Reconstruction of the pediatric burned hand.

Though the hand constitutes only 3% of the total body surface area, a burned hand is a major injury. Reconstruction of the burned hand is key to the overall rehabilitation of the burned patient. Whether an isolated injury, or part of burns to a large overall body surface area, loss of the hand represents a major functional impairment. The American Burn Association recognizes the importance of the burned hand by designating it a major injury. In addition, loss of the hand constitutes a 57% loss of function for the whole person. Thus, successful management of the burned hand is important.

Microvascular transfer of burned tissue for mandibular reconstruction.

We present a case of mandibular reconstruction using a free-vascularized fibula osteocutaneous flap after invasive infection of the mandible with mucormycosis. Unique to this case is the skin paddle that previously sustained full-thickness burn injury treated with cultured skin substitute (CSS). A 10-year-old boy sustained a 96% total body surface area burn. CSS was used to obtain wound closure. However, he developed invasive mucormycosis of the mandible requiring resection. The best option for mandibular reconstruction was the use of a free-vascularized fibular osteocutaneous flap with CSS as a skin paddle. The reconstruction was performed without complications. To our knowledge this is the first case describing the use of CSS in free tissue transfer. With the improved prognosis in massively burned patients and the increased use of cultured skin for wound coverage, complex reconstruction using previously burned tissue will be required. Previously burned skin including tissue grafted with skin substitutes attains vascularity and healing properties that allow flap elevation for burn reconstruction. Successful utilization of previously burned skin relies on the ability to provide adequate blood supply to the flap by preservation or regeneration of its angiosome.

Management of class IV skull burns using the bipedicled superficial temporal artery scalp flap.

Calvarial burns are extremely rare and pose a difficult challenge for both the burn and reconstructive surgeon. Reconstruction of these injuries is dependent on the depth of invasion and the amount of tissue loss. Fourth-degree burns include damage to the calvarium and the underlying dura and or cerebrum. Historically, these wounds have been treated conservatively. Two cases of electrical fourth-degree calvarial burns with large soft tissue defects as well as loss of calvarium and dura with cerebral herniation are presented. Each patient presented to Shriners Burn Hospital in a delayed fashion with infected wounds necessitating immediate intervention. Both patients were debrided and covered with a bipedicled superficial temporal artery scalp flap. The donor sites of each flap, as well as the remaining areas, were skin grafted. This flap provides immediate vascularized coverage in wounds that were unable to be treated conservatively. In the face of sepsis and other severe injuries where more complicated flaps are risky, this flap provides a reasonable and reliable method of calvarial coverage.

Early use of allograft skin: are 3-day microbiologic cultures safe?

BACKGROUND: Under the guidance of the American Association of Tissue Banks and the Food and Drug Administration, the use of allograft skin is safer than ever. In addition to the donor selection process and serology studies, current practice is to wait until 7 days of negative microbiologic cultures are completed before use. However, we have used 3 days of negative cultures in special cases as needed for clinical use. But how safe is this practice? METHODS: Between 2002 and 2003, 735 allograft skin donors were authorized for exceptional release. Exceptional release forms were signed by surgeons to document knowledge of the 3-day microbiologic cultures. RESULTS: Only three donors were recalled for positive cultures. The recall rate was 0.41%. CONCLUSIONS: The use of 3-day microbiologic cultures is 99.59% safe. Thus, the early use of allograft skin does not increase the chances of microbiologic contamination to patients.

A survey of current rehabilitation trends for burn injuries to the head and neck.

Burn injuries to the face and neck present a unique challenge to the burn team and must be treated with considerable care and vigilance by the rehabilitation team to prevent potential contractures that may occur. Standard guidelines for treatment of the head and neck have not been established. This article presents the results of a comprehensive survey that examined the similarities and differences in the rehabilitation techniques used in various burn centers for the treatment of these injuries. The results obtained from the survey responses demonstrate several similarities in treatment throughout the continuum of care, revealing the potential for the development of a uniform rehabilitation protocol for the treatment of burn injuries to the face and neck.

Management of postburn recalcitrant knee ulcers in pediatric patients.

The sequelae of severe lower-extremity burn injuries in children include ulcerations and unstable scars of the anterior knee. Although the weight-bearing and ambulatory demands on this joint predispose the ulcers to chronicity, recalcitrance to treatment in the absence of systemic factors may be indicative of the presence of less-than-optimal local factors mitigating against healing. In our experience, excessive skin tightness around the knee joint has played a key role in this respect. This retrospective study on 10 patients with 16 recalcitrant knee ulcers demonstrated the inadequacy of the traditional treatment approach of ulcer excision and grafting. However, incisional release of tight skin above the knee joint and resurfacing the defect with split-thickness skin graft (mean size, 118.26 +/- 35.32 cm2) eliminated excessive tension and allowed the ulcers to heal spontaneously and permanently. We found this approach useful in select patients, and we are favorably disposed to additional releasing incision and grafting if the need arises in the growing child.

Management of acute calvarial burns in children.

BACKGROUND: Although rare, head burns involving the calvarium are a serious complication of burns and electrical injury, and present therapeutic challenges to the surgical burn care team. We evaluated our experiences and compared available strategies to address this challenge. METHODS: Records of all burned children between January 1986 and December 2000 were reviewed. Twenty-seven children (15 boys and 12 girls) with scalp burns extending at least into the outer table of bone were identified and compared with a matched group of 30 patients admitted for acute thermal burns without skull injury. RESULTS: Flame burn was the injury mechanism in 78% of these patients and electrical injury was the injury mechanism in 22%. The incidence of calvarial burns in our patient population was 1.2% for thermal burns and 5.6% for electrical injuries during the study period. The age distribution was biphasic, with maximums in infancy for thermal burns and in puberty for electrical injuries. Eight of 27 patients (29.6%) developed full-thickness calvarial bone defects. In 23 patients, calvarial burn wound coverage was achieved with bone debridement and immediate or delayed placement of autograft skin. In four patients (all with electrical injury), local scalp flaps were required for closure. The length of hospital stay and overall number of acute operative procedures significantly increased for patients with calvarial burns. CONCLUSION: Acute calvarial burns are safely managed by bone debridement in combination with staged autografting or early flap coverage. Although flap coverage reduces the number of required procedures, the extensive wound size in thermal burns restricts acute flap procedures primarily to electrical injuries. Compared with patients without skull injury, length of hospital stay and the number of acute operative procedures are tremendously increased in patients with calvarial burns.

Burn scar contractures of the feet: efficacy of bilateral simultaneous surgical correction.

Children who sustain large total body surface area (TBSA) burns with involvement of the lower extremities frequently sustain injuries to the dorsum of the feet. Burn scar contractures of the feet can develop as a sequela of the burn injury. Such contractures frequently require surgical correction. Many surgeons proceed with staged unilateral corrections when both feet are equally in need of operative intervention. The purpose of the study is to determine if the morbidity for correction of bilateral dorsal foot contractures is different from that for the correction of unilateral dorsal foot contractures.A retrospective review from January 1994 to July 1999 was undertaken. Forty-five patients with photographic record of burn scar contracture of the feet were identified. Twenty-five patients underwent staged unilateral surgical correction and twenty patients underwent simultaneous bilateral correction of the feet. All patients underwent surgical correction with split thickness skin grafts (STSG). No statistical difference was found in terms of mortality, development of contracture, or number of reconstructive procedures. However, the length of stay revealed the efficacy of the bilateral simultaneous release of the dorsal feet.

The development, validation, and testing of a health outcomes burn questionnaire for infants and children 5 years of age and younger: American Burn Association/Shriners Hospitals for Children.

The 12-member American Burn Association/Shriners Hospitals for Children Outcomes Task Force was charged with developing a health outcomes questionnaire for use in children 5 years of age and younger that was clinically based and valid. A 55-item form was tested using a cross-sectional design on the basis of a range of 184 infants and children between 0 and 5 years of age at 8 burn centers, nationally. A total of 131 subjects completed a follow-up health outcomes questionnaire 6 months after the baseline assessment. A comparison group of 285 normal nonburn children was also obtained. Internal consistency reliability of the scales ranged from 0.74 to 0.94. Tests of clinical validity were significant in the hypothesized direction for the majority of scales for length of hospital stay, duration since the burn, percent of body surface area burned, overall clinician assessment of severity of burn injury, and number of comorbidities. The criterion validity of the instrument was supported using the Child Developmental Inventories for Burn Children in early childhood and preschool stages of development comparing normal vs abnormal children. The instrument was sensitive to changes over time following a clinical course observed by physicians in practice. The Health Outcomes Burn Questionnaire for Infants and Children 5 years of age and younger is a clinically based reliable and valid assessment tool that is sensitive to change over time for assessing burn outcomes in this age group.