The Effective Management and Outcome of Hand Burns

Burns is a common public health problem and these injuries can be accidental, suicidal or even homicidal in nature. Hands being the most active part of the body, are often involved in burns. Hand burns represent three percent of body surface area, and are involved in more than 80% of all severe burns. Hand burns predominantly affect young adults and therefore have serious social and financial implications. The hand is one of the most frequent sites of burns scar contracture deformity. The deformities and contractures result in lifelong physical problems and affects the normal functioning of the person.

Resurfacing the donor sites of reverse sural artery flaps using thoracodorsal artery perforator flaps

Background The reverse sural artery (RSA) flap is widely used for lower extremity reconstruction. However, patients sometimes suffer from donor site complications such as scar contracture and paresthesia, resulting in dissatisfaction with the aesthetic outcomes. This study investigated the characteristics of donor site morbidity associated with RSA flaps and described our experiences of dealing with complications by performing resurfacing surgery using thoracodorsal artery perforator (TDAP) flaps.Methods From April 2008 to August 2018, a total of 11 patients underwent contracture release and resurfacing surgery using TDAP flaps due to donor morbidity associated with RSA flaps. All affected donor sites were covered with a skin graft, the most common of which was a meshed split-thickness skin graft (six cases).Results Eight of the 11 patients (72.7%) suffered from pain and discomfort due to scar contracture, and seven (63.6%) complained of a depression scar. The donor sites were located 6.3±4.1 cm below the knee joint, and their average size was 140.1 cm². After resurfacing using TDAP flaps, significant improvements were found in the Lower Extremity Functional Scale (LEFS) scores and the active and passive ranges of motion (AROM and PROM) of the knee joint. The LEFS scores increased from 45.1 to 56.7 postoperatively (P=0.003), AROM increased from 108.2° to 118.6° (P=0.003), and PROM from 121.4° to 126.4° (P=0.021).Conclusions Planning of RSA flaps should take into account donor site morbidity. If complications occur at the donor site, resurfacing surgery using TDAP flaps achieves aesthetic and functional improvements.

Outcomes of grafted skin on the dorsum of the foot after car-tire friction injuries

Background A car-tire friction injury on the dorsum of a child’s foot often results in hypertrophic scarring of the wound margins. This study describes the clinical appearance of the injured areas and surgical complications that occurred during the follow-up period in a series of children with car-tire friction injuries who were treated with split-thickness skin grafts (STSGs). We describe the clinical features that we believe need to be highlighted when initially treating car-tire injuries in children.Methods From May 2003 to June 2016, our retrospective study included 15 patients with car-tire injuries on the dorsum of the foot who were treated with surgical excision and STSG to cover the wound.Results A total of 15 patients with car-tire injuries were treated. The average age was 6.26 years old. The average injury grade was 3.26. Two patients were treated using delayed repair, and 13 patients received STSG for initial management. Four patients experienced no complications, while 11 patients had hypertrophic scars and/or scar contracture after surgery.Conclusions A car-tire friction injury on the dorsum of a child’s foot often results in hypertrophic scar formation or scar contracture even if proper management is undertaken. Since the occurrence of these complications in childhood can lead to a secondary deformity, it is important to properly treat car-tire friction wounds, inform patients and caregivers about potential complications, and ensure regular follow-up evaluations over a 12-month period following the initial surgery.

Utilization of 3D MRI for the Evaluation of Sphincter Pharyngoplasty Insertion Site in Patients With Velopharyngeal Dysfunction

Sphincter pharyngoplasty is a surgical method to treat velopharyngeal dysfunction. However, surgical failure is often noted and postoperative assessment frequently reveals low-set pharyngoplasties. Past studies have not quantified pharyngoplasty tissue changes that occur postoperatively and gaps remain related to the patient-specific variables that influence postoperative change. The purpose of this study was to utilize advanced three-dimensional imaging and volumetric magnetic resonance imaging (MRI) data to visualize and quantify pharyngoplasty insertion site and postsurgical tissue changes over time. A prospective, repeated measures design was used for the assessment of craniometric and velopharyngeal variables postsurgically. Imaging was completed across two postoperative time points. Tissue migration, pharyngoplasty dimensions, and predictors of change were analyzed across imaging time points. Significant differences were present between the initial location of pharyngoplasty tissue and the pharyngoplasty location 2 to 4 months postoperatively. The average postoperative inferior movement of pharyngoplasty tissue was 6.82 mm, although notable variability was present across participants. The pharyngoplasty volume decreased by 30%, on average. Inferior migration of the pharyngoplasty tissue was present in all patients. Gravity, scar contracture, and patient-specific variables likely interact, impacting final postoperative pharyngoplasty location. The use of advanced imaging modalities, such as 3D MRI, allows for the quantification and visualization of tissue change. There is a need for continued identification of patient-specific factors that may impact the amount of inferior tissue migration and scar contracture postoperatively.

Mesenchymal stromal cells therapy alone does not lead to the complete restoration of the skin parameters in diabetic foot patients within a 3-year follow-up period

Introduction: Mesenchymal stromal cells (MSCs) administration is an effective option for the treatment of diabetic foot ulcers (DFUs). However, to date, studies assessing long-term outcomes and evaluating skin parameters after cell-based therapy are lacking. We presented the clinical outcomes of 3 patients, treated for DFUs with the bone marrow MSCs 3 years earlier. Methods: Ultrasound examination was used to compare collagen density and epidermal thickness in areas of healed ulcers in comparison with non-affected skin used as a control. Ultrasound and dermatoscopy were used to exclude neoplasm formation, to assess scar contracture and wound recurrence. Results: In all patients, no ulcer recurrence was detected, which was lower than the expected 60% rate of re-ulceration in diabetic patients in a 3-year period (OD [odds ratio] = 0.095, P = 0.12). No neoplasm formation, no contracture of hypertrophic scar, and adjacent tissue were registered. Collagen ultrasound density was decreased by 57% (P = 0.053) and epidermal thickness was increased by 72% (P = 0.01) in the area of healed ulcers in all patients. Conclusion: MSCs therapy alone did not result in the complete restoration of the skin parameters within a 3-year period. MSCs may represent important adjuvant to the therapy, however, other novel approaches are required to achieve better results.

Update on the practice of splinting during acute burn admission from the ACT study

Introduction Burn scar contracture (BSC) is a common pathological outcome following burn injuries, leading to limitations in range of motion (ROM) of affected joints and impairment in function. Despite a paucity of research addressing its efficacy, static splinting of affected joints is a common preventative practice. A survey of therapists performed 25 years ago showed a widely divergent practice of splinting during the acute burn injury. We undertook this study to determine the current practice of splinting during the index admission for burn injuries. Methods This is a review of a subset of patients enrolled in the Burn Patient Acuity Demographics, Scar Contractures and Rehabilitation Treatment Related to Patient Outcome Study (ACT) database. ACT was an observational multicenter study conducted from 2010-2013. The most commonly splinted joints (elbow, wrist, knee and ankle) and their 7 motions were included. Variables included patients’ demographics, burn variables, rehabilitation treatment and hospital course details. Univariate and multivariate analysis of factors related to splinting was performed. P< 0.05 was significant. Results Thirty percent of the study population (75 patients) underwent splinting during their hospitalization. Splinting was associated with larger burns and increased injury severity on the patient level and increased involvement with burns requiring grafting in the associated cutaneous functional unit (CFU) on the joint level. The requirement for skin grafting in both analyses remained independently related to splinting, with requirement for grafting in the associated CFU increasing the odds of splinting 6 times (OR =6.0, 95% CI=3.8-9.3, p<0.001). On average splinting was initiated about a third into the hospital length of stay (LOS, 35 ± 21% of LOS) and splints were worn for 50% (50 ± 26%) of the LOS. Joints were splinted for an average 15.1 ± 4.8 hours a day. The wrist was most frequently splinted joint being splinted with one third of wrists splinted ( 30.7%) while the knee was the least frequently splinted joint with 8.2% splinted. However, when splinted, the knee was splinted the most hours per day (17.6 ± 4.8 hours) and the ankle the least (14.4 ± 4.6 hours). Almost one third had splinting continued to discharge (20, 27%). Conclusions The current practice of splinting, especially the initiation, hours of wear and duration of splinting following acute burn injury remains variable. Splinting is independently related to grafting, grafting in the joint CFU, larger CFU involvement and is more likely to occur around the time of surgery. A future study looking at splinting application and its outcomes is warranted.

Postburn Hand Deformities: Principles of Management and Approach

The hand is one of the top 3 locations for burn scar contracture deformity. The functionality of the hands is one of the primary determinants of burns survivors’ quality of life. Although most burn abnormalities are preventable, they do arise when adequate treatment is not delivered in an emergency or when they are part of a major burn. Reconstructive surgeries can significantly improve hand function. For a burn’s survivor, the right methods and timing of surgery, followed by supervised physiotherapy, can be a game changer.