Burns Flashcards
Burns
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
acute hand burn
- 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:
- cooling (if local burn) and elevation of hand
- evaluation of the size and depth of the burn
- escharotomy if indicated
- application of proper wound care and dressing
- decision about conservative or operative treatment
- early operation of a stable patient (resuscitation, crush syndrome)
- initiation of early hand therapy and splinting
- surgical management - removal of eschar, transplantation of skin grafts, flap coverage if necessary
- early postop physical therapy
- functional rehabilitation
- secondary and tertiary corrections if necessary
stiff hand
- contraction of collateral ligaments
- fixation of volar plate
- capsular scarring
- adhesion of extendor tendons
- lumbricals contract
- gliding mechanism impaired
assessing burn depth
- colour
- sensitivity
- blanching
- hair follicles
- variable depth
- edema
burn grade
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
eletrical burns
- grade of burns
- skip area of electricity entrance and exit - requires second look - types:
- entrance/exit - deep
- arc - more superficial
- clothing ignition
hand burns in children
- skin (dermis) is thinner
- thinner keratin layer in the palm
- fewer dermal appendages for reepitheliazation
- less fluid balance
- less surface
escharatomy
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
timing of surgery
- 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
antibiotics
- no antibiotics as prophylaxis
- silvadene cream
- tetanus
- beat cellulitis if present - antibiotics
splinting acute trauma
post burn:
decreased edema
maximal ligament length
prevent 2° deformity
postop.:
motion from day 3-5 when the graft is adherent and growing in
palmar burns
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”
treatment of 2° burns
- 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
splinting - acute period
- splint has to fit the patients hand
- reduce edema
- protect tendon structures
- functional hand position
treatment 3° burns
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)
treatment of palmar burns
- conservative until there is a demarcation
- thick STSG or FTSG
- secondary healing with late reconstruction
acute burn wound coverage
temporarely:
- biobrane
- pigskin
- cadaver skin
- acticoat
- aquacel
permanent:
- autograft
- alloderm and graft
- integra and delayed graft (when there is no dermis in the wound)
joint and tendon exposure
- integra
- local flaps (reversed radial forearm flap, dorsal cross finger or reversed crossfinger flap)
- distant flap (groin, abdominal)
- microvascular free flap
marjolin’s ulcer
- 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
postop. care
- 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
burn reconstruction
therapy goals
- ROM improvement
- stretching of the contracture
- scar management
- strength and endurance (Durchhaltevermögen, Kondition)
- improvement or holding the plateau
anatomy of burn reconstruction
- 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
unstable scar
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
surface contour
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
dorsal hand burns
early finger flexion will decrease as the dorsal scars begin to contract - hand therapy very important - garments and skin care
web space reconstruction
- 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
soft tissue to skeletal ratio
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
boutonniere deformity
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
complications
- secondary infection
PIP-joint and Nailbed - antibiotic cremes and flap covery if necessary
- graft loss
debridement and regrafting
- early hypergranulation
corticoid cremes
postburn deformities by Achauer
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
postburn finger flexion contracture
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
