By X. Knut. Vaughn College of Aeronautics.
Treatment ofLarge Superficial Partial-Thickness Burns ( 30% TBSA) Homograft These are uncommon injuries that can lead to a high morbidity and mortality rate raloxifene 60 mg on line xymogen menopause. They are more prone to contamination and infection than medium-sized superficial burns discount 60mg raloxifene with mastercard zyrtec menstrual cycle, large amounts of fluid resuscitation are necessary, and intense swelling often occurs. Cardiogenic and noncardiogenic pulmonary edema are complications that carry a high risk of mortality in patients with these injuries. Superficial Burns 183 Best results are achieved if homograft is applied within 24 h of the injury. Under general anesthesia the wound is cleaned and all blisters and nonadherent epidermis removed. It is not uncommon to observe mixed areas of superficial and indeterminate depth in these large injuries. Areas of indeterminate depth are shaved superficially with the Zimmer or Padget powered dermatome with depth settings of 8–10/1000 inch. Cryopreserved or fresh homograft split-skin grafts are placed over the open dermal wound and secured with staples. If homografts are meshed, it is important not to open the mesh on the homograft: this can lead to desiccation, infection, and deepening of the underlying wound. Wounds are inspected at 48–72 h unless the condition of the patient dictates otherwise. When homografts are stable, the wound can be left open with petroleum jelly gauze covering to prevent desiccation or a light dressing applied (Fig. As the healing process progresses, homografts separate after leaving a completely re-epithelialized wound. When homografts are stable, patients can be gently showered or bathed; all areas that start to separate can be trimmed. Big dressing changes are not necessary, and pain control is easily achieved. Alternative temporary skin substitutes Biobrane can be used in the same way as for smaller injuries. There is a higher rate of wound infection, which can lead to loss of the Biobrane and deepening of the burn wound. Given the large surface area covered with Biobrane, if purulent collections develop under the synthetic membrane, patients can experience severe sepsis and septic shock. Therefore, we do not advise treatment of large areas with Biobrane unless human cadaver skin is not available. If Biobrane is chosen, daily inspection is absolutely necessary, with aggressive intervention and trim- ming of all nonadherent areas should the patients become unwell and septic. TransCyte can be used in a similar manner to Biobrane, and, as with medium size superficial burns, it is particularly helpful in neonates and small infants. Such skin does not adhere as well, and desiccation can lead to infection and deepening of the burn wound, requiring formal excision and autografting. It is our belief that homografts provide the best treatment for these injuries, because the grafts are viable and protect the healing wound by creating a permanent moist environment with the benefit of growth factors produced by dermal fibroblasts. Topical Antimicrobial Creams The traditional method of treatment for massive superficial partial-thickness burns has been for many decades the application of topical antimicrobials daily. Among them, 1% silver sulfadiazine has been the gold standard for many years. Patients require daily dressing changes, which are such a painful ordeal for patients that 184 Barret and Dziewulski A B FIGURE 12 Treatment of massive superficial partial-thickness burns with superfi- cial debridement and homograft application leads to a perfect outcome. Homograft skin does not vascularize, allowing re-epithelialization underneath. Silver sulfadiazine has been the traditional treatment for partial- thickness burns. It requires daily dressing changes, which create significant stress and procedural pain. It produces good outcomes is an ordeal to the patient and required hospital stay is significantly longer than with skin substitutes. Management of patients using topical antimicrobials can be much more difficult than with homograft application, but it is an ordeal for the patient and the hospital stay is much longer.
This type of flap is contraindicated when the Allen test shows insufficient vascular supply from the cubital system and the posterior interosseous of the hand [26 buy 60 mg raloxifene free shipping menopause panic attacks,47] or when the skin of the donor region of the forearm has been burned purchase raloxifene 60mg fast delivery women's health center kansas city. We do not reconstruct the radial artery after extracting the flap, and we have not observed any case of poor perfusion of the hand of the donor extremity. In occasional cases, scarring of the flap donor area is delayed, with partial losses of the cutaneous graft; it is usually sufficient to administer topical treatment alone to promote wound closure. For a detailed description of the anatomy and steps of operation for extraction of this flap and those to follow, we refer the reader to the text on microsurgery by Dr. In Figure 6, we present an example of the use of the free radial fasciocutaneous flap for coverage using a single surgical procedure of a deep burn on the palm of the hand. The functional results in the long term were excellent, with stable and sensitive coverage. Of the free muscular flaps, the free flap of the anterior serratus muscle, described simultaneously in 1982 by Buncke and by Takayanagi, provides great plasticity and a constant vascular pedicle of good size and length. When covered with a cutaneous graft, stable and long-lasting coverage is achieved. We use the last three muscular digitations for coverage of hand burn injuries that are not very extensive and that require coverage with high vascular density per gram of tissue supplied. They are especially indicated for coverage of high-voltage electrical burn wounds of the wrist, which may sometimes be corrected in associa- tion with nerve grafts in the same procedure (Fig. We emphasize the technical difficulties we often encounter when dissecting out the vascular pedicle from the bifurcation of the branch of the serratus and its entrance into the digitations we are going to transfer. A B FIGURE 6 Free radial flap for coverage of a hand with a full-thickness burn from contact with a hot solid. There are osseous lesions at the second metacarpal bone and affecting the palmar arch. Excellent functional results: stable and sensitive coverage 2 years after the accident following only one surgical procedure (A, B). A segment of the median nerve has been excised, and a sural nerve graft placed. To cover large burn injuries of the upper extremity, we use a free flap of the latissimus dorsi muscle covered by a cutaneous graft. Described by Maxwell in 1978, this flap is still in common use today due to its versatility, accessibility, and ability to provide filling and coverage for large injuries. The vascular system of the donor area is also from the subscapular–thoracodorsal artery (Fig. The free temporal fascia flap, first described by Smith in 1979, is based on the axis of the superficial temporal arteries and veins and allows coverage of burn injuries on the dorsal surface of the digits and hand. It provides well-vascu- larized coverage that is extremely thin and flexible and leaves a barely visible cosmetic defect on the scalp. The transferred temporal fascia, which easily allows a partial-thickness cutaneous graft, permits sliding of the deep structures of the digits and hand. A second surgical procedure is occasionally necessary to separate the syndactylized digits (Fig. OTHER PROCEDURES Placing the affected extremity in an elevated position, avoiding articular con- tractures with proper splinting, and limiting movement with proper therapy are crucial for the prevention of hand burn sequelae. In our opinion, it is essential The Hand 275 FIGURE 8 Free flap of the latissimus dorsi muscle for reconstruction of a large injury on the volar surface of the forearmfroma high-voltage electrical burn. Only a multidisciplinary group effort will be able to prevent the occurrence of sequelae and the need for secondary reconstruction of the hands of these patients. The ideal position for the burned hand depends on the location and depth of the burns. With dorsal and/or circumferential burns, the correct position is in the intrinsic plus (metacarpophalangeal [MCP] joints 50–70 degrees of flexion, interphalangeal [IP] joints in extension), with the thumb in opposition and ab- ducted. With deep burns of the palm of the hand, it is preferable to place the MCP and IP joints in extension, with the thumb and all the other digits in abduction. Prevention of hypertrophic scarring requires a correct initial diagnosis that makes possible coverage of the burned hands as soon as possible: within 2 or 3 weeks at the most.