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Electrical Injury: Reconstructive Problems

Introduction Severe cases [of electrical injury] coming for reconstruction present a formidable problem of flexion contracture and loss of many tendons and nerves, new pedicled skin and grafted-in tendons and nerves usually being necessary. One encounters inside the limb the same type of destruction and cicatrix as is found after any severe infection. STERLING BUNNELL, 1948 This chapter will focus on the multitude of surgical and…

Reconstruction of Burn Deformities of the Lower Extremity

Assessment of Salvage Potential Acute care of a burned lower extremity prioritizes circulation and coverage. These goals are achieved through escharotomies and fasciotomies as necessary and excision and coverage of the burn wounds. Reconstruction of lower-extremity burn sequelae, however, requires a more complex and detailed definition of defects, deformities, and functional goals. Assessment of a lower limb for secondary postburn reconstruction is therefore directed toward a…

Management of Burn Injuries of the Perineum

Introduction Burns of the perineal area are relatively uncommon despite the common involvement of the lower trunk and the lower extremities in burn injuries. The incidence of perineal burns was reported at around 12/1000 admissions more than 25 years ago. While the occurrence of perineal burns has remained at around 1.0–1.5% at our institution, 35 children underwent genito-perineal reconstruction out of 1133 presenting with perineal burns…

Acute and Reconstructive Care of the Burned Hand

Introduction The hand is a primary means of communication, aesthetics, emotion, and sexuality. It exists at the core of our humanity. Particularly in the modern age of digital communication, the inability to interface with the digital world via hands is socially and intellectually isolating. Hands are injured in 80% of severe burns and are a primary American Burn Association referral criterion. Loss of hand function from…

Management of Contractural Deformities Involving the Shoulder (Axilla), Elbow, Hip, and Knee Joints in Burned Patients

Introduction Burn injuries, regardless of the etiology, rarely involve a joint itself. However the joint function is often impaired because of burns. The joint problems and joint deformities noted in burn patients are mostly due to physical inactivity combined with limitation of joint movement because of scar contracture. The consequences of joint dysfunction are usually left for reconstruction later in the course of burn convalescence. Contractural…

Trunk Deformity Reconstruction

Introduction Burn injuries to the trunk may have functional and cosmetic consequences. The torso, abdomen, and back connect anatomically with the shoulder girdle and the axilla laterally, with the neck superiorly, and with the groin tissue and the lower limbs inferiorly. This means that burn injuries to the trunk may cause damage primarily to three areas: a. Damage to soft tissue layers including skin, subcutaneous tissue,…

Management of Postburn Alopecia

Introduction The importance of burn involvement of the scalp is due to its very visible location on the body. Deformities of the scalp may not always be easy to hide or camouflage, causing great distress to the individual. In large surface area burns, the scalp may be involved in 25–45% of cases. Superficial burns of the scalp heal rapidly owing to the abundance of dermal epithelial…

Reconstruction of the Head and Neck after Burns

Introduction Reconstruction of the head and neck following burn injuries presents great challenges and great opportunities. Successful treatment requires sound surgical judgment and technical expertise, as well as a thorough understanding of the pathophysiology of the burn wound and contractures. Many disciplines are required to successfully care for patients with burns of the head and neck. These include skilled nursing, experienced occupational and physical therapy, and…

Reconstruction of Bodily Deformities in Burn Patients: An Overview

The severity of burn injuries can usually be ascertained if not by patient survival then by the consequences of the injury: scar hyperplasia/hypertrophy, scar contracture, and structural deformities due to loss of bodily components. Since bodily deformity is closely related to the magnitude of injury, restorative procedures are seldom indicated if the depth of injury is superficial and the burned area limited ( Fig. 49.1 ).…

Musculoskeletal Changes Secondary to Thermal Burns

Acknowledgment This chapter was originally written by E. Burke Evans, MD. He passed away in May 2012. We are indebted to his knowledge of burn care. Care was taken to preserve as much of his original material while adding new information. Introduction Burn injuries have a tendency, even as they heal, to create musculoskeletal deformity. In addition, the protracted burn illness that accompanies severe burns may…

Burn Rehabilitation Along the Continuum of Care

Introduction The physical rehabilitation of patients who have sustained a burn injury is a serious undertaking and requires, among other disciplines, the involvement of physical therapy, occupational therapy, and exercise physiology in order to produce the best functional and cosmetic outcomes. Recent advances in medicine have significantly contributed to increased patient survival rates, and this necessitates faster, more comprehensive, and prolonged burn rehabilitation. With severe burn…

Pathophysiology of the Burn Scar

Introduction Prehistoric and Historic Perspectives Wounds due to combat, hunting injuries, accidents, and thermal injuries have been the leading causes of death in humans for millennia, whereas prolonged survival of large full-thickness wounds is a recent phenomenon. Complex biological responses to cutaneous injury have evolved over time without evolutionary pressure to evolve appropriate healing responses to large wounds. There are records of human attempts to improve…

Molecular and Cellular Basis of Hypertrophic Scarring

Introduction Clinically postburn hypertrophic scars (HTS) are elevated, erythematous, pruritic, and inelastic. In addition to poor cosmesis, these scars typically form contractures resulting in dysfunction and discomfort, leading to significant morbidity for burn patients ( Fig. 45.1 ). HTS is fundamentally different from normal skin and mature scar in several key ways: (1) the extracellular matrix (ECM) of HTS is significantly altered in both composition and…

The Burn Problem: A Pathologist’s Perspective

Introduction A large burn is not a simple injury but a very complicated disease. This statement, restated from its publication in 1840, holds true with additional force in 2016. Massive destruction of skin tissue by burns stimulates many complex reactions that are still only partly understood. Malfunction of every organ system complicates the responses of patients to large burns. These malfunctions can be clarified by examination…

Burn Injuries of the Eye

Introduction Both immediate and delayed presentations exist for eye problems in burned patients. Accordingly, in burns, the structure and function of a normal eye can be disrupted by concurrent blunt or penetrating injury, electrical current, thermal energy, or chemical agents. After the initial insult, foreign bodies, ongoing chemical injury, deterioration of the facial burn wound, infection, and environmental exposure can cause additional damage or progression of…

Exfoliative Diseases of the Integument and Soft Tissue Necrotizing Infections

Introduction Acute, severe, exfoliative and necrotizing diseases of skin and underlying structures may cause significant morbidity and mortality in the afflicted patient. The problems associated with these diseases, such as wound infection, sepsis, inadequate nutrition, and pain, are similar to those seen in patients with major burns. Thus burn centers, with their multidisciplinary teams, have been advocated to provide the treatment and management for this unique,…

Radiation Injuries and Vesicant Burns

Radiation Injury: Introduction In the aftermath of 9/11 and more recent acts of unrelenting terrorism, such as the mass killings in Paris, Brussels, and Orlando, the possibility of the use of nuclear weapons or crude nuclear devices in attacks on nuclear facilities and use of chemical agents cannot be ignored. Given the devastating medical consequences that would follow the use of such weapons, the training of…

Chemical Burns

Introduction Chemical burns represent a small percentage of burn injuries yet up to one third of burn-related deaths. Many common household and industrial compounds have the potential to induce severe chemical burns. The American Association of Poison Control Centers' National Poison Data System 2014 annual report demonstrated 199,291 cases of exposure to cosmetic or personal care products; 198,018 household cleaning substances; 83,005 pesticides; 31,903 hydrocarbons; and…

Cold-Induced Injury: Frostbite

History of Frostbite Frostbite is a traumatic injury caused by the failure of normal protective mechanisms against the environment, resulting in freezing of tissue. Cold-induced injury remains surprisingly frequent in the United States owing to increasing interest in outdoor winter recreational activities as well as the common presence of homeless and socioeconomically disadvantaged individuals in large urban centers. The incidence of and circumstances surrounding frostbite have…

Electrical Injuries

Introduction The harnessing of electricity may be the technical advance with the greatest impact on human life and culture in recorded history. The tools of modern life are increasingly powered by electricity, and life without it would be unrecognizable. There is, however, a price to be paid for this advancement. Electrical burn injuries are estimated to make up several thousand admissions to burn centers each year…