the skin graft has several advantages, including expanding the square centimeters of coverage, allowing for drainage of fluid from under the graft, and allowing for placement of the graft over contoured areas, such as the knee or ankle. The disadvantage of the meshed skin graft includes a permanent weave-like appearance of the healed scar site, and increased contraction [17].


Many authors have described innovative methods for performing skin grafting in resource-poor settings [49]. With minimal financial resources, using readily available modified household or industrial materials a surgeon is able to sharpen the Humby knife and use a pizza cutter for meshing grafts [48, 50].

Methods of optimizing hemostasis and minimizing blood losses include meticulous attention to maintaining the patient’s core body temperature (operating in a warm environment, isolating surgical fields, warming intravenous fluids, warming humidified air circuits for anesthesia), the use of cautery, the application of topical epinephrine solutions or topical thrombin solutions, injecting dilute epinephrine tumescent solution below the eschar, and the use of topical fibrin sealants.


The use of tumescence and tourniquet in burn excision significantly reduces intraoperative blood loss and facilitates accurate wound excision.  Epinephrine is diluted in saline to a concentration of 1:500,000 (2mg/l) and large volumes are injected beneath the wound to be excised.  Use a concentration of 1:1,000,000 for children. The edges of the wound are scored with a scalpel and the burned dead skin is sliced away with a grafting knife.  Tangential excision is continued to the point where the dermis looks healthy, clean and pearly white, fat appears shiny and yellow with no haem staining and small visible vessels have patency and flow.  If the fat does not look healthy consider excision down to the fascia which is possessed of a better blood supply than the fat.  Bleeding vessels are coagulated and the wound is wrapped in adrenaline saline soaked gauze while natural haemostasis takes place. Attention is the turned to the donor site and a template of gauze from the excised wound is used to measure the area of skin to be harvested.  Adrenaline saline is injected beneath the donor site till the skin is taught and blanched then it is harvested with the humby knife or power dermatome.  The donor wound is wrapped in adrenaline saline gauze while attention returns to the burn site.  When hemostasis is satisfactory the grafts are applied and secured in place. Local anesthetic can also be added for small wounds, with 20ml of 1% xylocaine added to 1 L of solution. The addition of local anesthetic to the solution can decrease pain, reducing anesthetic agents and narcotics during surgery but the toxicity of xylocaine exceeds that of the adrenaline.  A number of recent papers have addressed the safety of high dose adrenaline tumescence during burn excision and are cited here to placate anesthetic concerns.  Atropine and ketamine are poor choices for tumescent burn excision as the patient will be tachycardic and hypertensive even before adrenaline infiltration is begun.  Excision of burns from the extremities under tourniquet control can minimize bleeding significantly


If possible, donor sites should be chosen that are inconspicuous and will have a good color match for the wound bed. Donor sites may develop hypertrophic scars and should not cross joints. Potential donor sites include the upper thigh or the buttock, which remain hidden with normal clothing and the back, which heals well but is technically difficult to harvest with a hand held grafting knife. Selection of the donor site should also consider the color match of the wounded area, which is most significant on the head and neck. A number of types of donor site dressings are available. The first type is a fine-mesh cotton gauze that may or may not be impregnated. Dressings of this type include Scarlet Red and Xeroform, which have the advantage of low cost and familiarity. These may need to be reinforced with more gauze initially that can be removed in 24-48 hours, and the inner layer left intact. The adherent gauze will start lifting in 1-2 weeks as the wound re-epithelializes. The edges can be trimmed off as they spontaneously lift. An occlusive dressing such as OpSite/tegaderm can also be used, but may require a few holes to drain seromas [47].


Loss of dermis leads to significant scarring and wound contracture. There are a number of dermis substitutes that can be used such as Integra and AlloDerm. These products allow the use of a very thin partial thickness skin graft on top of the dermis. These products require a very clean wound bed, and meticulous cleanliness post-operatively to prevent infection. These two options are very expensive, though, and are not mainstays of the armamentarium of burn surgeons in the developing world.


Grafts must be held in place by sutures or staples. Some form of dressing is required to hold grafts in place. In more mobile locations, a bolster dressing may be placed on top of the graft.  An inner layer that can maintain moisture (petroleum jelly or mineral oil product) should be placed before gauze. Grafts over joints will require casting/splinting for the time period for grafts to take, usually 10-14 days. Dressings are left intact during the time period. 


8.2. Specific anatomic considerations

Particular anatomical regions require specific treatments. The head and neck region is well vascularized and this is protective against invasive infection. Excision and grafting of the face is ideally done in full aesthetic units (Figure 5). Early excision of eschar is not recommended in order to preserve any dermal and epidermal structures that may survive. Once the eschar separates in 10–14 days, the underlying wound can be grafted. The color of the skin in this area is relatively specific; therefore, autograft skin should be obtained from donor sites above the clavicles. The scalp is an excellent donor site for the face [21].


With regards to the breasts, keratinocytes are often found deep beneath the skin. These will proliferate and facilitate wound closure if left in place. The coloration of the areola is also very specific so the nipple/areolar complex should not be excised.


The buttocks and perineum are in a very difficult position for skin grafts to take, since the dressings applied are often soiled from excrement, and cleaning, often shearing the grafts. It may be necessary to leave the patient in the prone position at later operations after application of grafts to this area while they adhere. In extreme cases, a temporary defunctioning colostomy may be considered until the burn wounds in the perineum are closed. 


The penis and scrotum have an excellent blood supply, so they will usually heal in a timely fashion. The skin in this region occupies a highly important function, so, in general, excision is avoided. In the case of a small burn to the shaft of the penis, excision and primary closure akin to a circumcision can suffice. The scrotum is also a very good donor site because it heals well, is relatively hidden, and can be vastly expanded to provide a surprising amount of donor skin.


The hands are very important in terms of function and cosmesis. Most burns of the hand are limited to the dorsal surface as the hand is clenched during injury. Unfortunately, sometimes the digits sustain a second injury associated with diminished perfusion during resuscitation. Escharotomies along the axial lines may salvage digits during resuscitation.  Grafts placed on the hands should either be unmeshed or meshed tightly at a 1:1 ratio to improve cosmesis. Burns through to the extensor tendons can result in boutonniere deformities even with complete wound closure due to sliding of tendons medial and lateral around the proximal interphalangeal joint. Extension contractures at the metacarpophalangeal joint are also common because the burn and subsequent scarring are limited to the dorsal surface. For these two reasons, consideration should be given to fixing the digits in extension at the proximal interphalangeal joint and flexion at the metacarpophalangeal joint by insertion of threaded Kirschner wires which are removed after complete wound healing, at which time the position can be maintained easily with splints [21]


Burns to the palm of the hand should be treated conservatively with gentle debridement, as they will often heal spontaneously because of the depth of the skin. In the paediatric population contractures may develop, either in the acute phase or, years later, as the scar growth is less than that of the normal tissue.

For the feet, great care must also be taken with excision of full-thickness eschar in this area, because the extensor tendons are in very close proximity to the skin. Autograft skin applied to this area should be of a narrow mesh to avoid hypertrophic scarring, which can make it difficult to fit shoes. The toes require the same considerations as the fingers [21].

 

9. REHABILITATION


The goals of the rehabilitation process are to maximize function and appearance of the scars.  This is done by trying to counteract two main physiologic processes, scar hypertrophy and contracture.


9.1. Hypertrophic Scarring

Hypertrophic scarring generally does not develop in burns that require less than 2 weeks to heal.  Hypertrophic scarring develops in 33% of wounds that take less than 3 weeks to heal, but 78% of wounds that take more than 3 weeks.  It also affects skin grafts. Hypertrophic scars are thickened, red, and raised scars which can often be very itchy. Unlike keloids, hypertrophic scars do not outgrow their boundaries. They will also generally remodel and regress over time, but this may take a number of years, and contractures may develop in the interim. Although children generally heal quickly, they are at higher risk of hypertrophic scarring if there is delayed healing. In addition, individuals with darker skin pigmentation are also at greater risk of hypertrophic scarring and keloids. Tangential excision and grafting of burns that require greater than 3 weeks to heal can help prevent or reduce hypertrophic scarring. 


Scar compression is the mainstay of non-surgical hypertrophic scarring prevention and management. This can be achieved with customized compression garments, or with elastic tensor bandages. The goal is to have pressures of approximately 25mmHg. If using tensor bandages, they must be wrapped from distal to proximal, taking care not to cause ischemia or venous stasis.  Using tensors for compression over grafts should be initiated after grafts are well healed, approximately 2-3 weeks after grafting. This should continue until scar maturation, which can take up to 1-2 years, and is gauged by when the scar is softened and stabilized.   


Scar massage can also help with breaking down of excess scar tissue. This is often done in combination with stretching exercises to prevent scar contractures. Scar massage should be done 2-3 times per day with a hypo-allergenic lotion or cream, or petroleum jelly (Vaseline).  Moisturizing and massaging the scars, which can be dry due to the lack of glands in the scar tissue, may be sore at first, but usually becomes soothing, and can help with the itchiness of the scars. Massaging must press hard enough to blanch the pink scars. Maturation and flattening of the scars can take 1-2 years, particularly in children where the hypertrophic phase may be longer.  Most scars will eventually fade and lose their pink colour over time, but the 1-2 year time frame may be longer.   


Silicone gel sheets can also be beneficial. The exact mechanism is unknown, but they appear to help soften the scar. To reap the benefits, they must be worn for long periods (over 20 hours a day) to be beneficial. They can be placed under compression garments, or simply taped on for areas not amenable to compression. These can be washed daily and reused.   


9.2. Contractures

Joint contractures are one of the most challenging aspects of burn management, and are the main source of disability from thermal burns. Scar contracture is due to activity of the myofibroblasts which act to contract scars. When the scars are across joints, particularly flexion joints, these can lead to permanent flexion deformities. In addition, flexed positions are often positions of comfort during the acute phase of burn management, exacerbating the problem. To combat joint contractures, stretching and splinting is necessary. Stretching and range of motion exercises should be initiated from the beginning. With initial edema, movement may be a bit difficult but should be encouraged with daily exercises. 


To combat joint contractures, stretching, careful positioning and splinting are necessary. Necks should be hyperextended with a roll under the shoulders. Axillae should be carefully positioned. Upper thigh/lower abdominal burns require positioning to prevent flexion of the hips. Stretching and range of motion exercises should be initiated from the beginning. With initial edema, movement may be a bit difficult, but should be encouraged with daily exercises.


9.3. Splinting

Contractures are the most debilitating residual stigma of burns, and high-risk patients (deeper burns over flexion joint surfaces) can easily be identified. Contractures are much easier to prevent than to fix. Once developed, can be very difficult to manage and correct.  Elevation of the burned limb reduces edema and facilitates early joint mobilization.  Where surgical treatment is limited by resource issues; hyperalimentation, good dressings, splinting and aggressive stretching can still make a big difference to patient outcomes.  Equally, surgical results will improve dramatically with good post-operative splinting and early mobilization as soon as the grafts are solid.


Splinting should be considered when any loss of extension is noted across elbows and knees. Hands should be splinted from the onset.[51] Simple plaster slabs covered in elastic tube bandage  or “stockinet” make excellent volar hand splints, can be wrapped on with tensor bandages and are re-usable till soiled. Splints are often applied overnight, allowing for mobilization and function in the daytime.


There are numerous splinting techniques suggested. Both static and dynamic splints can be used.  Dynamic splints may be better for reversing any contractures, as they may gain extension, not only maintain the gains during therapy. However, they are significantly more costly to produce, and long-term gains have not consistently been shown. Many local materials have been used to produce inexpensive splints, including easily malleable aluminum sheets.


Neck collar braces, or custom thermoplastic splints may be used to prevent flexion contractures, and stretches should include both extension and lateral flexion. The splint should be properly padded to prevent pressure points. There are also alternative splinting techniques for the neck [52]. Axilla contractures can be challenging to splint, with various materials used for “airplane splints”. Because splinting in abduction can be uncomfortable and awkward, this is sometimes neglected. However, the inability to abduct the arms leads to significant morbidity, and it severely limits overhead activities [53]

The ankle can have contractures in both directions.  Burns and scar contractures to the dorsum are more common, which must be combated with plantar flexion exercises and splints. However, the Achilles tendon may also become shortened with a prolonged planter flexion. For an ambulating patient, this is not a concern. However, for a patient who is bed-ridden, splinting should be initially for dorsiflexion to prevent Achilles tendon shortening.


Fingers and hands should be splinted in the position of safety (figure 6), with MCPs flexed and IPs extended. If there is a severe burn over the palmer aspect of the MCP joints, the MP joints can sometimes be splinted in extension, but it becomes very important to ensure that daily exercises maintain good flexion of the collateral ligaments of the MCP joint, which can tighten when in extension. 


Oral burns, particularly commissure burns can lead to complications of microstomia.  These can be initially managed with mouth exercises, and gradually increasing the amount of mouth opening.  Splints can also be fabricated to stretch the commissures [54].



10. SURGICAL RELEASE


Surgical release of burn contractures can involve local flaps for reorientation of the scar, but often also include a skin deficit which must be filled with a graft or flap. Skin grafts are also more prone to contractures, and aggressive post-operative therapy much be implemented.  Repeat surgeries may be necessary. Thick (full thickness if the area is small enough) unmeshed grafts offer less contracture. Alternatives include artificial dermal substitutes that will allow decreased contracture with thinner split-thickness grafts. However, dermal substitutes such as Integra, a bovine collagen product, are commercial produced and extremely expensive.  If skin or myocutaneous flaps are possible, they offer the advantage of coverage with minimal contracture and need for repeat surgery. These include both local flaps such as z-plasties and transposition flaps, but also pedicled or free vascularized flaps. The surgeons will require an armamentarium of possible flaps and grafts to apply to the situation. Figure 7 gives a possible algorithm for selective various surgical options [55]. Other general principles include the release of more proximal contractures before distal ones in limbs with multiple levels involved, such as elbow  release followed by wrist, then fingers. Certain anatomic areas are more prone to contractures and have specific complications.

 

 

 

 

10.1. Neck Contractures

Neck flexion is often associated with webbing of the neck. There is often a severe shortage of skin, and a significant size skin graft may be necessary for coverage of the defect after release.  Unless very minor, or featuring a narrow band of scar, these are usually not amenable to z-plasties. Another challenge for severe neck contractures is difficulty with intubation. The release of the neck may need to be done under local anesthetic to allow for neck extension before initiation of general anesthetic and reconstruction of the defect. If the injury is anterior only, a good alternative for coverage of the neck is a pedicled latissimus dorsi flap, which would provide normal skin coverage without risk of contracture recurrence [56]. 

 

10.2. Hands

Contractures in the hands include flexion contractures of the fingers and wrist, web space narrowing of the digits, as well as hyperextension of the MCP joints. 

Finger contractures can sometimes be released with z-plasties, if the burn area is isolated to the central palmer aspect of each finger. If z-plasties are used, care should be taken not to cause excess tension with closures leading to finger ischemia. Release of prolonged flexion contractures can also have ischemia from overstretching of shortened neurovascular bundles.  Release may need to be staged, or stretched post-operatively with therapy. Kirshner wires may be beneficial for the first 1-2 weeks until the skin graft take is reasonable. They also facilitate the fabrication of post-operative splints which are best fashioned with the K-wires still in place. Web-space deepening is particularly important in the first web-space. A 4-flap or 5-flap z-plasty (figures 8&9) will allow deepening of the webspace and increased abduction of the thumb. A


5-flap z-plasty (also known as a double Z-plasty with V-Y advancement) allows for more deepening, while a 4-flap allows for much greater lengthening. These are used primarily in the 1st webspace. Deepening of the other webspaces is often performed using techniques for congenital syndactyly, with a skin flaps used to reconstruct the base of the webspace to prevent future web creep. Skin grafts are often necessary to fill in the gaps on the sides of the fingers[57]. 

 

 


 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



10.3. Axilla

Axillary scar contractures are also very common. These can at times be treated with a large 4-flap z-plasty, similar to for the first webspace, or multiple z-plasties or V-Y plasties [58].  Alternatively, they can sometimes also be managed with release and skin grafts. The use of skin grafts requires post-operative splinting, often in airplane splints to prevent recurrence. An alternative may be a Figure-of-8 splint which also helps to hold the graft in place [59]. Recurrent or very tight contractures may be amenable to local flaps if the burn is localized to the axilla with sparing of chest or back tissue. These include latissimus dorsi, or pectoralis major/minor myocutaneous flaps [60].

 

10.4. Deep Structures

Release of the scar may be insufficient for chronic contractures. Contractures may be limited by deep structures, such as joint capsules, tendons, or nerves. Some of these may be released or lengthened (such as tendons or joints), while others may limit the release to limited stages serial casting/splinting postoperatively. The exposure of tendons or nerves in the scar bed may require a flap rather than graft coverage. Preservation of the peritenon on the tendon/peritenon may allow for a primary skin graft to survive. However, if the tendon is in an area that requires significant mobility, the skin graft may tether the tendon leading to decreased mobility. Caution should be also taken when putting a skin graft on an exposed nerve, as this may lead to complications of neuromas, or hypersensitivity in the area. 


10.5. Face

Eyelid contractures can be released with skin grafts. Patients with eyelid burns must be followed to watch for ectropion, which can lead to corneal abrasions. These can be release with preferably full thickness skin graft placement. Thin full-thickness skin can be harvested from the pre or post-auricular region if available. Microstomia and commissure burns can be treated initially with splinting and stretching exercises. Customized splints can be made, preferably with the ability to slowly expand the mouth. With severe microstomia, a commissureplasty using mucosa to recreate vermillion may be necessary [54]. Esselman et al. has a literature review of rehabilitation evidence in burn management.  [61]


 11. Conclusions

Many accomplishments have been made in burn care over the past several decades, as illustrated below (figure 10) [31].

  

Figure10

Figure 10:  Advances in Burn Care – A schematized time line of important advances in burn care ICU=intensive care unit, LA50=survival of half of patients, depending on the percentage of total body surface area (TBSA) burned, Rx=therapy, TPN=total parenteral nutrition [31]

 

 Encouragingly, these have resulted in steady improvements in mortality rates.

This progress has also been noted in a number of centers in resource-poor countries where a multi-disciplinary, global approach to the burn patient has been embraced; from prevention to rehabilitation.

 

An excellent reference for burn surgeons in resource poor countries is the Burns Manual, written by Dr E J van Hasselt. The most recent 2008 edition should be made available to all surgeons.


See Van Hasselt Burns Manual http://www.ptolemy.ca/members/library.htm. International collaboration is also available and encouraged through organizations such as Interburns, the International Network for Training Education and Research in Burns, who run courses such as Emergency Burn Care and other public awareness programs, http://www.interburns.org/index.htm


This review has demonstrated that specific changes in clinical practice can and do improve outcomes. As medical professionals, we must not be paralyzed by the magnitude of the task ahead. Instead we must think of each small step as a significant improvement.  With focused attention and the application of evidence-based knowledge, we will see change both measurable and meaningful in the treatment of burn patients.

 


12. Recommendations


The following recommendations capture the key elements of a simple, but effective approach to better burn management tailored to developing countries:

  1. Community leaders and burn surgeons must collaborate in developing local prevention strategies as well as community education strategies on immediate first aid steps for burn victims and the critical importance of early transportation to the nearest source of appropriate medical services.
  2. Medical personnel must be trained in resuscitation; including aggressive fluid resuscitation, monitoring for airway compromise, and high flow oxygen, all of which to be initiated within the first hours in the case of a major burn. The burns must be assessed for depth, size, need for escharotomy and risk of inhalation injury on presentation
  3. Both Physiotherapy, including early active and passive movements and splinting for high risk joints and high protein, high caloric frequent feeds should be in place as of the first day.
  4. Wound care must be performed daily, with careful attention for signs of invasive infection. Appropriate analgesia, sterile conditions and topical antibiotics (SSD) should be used.
  5. Whenever possible, deep second degree burns and third degree burns should be grafted within 10 days of the injury. Techniques to minimize blood loss such as tumescence and tourniquets should be standard practice.
  6. Systemic antibiotics should be reserved for single-dose immediate pre-operative prophylaxis and treatment of invasive wound sepsis, tailored if possible to wound culture results and institutional resistance patterns.
  7. All practicing physicians and surgeons working in areas without a regional burn center should receive training in skin grafting.
  8. Blood transfusion should be limited to when physiologic need exists.
  9. Life-long seizure prophylaxis and patient education regarding the importance of compliance must be part of burn care prevention in all epileptic patients.

 

 


Davey M.  &  Ayeni B.

McMaster University, Hamilton, Ontario, Canada

Ying Y. & Duncan MJ.

Department of Plastic Surgery,

Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada

 


13. References


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54. Bell, M., M. Duncan, and S. Shanhrokhi Ebrahimipour, Successful Skin Grafting in Developing Countries. . Tropical Doctor, 2000. 30(3): p. 149-51.


55. Bell, M. and M. Duncan, Need A Pizza Meshed Skin?  A Simple Expansion Device. Tropical Doctor, 1997. 27(4): p. 229.


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63. Lee, W. and A. Salyapongse, Thumb Reconstruction, in Green's Operative Hand Surgery, G.e. al, Editor. 2005.


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67. Hallock, G.G., A Systematic Approach to Flap Selection for the Axillary Burn Contracture. Journal of Burn Care & Rehabilitation, 1993. 14: p. 343-7.


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