Burns

Question 1

Burns

Answer 1

1-2 % body surface area (BSA) - but 80% of all burns (protection and most common in all dealing things)

dorsal - explosions or flame injury

palm - electric, friction burns, chemical exposure

scald injury (Verbrühung) - high capacity of spontaneous healing without surgery

burns cause: coagulation of blood vessels, denaturation of proteins, increase of capillary permeability

pathophysiology of burns: 3 zones

coagulation - necrosis

stasis

hyperemia with impaired circulation

capillary permeability increases in the first 24 h - massive loss of fluid - massive edem - urgent resuscitation - with burns of more than 20% than generalized edema which is protein rich

in hand a edema which does not resolve in the next 72 hours causes leads to subcutanoues fibrosis with consequent stiffness of joints

edema:

• fibrin deposits in elastic tissue
• immobilization : collagen invasion
• massive collagen synthesis and remodelling
• scarring with reduced function

Question 2

acute hand burn

Answer 2

• splinting
• early excision and grafting
• hand therapy
• pressure garments
• no prophylactic antibiotics

goals of treatments:

• avoid any additonal injury
• achieve early wound closure
• maintain active and passive range of motion
• prevent infection or loss of soft tissue coverage
• initiate early functional reahabilitation

treatment over time:

1. cooling (if local burn) and elevation of hand
2. evaluation of the size and depth of the burn
3. escharotomy if indicated
4. application of proper wound care and dressing
5. decision about conservative or operative treatment
6. early operation of a stable patient (resuscitation, crush syndrome)
7. initiation of early hand therapy and splinting
8. surgical management - removal of eschar, transplantation of skin grafts, flap coverage if necessary
9. early postop physical therapy
10. functional rehabilitation
11. secondary and tertiary corrections if necessary

Question 3

stiff hand

Answer 3

• contraction of collateral ligaments
• fixation of volar plate
• capsular scarring
• adhesion of extendor tendons
• lumbricals contract
• gliding mechanism impaired

Question 4

assessing burn depth

Answer 4

• colour
• sensitivity
• blanching
• hair follicles
• variable depth
• edema

Question 5

burn grade

Answer 5

grade I:

sunburn - damage of the epidermis - restitutio ad integrum

grade IIa:

blisters, redness - damage to the epidermis and dermis (stratum papillare) - most adnexal elements are intact - restitutio ad integrum - epitheliziation from the surrounding epidermis and the adnexal elements (hairfollicles, sweat glands) - very painful - the deeper the burn, the poorer the qualitiy of regenerated skin - open blisters is necessary (fluid contains - proinflammatory cytokines IL-6, IL-8, prostaglandine)

grade IIb:

inelastic eschar white or brown pale colour - damage to the epidermis and deep dermis (stratum reticulare) - most of the adnexal elements are destroyed - less painful in centre - painful at the border - moderate sensitivity - heals over 2-3 weeks - no blisters - risk of hypertrophy - often poor quality scar - unstable with less dermis with poor quality and scarring - therefore better excision and grafting - treatment maybe conservative - excision, grafting, mobilization - excision with 0,3-0,4mm for donor site

grade III:

insensate at first - damage with subcutaneous tissue - white grey colour - dry eschar - extreme hand swelling - suberdermal vessel thrombosis - restricted motion

grade IV:

charred - insensate - no function - risk of myoglobinuria and hypercalemia - early amputation

Question 6

eletrical burns

Answer 6

• 4. grade of burns
• skip area of electricity entrance and exit - requires second look - types:
• entrance/exit - deep
• arc - more superficial
• clothing ignition

Question 7

hand burns in children

Answer 7

• skin (dermis) is thinner
• thinner keratin layer in the palm
• fewer dermal appendages for reepitheliazation
• less fluid balance
• less surface

Question 8

escharatomy

Answer 8

always: skin and subcutaneous tissue

• ischemia progressive
• paresthesia in fingers
• doppler superficial arch with less signal
• intrinsic minus hand
• pulse oximetry < 95%
• less thorax excursion

in doubt do it!!!!

over lateral aspect of the arm to the acromion maybe lateral to the thorax - over the dorsum of the hand with ongoing to the finger D2 and D 3 ulnary - D4 and D5 radially- decompression of all intrinsic and maybe the adductor policis

afterwards splinting in intrinsic plus

finger in 0°

MCP 80-90° flexion

wrist 35 -45° extension

take care of the skin over the PIP-joint - skin is very thin and breaks - burned caused boutonniere deformity

Question 9

timing of surgery

Answer 9

• stabalize patients fluid balance
• priorizize burn wounds
• day 3-5 post injury:
• edema receding - low bacterial count

grafting with FTSG - best pressure over the wound bed is 30mmHg- established with bolster tie-over dressing - Vacuum gloves are use in modern surgery

Question 10

antibiotics

Answer 10

• no antibiotics as prophylaxis
• silvadene cream
• tetanus
• beat cellulitis if present - antibiotics

Question 11

splinting acute trauma

Answer 11

post burn:

decreased edema

maximal ligament length

prevent 2° deformity

postop.:

motion from day 3-5 when the graft is adherent and growing in

Question 12

palmar burns

Answer 12

thicker keratin layer

thicker dermis

high densitiy sweat glands and adnexal elements

“a few extra days of conservative treatment if possible of healing palm primarily”

Question 13

treatment of 2° burns

Answer 13

• early tangential excision through punctual bleeding
• preserve maximal dermis
• viable dermis ideal for grafts

protect new epithelziation with cremes with vitamin A and D - prevent dehydration of the new skin - requires some maturation befor sebaceous and sweat gland function recovers

sulfazadine gloves or goretex gloves

biobrane gloves

Question 14

splinting - acute period

Answer 14

• splint has to fit the patients hand
• reduce edema
• protect tendon structures
• functional hand position

Question 15

treatment 3° burns

Answer 15

remove restrictive eschar

preserve venous system

resect to peritendinous tissue if needed - here you can graft on or graft on fat tissue

temporary coverage:

when patient is unstable or bleeding of the wounds - next operation in 24h

if the woundbed is clean maybe integra coverage (when there is no dermis in the woundbed)

Question 16

treatment of palmar burns

Answer 16

• conservative until there is a demarcation
• thick STSG or FTSG
• secondary healing with late reconstruction

Question 17

acute burn wound coverage

Answer 17

temporarely:

• biobrane
• pigskin
• cadaver skin
• acticoat
• aquacel

permanent:

• autograft
• alloderm and graft
• integra and delayed graft (when there is no dermis in the wound)

Question 18

joint and tendon exposure

Answer 18

• integra
• local flaps (reversed radial forearm flap, dorsal cross finger or reversed crossfinger flap)
• distant flap (groin, abdominal)
• microvascular free flap

Question 19

marjolin’s ulcer

Answer 19

• later on a burn wound, that will not heal
• prevalence 1 - 2% - rare
• aggressive squamous epithelium carcinoma
• resection with a margin of 20mm
• maybe amputation necessary

Question 20

postop. care

Answer 20

• splinting
• compressive gloves, inserts, conformers
• sun protection
• skin care with fat creme
• early hand therapy
• silicon sheeting
• careful observation
• prophylaxis for scarring and functional impairment
• psychologic therapy

Question 21

burn reconstruction

therapy goals

Answer 21

• ROM improvement
• stretching of the contracture
• scar management
• strength and endurance (Durchhaltevermögen, Kondition)
• improvement or holding the plateau

Question 22

anatomy of burn reconstruction

Answer 22

• epidermis
• dermis (near under epidermis - stratum papillare and stratum reticulare)
• sebaceous glands near epidermis
• sweat glands deeper
• hair follicles deeper
• than blood vessels
• subcutaneous tissue and fat
• fascia
• muscle
• bone

Question 23

unstable scar

Answer 23

the defect is always bigger than you think

surface contour influences the outcome

ratio of soft tissue to skeletal length will affect functional outcome

scar reconstruction:

• excision and closure
• STSG
• FTSG
• local flap
• distant flap
• tissue expansion
• allograft dermal matrix
• integra and delayed grafting

Question 24

surface contour

Answer 24

specific contours have higher procentage of recurrence

CONCAVE vs. CONVEX

concave surface such axilla and webspace have more scarring and recurrence - not so much oppositional force!!!

convex surface like elbow, dorsal finger joints - not so much problems

Question 25

dorsal hand burns

Answer 25

early finger flexion will decrease as the dorsal scars begin to contract - hand therapy very important - garments and skin care

Question 26

web space reconstruction

Answer 26

* concave surface * adduction contracture * static splinting / conformers * restricted motion - dorsal to volar flap to protect the webspace - skin graft lateral and medial * lengthening plasty of the first webspace with five-flap VY and 4-Z-plasty gives a good depth and length with a good smooth contour

Question 27

soft tissue to skeletal ratio

Answer 27

important for planning scar reconstruction after burns normal motion / restricted motion = ratio everything over 0,7 ratio give good results in the end ratio \< 0,4 soft tissue expansion or skeletal reduction to have a good outcome ratio \> 0,7 skin graft or local plasty is possible

Question 28

boutonniere deformity

Answer 28

deep burn wound what shrinkes the central slip - correction with best outcomes is the fusion of the PIP joint Pseudoboutonniere deformity scarring of the skin with typical boutonniere deformity - mostly with dorsal hand burns - no functional flexion in the MCP joints leads to Hyperextension with secondary PIP flexion contracture

Question 29

complications

Answer 29

* secondary infection PIP-joint and Nailbed - antibiotic cremes and flap covery if necessary * graft loss debridement and regrafting * early hypergranulation corticoid cremes

Question 30

postburn deformities by Achauer

Answer 30

A - claw deformitiy B - palmar contracture C - web space deformity D - hypertrophic scar and contracture bands E - amputation deformity F - nail bed deformity G - elbow H - axilla in literature the results show a good management with burns - complex therapy - there is more less need of secondary surgery

Question 31

postburn finger flexion contracture

Answer 31

classified by Kurtzman and Stern: Type I skin only, MP joint in passive flexion, PIP joint can fully extended (Z-plasty or full thickness skin grafts) Type II palmar capsule structures, MP joint in passive flexion, PIP joint can not fully extended (capsule release of checkrein ligaments and volar plate - flap coverage may be needed (artery-vein-artery flap)) Type III soft tissue, joint structures - fixed PIP regardless of MP joint position - radiograph findings fusion of the PIP joint Boutonniere - reconstruction of the lateral bands are unsatisfied - fusion is the best option dorsum of the hand - excison of all scars and mobilization of the joints if needed - than full thickness skin grafts thumb loss of distal phalanx give good function, web space widening, severe cases toe-to-hand transplantation, pollicization