Reconstruction of the burned hand.

There is no "cookbook" for reconstructing the burned hand. Multiple issues can color the chances for a successful outcome. What is the endpoint of surgical effort? Is it when the patient tires, becomes discouraged, or ceases to return? These questions are not rhetorical. Whereas an appendectomy cures appendicitis, no single surgical procedure or series of procedures cures burns. Many patients spend their lives searching to be as they were preinjury. Although physicians as healers do not want to destroy hope, ethics command that we attempt to keep these patients focused on reality. Although there is always something that could be done, judgment dictates what should be done. The major goals are early independence and resumption of preburn lifestyle for the patient. A thoughtful surgical plan set up in conjunction with the burn team and with timed goals gives the patient the best chance for success.

The expanded myocutaneous flap for reconstruction of the difficult pressure sore.

This paper presents the use of the expanded myocutaneous flap for the reconstruction of the difficult pressure ulcer. The results of expanded myocutaneous flaps on 10 patients with a variety of locations of pressure ulcers showed few complications. A review of the literature on the use of expanded flaps indicates the potential for this technique to be more frequently used.

The perioperative antimicrobial management of pressure ulcers.

No clear data exist as to the efficacious use of antibiotics during the perioperative period for repair of pressure ulcers. Results of a survey from 50 university departments of plastic surgery and spinal cord injury centers revealed that 58% reported routine use of antibiotics for flap surgery with cephalosporins as the choice at 69% of the centers. Clinical experience with 35 patients perioperatively showed good results with a third generation cephalosporin.

Burn accidents and the elderly: what is happening and how to prevent it.

Individuals over 60 and children under 2 form the two most burn-prone age groups in the United States. These figures are confirmed in other western cultures. The majority of injuries sustained in these two groups are preventable and relate to inadvertent scalding from hot water at the tap or spilled liquids in the kitchen and ignition of fabrics by faulty heaters or cigarettes. These injuries among the elderly lead to permanent change in health care status in over 40% of such accidents, and their prevention could significantly reduce morbidity associated with aging. Recommendations to promote burn prevention include reducing the temperature of hot water at the tap, introducing self-extinguishing cigarettes, and placing smoke detectors in all residences.

The problem of Social Security disability determination for the burn patient. A report from the Committee on Rehabilitation of the American Burn Association (ABA).

The ABA Rehabilitation Committee has developed a form to be included in the hospital record at discharge that should facilitate the Social Security disability determination process for the burn patient. This form should aid in the disability determination process by guiding the Social Security disability examiner to the pertinent evidence of limitation and chronicity in the often cumbersome medical record and by emphasizing the multiple body system nature of the severe burn injury.

Soft tissue injuries of the hand.

This article emphasizes the importance of good principles of wound management, including control of hemorrhage, the taking of a complete history, physical examination, assessment of vascular integrity, diagnosis of the presence of injured nerves, and closure of the wound. Also discussed are the following specific injuries: fingertip injuries, avulsion injuries, ring injuries, high pressure injection injuries, and burns.

Rehabilitation of the burn patient.

A successful outcome to the management of the significantly burned patient requires a team approach. Although at one time survival alone was considered a sufficient indicator of success, the quality of that survival now must be closely assessed prior to self-congratulations. The burn team, in addition to the usual medical personnel, requires occupational and physical therapy, as well as rehabilitation medical specialists, whose goals are to preserve function and restore independence. Burn care that does not emphasize these goals from the first day of injury, and extended well beyond initial discharge from the hospital, does not match contemporary standards of excellent care.

Physiologic profile monitoring in burned patients.

Physiologic profile monitoring was performed on 18 elderly patients (mean age, 71.3 +/- 11.7 years) with major burns (mean, 49% +/- 17% BSA) on days 1 to 4. Nine had associated inhalation injury. Ten patients survived more than 10 days. Degree of myocardial dysfunction in response to burn injury is unpredictable. Sixteen of the total 18 patients needed inotropic support. Cardiac output is probably a more accurate means of assessing efficacy of resuscitation than hourly urine output. Maintenance of cardiac index at higher than normal levels is a physiologic necessity. Failure of cardiac index to remain high after 3 days predicted nonsurvival in this group of patients. In presence of combined cutaneous and inhalation burn injury fluid requirement is unpredictable, and the optimum resuscitation in these patients merits further definition. Physiologic profile monitoring in these older patients is a very useful guide to the precise management of fluid resuscitation, early detection, and treatment of ventricle dysfunction, and results in improved survival.

Evaluation of early excision of dorsal burns of the hand.

To determine the best method for treating deep second- and third-degree burned hands in our institution, a prospective study comparing early excision and grafting with nonsurgical treatment was undertaken. The patients were randomly assigned to two groups, and the hands in the first group were excised and grafted within 5 days after the burn. In the second group, burns were treated with topical chemotherapy and hydrotherapy, and the eschar was allowed to separate spontaneously and heal. Some required skin grafting, forming a subgroup. All hands in the study received the same vigorous physical therapy twice daily, and splints were applied according to the patient's individual needs to maintain an anti-deformity position. Grip strength, power pinch, and accurate range-of-motion measurements of each finger joint were measured upon discharge and 1, 2, 3, 6, and 12 months after the burn. A mean total degrees of motion (including flexion and extension) in each joint and strength values were determined for comparison among the three groups. At discharge, the spontaneously healed hands had the best range of motion and function. Although the rate of improved function was greatest in the interval from discharge to 6 months in all groups, by 1 year there was no statistical difference in function regardless of the initial treatment. Thus in deep second- and third-degree burns of the dorsum of the hand, care may be individualized according to other systemic factors without fear of sacrificing ultimate function.

Peripheral nerve complications following burn injury.

The involvement of peripheral nerves in burn injury is not common, but when nerves are involved, prompt therapeutic intervention is necessary to avoid increased morbidity. Aside from the direct effects of the trauma, the burn team must anticipate dangerously excessive edema from circumferential burns, and avoid secondary nerve damage from inappropriate splinting, exercises or traction.

Effects of trauma and partial devascularization on protein synthesis in the avian flexor profundus tendon.

Destruction of the blood supply to tendons adversely affects healing of repaired flexor tendons. In cut and sutured avian flexor profundus tendons, protein synthesis was maximal on Day 10 post-trauma with a broad peak that spanned at least 12 days. Partial devascularization of cut-sutured tendons reduced protein synthesis to 43% of the value for nondevascularized-cut-sutured tendons on Day 10. Both collagen and noncollagen protein synthesis in cut-sutured tendons followed a bimodal pattern with peaks on postoperative Days 10 and 18. Collagen and noncollagen protein synthesis in partially devascularized tendons was decreased. Relative collagen synthesis, that is, the amount of collagen produced compared with the amount of all other proteins produced at the same time, was increased (Days 10 to 15) in the tendons that were cut-sutured and partially devascularized. The latter observations indicate that: 1) cutting a tendon results in increased protein synthesis; 2) partial devascularization of the cut tendon results in a lesser increase in protein synthesis; and 3) although overall protein synthesis, and collagen synthesis in particular, are reduced in partially devascularized, healing tendons, the relative amount of collagen produced is increased, emphasizing the importance of collagen to the healing tendon during the time of maximum synthesis.

Comparison of the bacterial clearing effects of different biologic dressings on granulating wounds following thermal injury.

In 16 patients with thermal injury, no difference in bacterial clearing was noted when wounds were dressed with cadaver homograft skin, porcine skin, either mesh or sheet, and with amnion. Because of cost and ease we prefer fresh porcine skin for second- and third-degree burns.

Biological dressings and evaporative water loss from burn wounds.

Increased evaporative water loss following thermal injury sometimes results in electrolyte abnormalities, negative nitrogen balance, and hypothermia. Because different biological dressings have been claimed effective in diminishing evaporative loss, a prospective study was designed to compare them. Cadaver allograft, porcine xenograft (sheet and meshed), and amnion were placed on 28 granulating wounds for twenty-four hours. Water loss was then measured with an Evaporimeter, revealing that in both full-thickness and partial thickness wounds, allograft was twice as effective as sheet porcine and five times as effective as meshed porcine or amnion. In the absence of available cadaver allografts, sheet porcine xenograft is a satisfactory substitute for use on granulating wounds to diminish evaporative water loss, while amnion and meshed porcine are less effective.

Burn wound sepsis: effect of delayed treatment with topical chemotherapy on survival.

Using a standardized laboratory rat model of burn wound sepsis, a regimen of once a day application of Silvadene has been found to be more effective treatment than Sulfamylon or cerium-Silvadene. Delaying treatment following infection resulted in decreased survival. Possible reasons for difference in mortality are once-daily application, or perhaps a change in sensitivity between drugs and the infective organism (Ps. aeruginosa) over time.

An adherence tensiometer for evaluation of burn dressings.

The measurement of adherence is a function of pulling force and velocity. The machine described measures and records adherence accurately and precisely. In both engineering and clinical laboratory tests, it has shown the ability to be used as standard equipment for quantitatively evaluating dressings and grafts. It is adapted for both laboratory and patient studies.

A clinical and laboratory evaluation of a polyurethane foam: a new donor site dressing.

A polyurethane foam (Lyofoam) has been reported to accelerate epithelization of a wound. The purpose of this study was to evaluate its efficacy as a donor-site dressing for thermally injured patients. Thus, partial-thickness injuries were made in ten pigs and covered with Lyofoam, Xeroform, Telfa, Scarlet Red, and fine-mesh gauze. Gross and histologic examinations failed to show accelerated healing under the Lyofoam dressing but did show that Scarlet Red covered donor sites healed the fastest. On clinical evaluation, nine patients only showed that Lyofoam separated earlier from the underlying wound but there was no evidence to suggest that the wound was more mature than that covered with fine-mesh gauze.

Evaluation of digital escharotomy in burned hands.

A controlled study of digital escharotomy showed a statistically significant increase in the number of salvaged phalanges. This procedure has minimal risk and should be considered in patients with vascular compromise of the upper extremity requiring escharotomy, who also have circumferentially burned fingers.

Comparison of coarse mesh gauze with biologic dressings on granulating wounds.

Twenty patients with large area granulating wounds were selected for the study. On each patient, a small area of uniform appearance was divided into four subareas, and each subarea was randomly assigned treatment with a single 24 hour application of cadaver allograft, fresh porcine xenograft, formalinized xenograft, or "wet-to-dry" applications of coarse mesh gauze changed three times daily. At 24 hours, all four areas were uncovered. The subareas were ranked in terms of appearance on a best, second best, third best, and worst scale by experienced paramedical personnel who were not told which area received which treatment. Contact sponge quantitative microbiology was performed on each subarea before and after treatment on seventeen of the twenty patients. The results of these rankings suggest that coarse mesh gauze, changed three times daily, was significantly better at improving wound appearance than any of the biologic dressings. Among the biologic dressings, formalinized xenograft was significantly the worst. There was no significant difference between cadaver allograft and porcine xenograft. Analysis of quantitative cultures was limited by the problems of applying statistical methods to series of paired cultures in which initial values are quite different. Within the framework of such limitations and our 24 hour study, there was not significant change in surface colonization when either coarse mesh gauze or biologic dressings were used.