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Innovation and clinical specialities: burns 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 fullthickness 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 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. 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. 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. 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 <strong>Hospital</strong> and Healthcare Innovation Book 2009/2010 63
Innovation and clinical specialities: burns 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 Figure 6: Position of safety significant morbidity, and it severely for splinting hands 59 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 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. 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 Figure 7: An algorithm for the cover of burn contractures of the extremities, after adequete release: band contracture (ROM = normal joint rnage of motion) 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 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 Axilla Axillary scar contractures are also very common. These can at 64 <strong>Hospital</strong> and Healthcare Innovation Book 2009/2010
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International Hospital Federation I
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Introduction Sterile Barrier System
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Contents Healthcare transformation
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International Hospital Federation H
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Introduction Introduction ERIC DE R
Page 13: Innovation and strategy 14 Creativi
Page 16 and 17: Innovation and strategy: creativity
Page 18 and 19: Innovation and strategy: risk manag
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Page 30 and 31: Innovation and policy: disease surv
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Page 42 and 43: Innovation and strategy: infectious
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Page 90 and 91: Company Profile: Shimadzu Europa Gm
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Innovation and clinical specialitie
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Innovation and clinical specialitie
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Company Profile: Wipak Medical Wipa
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Innovations in patient care: infect
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Innovation in patient care: patient
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Innovation in patient care: patient
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IHF reference The International Hos
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C M Y CM MY CY CMY K with support f
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IHF reference IHF Governing Council
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IHF reference IHF Consultants Audit
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IHF reference JAPAN JAPAN HOSPITAL
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IHF reference KENYA THE NAIROBI HOS
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IHF Corporate Member Profiles GE He
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How Can Health Organizations Get th
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