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Innovation and clinical specialities: burns
Figure 8: 4-Flap Z-plasty 63
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.
Figure 9: 4-Flap Z-plasty 63
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
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
Burn TBSA, %
80
70
60
50
40
30
20
10
0
Penicillin
Resuscitation
Burn centres
More antibiotics
Ventiilators
Topical Rx
Skin banks
TPN
More antibiotics
Early excision
1940 1950 1960 1970 1980 1990
Burn LA
50
Nutrition
ICU
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
Conclusions
Many accomplishments have been made in burn care over the
past several decades, as illustrated below (Figure 10). 31
Encouragingly, these have resulted in steady improvements in
mortality rates.
This progress has also been noted in a number of centres in
resource-poor countries where a multidisciplinary,
global approach to the burn
patient has been embraced; from
Excision common
Figure 10: Advances in burn xare – 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
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
Hospital and Healthcare Innovation Book 2009/2010 65