18. Burns – Part 3
Rehabilitation and Reconstruction
- Aesthetic and functional considerations: While it stands to reason to say that the greater the area and the depth of a burn wound, the greater will be the morbidity, some exceptions need to be noted. A burn ofthe neck and the face and the upper torso (involving the breasts in females) has greater consequences than burns elsewhere vis a vis the patient’s social and psychological rehabilitation.
- The same is true for the hands. Not only are they exposed, but any significant contracture of the hands impairs functions not only of daily living but also at the place of work. There is hardly a job where hands can be spared.
- Therapy during acute phase: Such facts must be remembered by the team treating burn patients as therapy begins during the active phase in the treatment of burns. It must be noted that, because of the concavity of the neck, the uneven surface of the face and the extremely thin skin in the dorsum of the hand and the fingers,early excision is not always possible and healing will take place with some delay in grafting. The hands need to be elevated to reduce oedema. The hand also must be splinted as soon as possible with the wrist in dorsi-flexion, metacarpo-phalangeal joints at 90° flexion and the fingers in extension. The thumb must be kept away from the palm and in fact all the toes and fingers must be dressed separately with an intervening dressing in the web spaces to prevent post burn scar syndactyly. The neck as far as possible should be placed in extension with some support behind the upper back, but the head end of the bed may be raised to prevent oedema of the face. The face, which is difficult to wrap in a convenient dressing, may be irrigated frequently to remove crusts and scabs and then covered with the antibacterial cream.
- Mobilisation: Mobilisation of all joints is essential while the patient is in bed, putting them through their normal range of movement. Compliance is not always easy to achieve at this stage, nor when the patient is being mobilized as a whole.It helps to have the same therapist over a period of time and analgesics and anti-pyretics might need to be administered before the therapy begins because patients are stiff and in pain and frequently run a temperature even though there are no overt signs of infection, and the burn wounds might appear to be almost closed. While mobilizing the patient donor areas must be protected because they can be a source of great pain and bleed when the patient is made to stand.
- Scarring: That ungrafted areas produce scars is well known but what remains unpredictable are scars that develop even in grafted areas. It is not uncommon to see in a single patient, where the technique employed and the surgeon remain the same, that some areas might show healing with hypertrophic scars while others don’t. Even donor areas might behave differently in the same patient in different parts of the body. Generally speaking (empirically) firm dressings are employed in as many areas as possible and face masks made to measurecan be applied to the face with a thin vaseline gauze dressing underneath, even before grafting is undertaken. Soft collars followed by rigid splints are also used to prevent contractures of the neck. Pressure prevents excessive hyperaemia and also reduces exuberant granulation tissue.
- Pressure garments: The principle that pressure helps is extended in the post grafting phase by employing pressure garments which help to reduce hypertrophic scarring and contractures. Ordinary but tight elastic elastic stockings for the extremities and separate vests for the torso are available in allsizes. Further, custom made special clothing, a veritable armour with zips, are manufactured to order by garment makers who suggest that the patient should wear them for at least twenty hours in a day. This ideal is rarely reached and patients are not infrequently exasperated by this regimen. However some compliance is achieved. Pressure garments have now become a routine part of the treatment for cases of burns. The garment should be such as to allow passive and active range of motion when in place.
- Representational photographs of various types of pressure garments.
Photographs courtesy: Mala Shukla
Sunil Keswani from Mumbai adds that his patients tolerate pressure garments made of medical grade lycra for as many as 23 hours with no discomfort.
- Post-burn symptom complex: Following the closure of burn wounds by skin grafting or when they heal spontaneously with epithelialised scars, most patients will remain symptomatic. Pain, itching, intermittent redness or swelling, a feeling of burning and a general sense of discomfort as well as poor sleep are some of the oft repeated complaints and may persist almost up to a year if not more. The appearance of scars is a huge problem particularly in the neck and the face. Functional impairment due to scarred joints particularly of the hand, inability to squat and severe stiffness on waking in the morning are all part of the post-burn symptom complex. Stiffness is treated with physio– and occupational therapy either through a trained therapist or on a ‘taught’ basis with intermittent supervision by a therapist. In addition to passive splints, dynamic splints are constructed mainly for the hand and have to be custom made because each contracture in the hand is slightly different. For symptomatic relief opioids or non-steroidal anti-inflammatory agents, anti-histamines, H-receptor antagonists, tranquillisers and sedatives and occasionally corticosteroids are used in different combinations over long periods. Psychological help through trained workers are a great help. Scars and grafts cannot have the normal thermo-static function of skin, with its control of evaporative and lubricating mechanism, and may be responsible for causing these symptoms. This is an area where little experimental work has been done.
- Problems of reconstruction: There is really no end to the amount of reconstructive or aesthetic surgery that one can do to a severely burnt but healed patient. The surgeon has an important role to play here. He must indicate to the patient that though dramatic improvements can occur functionally after release of major contractures there are severe limitations to surgery when it comes to improving appearances. Even in contractures which have been released bridlemarks are not uncommon. Contractures might recur and the overall appearance can never approach that of the normal. Small joints in the hand which are very difficult to splint in the acute phase invariably develop subcutaneous oedema and on the dorsum of the fingers where skin is quite thin, tendons too can suffer burns and the consequent scarring does not restrict itself to the skin but involves joint capsules, ligaments and delicate tendinous expansion which function with great intricacy during normal life. Skin cover alone cannot be the solution to this problem and, what is more, operating on deeper structures through skin grafts is difficult because proper planes are not available. Occasionally flaps might have to be performed for such areas but even then the delicate and intrinsic balance normally maintained by the small muscles of the hand is very difficult to restore. Judicious arthrodesis of some joints to achieve functional positions allowing for a firm grip and an opposable thumb then becomes the only remaining option.
- Release of contractures: When releasing major contractures timing is important. The joint should go through whatever motion is possible pre-operatively without force, the scars should be stable i.e. they should not be hyperaemic and preferably free of any ulceration. An established contracture of the skin across joints usually means that there is secondary contracture In deeper tissues such as fascia, tendons and even nerves and vessels. When releasing the skin contracture it is not only not necessary to divide and cut the deeper structures but it can be dangerous, particularly in the fingers where circulation might suffer. In a released contracture where there is a good take of graft this graft will usually stretch gradually with serial splinting and the secondarily contracted structures will follow suit. In the event that the skin is found not to stretch or grow over a period of time more skin can be added by another procedure to achieve the final result.
- Myositis ossificans: A troublesome but unusual complication of burns around joints, mostly in the upper extremities and commonest around the elbow, is heterotrophic calcification, also called myositis ossificans, not seen on x-rays in its early stages but later well formed bone becomes visible. Attention is drawn to this condition when there is no gross evidence of a contracture of skin around the joint yet the motion gets restricted and the joint is frequently painful. Even here, as in scars, a waiting period helps to let the bone mature and it might become possible to excise it as a block when it is hugging the bone with a clear plane underneath. In some cases of this condition the bone deposition appears piecemeal and in fragments in various layers, and it is almost impossible to excise satisfactorily.
- The burnt ear: The treatment of burnt ears needs considerable patience. The exposed cartilage will need to be trimmed frequently to allow granulation tissue to form which can then be grafted. The saved portion of the ear can then be incorporated in a reconstruction to make it appear as normal as possible. Unlike in a case of congenital microtia where the skin is normal, in cases of burns the scarred skin cannot be lifted with safety to create a pocket for the cartilage, and therefore recourse needs to be taken to place the cartilage on a newly created raw area and then cover it with a thin flap. The ear can then be lifted up from the mastoid region later. The temporal fascial flap is useful in this situation and unless deep burns have caused deep scarring in the temporal area as well. Excellent prosthesis are now available for severely burnt ears as well as the nose which are mounted on spectacles. In a badly burnt nose no flap is available which will mimic the normal nose after reconstruction. Nostril stenosis can be treated with skin grafts and tube splints or a nasolabial flap if that area is spared from the original burn injury.
- Treatment of burns of the eyelids: Unlike in the ear where temporizing allows healing with minimal loss of cartilage, in the case of eyelids aggression must be the rule in order to prevent ectropion and to prevent corneal ulceration.Grafting must begin very early and might need to be repeated. In order to prevent recontracture of grafted upper eyelids, to give rest to the part and also to protect the eye when the treatment is in progress, a lateral tarsorhaphy can be employed and can then be taken down at the appropriate time. A blind and an unsightly eye can be treated with contact lenses or with a prosthesis matching the opposite eye.
- Alopecia following burns is another area which affects the patient considerably. Small areas can be serially excised to bring hair-bearing skin together. Larger areas can be covered with flaps and the resultant skin grafts from the movement of the flaps are placed in such a manner that long hair can cover the area. Tissue expansion hopefully does not leave secondary defects and such expansion can be done in the proportion of one to two so as to cover large areas of alopecia. Scarred scalp is a poor recipient bed for free hair transplant. Excellent wigs are now available which are almost indistinguishable from the patients’ normal hair.
- With the advent of microvascular free flaps some contractures in the neck are treated with thin flaps (e.g. a lateral thigh flap) and have certainly reduced the incidence of re-contracture. In the neck, in the past local flaps such as the latisimus dorsii flap covered with a skin graft were tried but are not now preferred because of their bulk. Flaps are also used across joints when the burns are deep or when immobilization after burn release is cumbersome for example in the axilla.