Additional Management Pearls for Different Regions

13.5.1 Scalp

■ Tissue expanders sometimes of use here because of:

- Inherent convex surface

- Relatively unyielding deep surface

- Rich vascular supply

13.5.2 Face

■ Klein and others propose decision-making at around day 10 to select areas that are not likely to heal within 3 weeks of injury to undergo excision and grafting (Fig. 13.4; J Burn Care Rehabil 2005)

■ Other commonly prescribed treatment like devices to prevent micro-stomia via stretching and wearing of facial masks, usually starting at 2 weeks postoperatively (Serghiou et al., J Burn Care Rehabil 2004)

13.5.3 Neck

■ The usual methods used in contracture prevention like pressure, stretching, splinting and surgery can be used to tackle troublesome scarring

■ Use of collars can be an adjunct in managing torticollis associated with neck burns (J Burn Care Rehabil 2003)

■ Position of the neck should either be in neutral or slight extension

Fig. 13.4. Facial burns are not uncommonly associated with respiratory embarrassment as well as microstomia

13.5.4 Axilla

■ Normal individuals have relatively thin skin in the axillary region

■ Although reports of flap usage are sometimes reported in plastic surgery journals, try to avoid flaps in this area

■ Whenever possible, use skin grafting, followed by postoperative splintage in abduction for adequate periods

13.5.5 Back

■ The skin of the back of humans is very thick

■ Seldom do we see really deep burns on the back

■ In most cases skin grafting suffices

■ An occasional patient may be considered for tissue expanders

13.5.6 Hand

■ Burns involving the hand commonly cause deformity due to the superficial locations of the tendons. Examples include claw-hand, mallet finger and boutonnière deformities

■ The principle of managing these burns includes early excision and grafting, ROM exercise, splinting, pressure garments and reconstruction (Burns 1998). In addition, adjunctive use of axial Kirschner wires to maintain functional joint positioning like 70-90° metacarpophalangeal joint flexion and proximal interphalangeal joint extension (J Trauma 1995)

13.5.6.1 Useful Tools for Assessing the Burnt Hand

■ ROM: many researchers prefer to document the "total active motion", besides noting the motion of individual hand joints

■ Jebsen Hand Function test: useful tool to predict hand function after burn injuries (Van Zuijlen et al., Burns 1999)

■ Michigan Hand Outcome Questionnaire (Umraw et al., J Burn Care Rehabil 2004)

13.5.6.2 Challenging Scenario: Post-Burn Thumb Deformity with Loss of Prehension

■ Reconstruction of thumbs so affected can be carried out by advancement and transferral of the second ray remnant onto the remaining metacarpal stump of the proximal thumb

■ This technique combines the advantages of thumb lengthening and pollicisation procedures in a single operation and has been a useful method of restoration of single hand prehension in the severely burned hand (May et al., J Hand Surg 1984)

13.5.7 Lower Limb

■ One of the major goals here is to aim at management options that allow the patient early weight-bearing, as recommended by workers like Burnsworth (J Burn Care Rehabil 1992) and Grube (J Trauma 1992)

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