Lecture 10_2023 Burns & Wound Management, Scar Management, and Amputation PDF

PHT2012 Orthopaedics, Traumatology & Rheumatology Lecture 7 Burns and wound management. Scar management. Amputation Contents of this lecture are intended for use by BSc (Hons) students of TWC only Dr Anthony Kwok, PhD, FHKHSE, FCHSM, FAIHS, RPT Associate Professor/Clinical Co-ordinator (Physiother...

PHT2012 Orthopaedics, Traumatology & Rheumatology Lecture 7 Burns and wound management. Scar management. Amputation Contents of this lecture are intended for use by BSc (Hons) students of TWC only Dr Anthony Kwok, PhD, FHKHSE, FCHSM, FAIHS, RPT Associate Professor/Clinical Co-ordinator (Physiotherapy) School of Medical and Health Sciences 1 Read as an adjunct: Apley & Solomon’s System of Orthopeadics & Trauma: • Chapter 22 (Page 681, 691 - 697) • Chapter 23 (page 730 – 731) • Chapter 27 (Page 827, 829 – 830) • Chapter 32 (page 953) • Chapter 12 (page 340 – 342) Burn An injury to skin, or other tissues, caused by heat, cold, electricity, chemicals, friction, or radiation. Burn: Dry heat & flame Scald: wet heat from boiling water or steam. Others: friction, electrical, chemicals and radiation (e.g. sun burn). • Women are commonly injured in the developing countries due to the risk relating to use of open cooking fires/unsafe cook stoves. • Men are commonly injured in the developed countries due to risk relating to the work environments. • Alcoholism and smoking (fall asleep while smoking cigarettes) are other risk factors. • Burns can also occur as a result of self-harm or violence between people. • Smoke inhalation may happen at the same time at burn and could be fatal . • First-degree burn (superficial burn): Burns affect only the superficial skin layers: appear red without blisters and pain typically lasts around 3 days. • Second-degree burn (partial-thickness burn): Burns extends into some of the underlying skin layer: Blisters are frequently present and they are often very painful. Healing can require up to 8/52 and scarring may occur. • Third-degree burn (full-thickness burn): Burns extends to all layers of the skin: no pain and the burnt area is stiff. Healing typically does not occur on its own. Note: (Some classification): Fourth-degree burn (mainly used in USA where more heavy industry manufacturers and foundries to denote deeper burn than the Third-degree): Burns involves injury to deeper tissues, such as muscle, tendons, or bone: The burn is often black and frequently leads to loss of the burned part. Smoke inhalation • Occurs when a fire victim breathe in harmful smoke particles and gases that the inhaling harmful smoke inflames his/her lungs and airway, causing the air passage to swell and block oxygen: may lead to acute respiratory distress syndrome and respiratory failure. • Can be fatal. • Commonly happens when a fire victim get trapped in a contained area, such as a kitchen or home, near a fire. YMT Fire caused 8 death on 15/11/2020: Smoking Inhalation, Suffocation, Toxic gases…. Burn Epidemiology Actual number fires in HK: • 38,112 in 2016, • 33,934 in 2017, • 33,463 fires in 2018 Worldwide: • In 2015 fire and heat resulted in 67 million injuries (resulted in about 2.9 million hospitalizations and 238,000 dying; down from 300,000 deaths in 1990) and is the 4th leading cause of injuries after motor vehicle collisions, falls, and violence. • About 90% of burns occur in the developing world (attributing factors: overcrowding & an unsafe cooking situation). • Females 2x risk > Males (due to frequent accidents in the kitchen or domestic violence). • 60% of fatal burns occurred in Southeast Asia (rate of 11.6 per 100,000). • Number of fatal burns: changed from 280,000 in 1990 to 176,000 in 2015. • In the developed world: adult males have 2x the mortality as females from burns (due to their higher risk occupations and greater risk-taking activities). • In children: deaths from burns occur at > 10x the rate in the developing than the developed world. Children is one of the top 15 leading causes of death. • 1980s to 2004: a decrease in the rates of fatal burns and in burns in many countries. Fire types analysis: • dry heat/fire or flame (44%), • wet heat/scalds (33%), • hot objects (9%), • electricity (4%), and • chemicals (3%). Common Locations of Fires: • 69% burn injuries (home or at work); • 9% are accidental; • 2% due to assault; • 1–2% resulting from a suicide attempt; • 6% caused by the inhalation injury to the airway and/or lungs. • Occur commonly among the poor, and fire-related burns are more in colder climates. • Risk factors in the developing world: cooking with open fires/on the floor + developmental disabilities in children and chronic diseases in adults. Classification of Burns: 1. Thermal burn: 65% of all burns: contact with hot objects (cause of 20–30% of burns in children), fireworks (common cause of burns during holiday seasons in adolescent males). 2. Chemical burn: 2 -11% of all burns and contribute to 30% of burn-related deaths: caused by strong base (55%) or a strong acid (26%). Most chemical burn deaths are secondary to ingestion. Common causative agents: Sulfuric acid (H2SO4) in toilet cleaners, sodium hypochlorite (NaClO) in bleach, and halogenated hydrocarbons (such as Chlorofluorocarbons, CFCs) in MTR stations for emergency fire extinguishing. Hydrofluoric acid can cause deep burns that may not become symptomatic until some time after exposure. Formic acid may cause the breakdown of significant numbers of RBCs. 3. Electrical burn: high voltage (> 1000 volts), low voltage (< 1000 volts), or as flash burns secondary to an electric arc. Electrical burns in children are electrical cords (60%) followed by electrical outlets (14%). Lightning resulted in electrical burns in outdoor activities, mountain climbing, golf & field sports, water sports (canoeing & wind surfing) and working outside (in the air field, fishing malls, etc.). Mortality from a lightning strike is about 10%. Electrical injuries may also cause # or dislocations secondary to blunt force trauma or muscle contractions. In high voltage injuries, internal organ damage may be occurred leading to fatal result (the extent of the injury cannot be judged by examination of the skin alone). Contact with either low voltage or high voltage may produce cardiac arrhythmias or cardiac arrest. 4. Radiation burn (exposure to ultraviolet light from the sun, tanning booths or arc welding) or from ionizing radiation (e.g. radiation therapy, Xrays or radioactive fallout). Sunburn: a radiation burns of superficial thickness (variation bases on their skin type). Skin effects from ionizing radiation depend on the amount of exposure to the area, with hair loss seen after 3 Gy (Gray Unit), redness seen after 10 Gy, wet skin peeling after 20 Gy, and necrosis after 30 Gy. Radiation burns are treated the same as other burns. 5. Microwave burns: via thermal heating from the steam (2 seconds exposure may result in burns). 6. Non-accidental reasons: 3–10% are from assault including child abuse, personal disputes, spousal abuse, elder abuse, and business disputes. Recognition of a child abuse: an extremity/the buttocks are held under the surface of hot water : a sharp and symmetrical "sock burns", "glove burns", "zebra stripes“, deliberate cigarette burns on the face/back of the hands & feet, circumferential burns, the absence of splash marks, a burn of uniform depth, and association with other signs of neglect or abuse. 7. Bride burning: a form of domestic violence in some cultures in India; acid burns in Pakistan. 8. Self-immolation (setting oneself on fire) is also used as a form of protest in various parts of the world (especially during the Anti-Vietnam War period in 70s). Pathophysiology of Burn: Predominantly 3 degrees of burns At temperatures > 44 °C, proteins begin losing their three-dimensional shape and start breaking down → results in cell and tissue damage. Many effects of a burn are secondary to disruption in the normal functioning of the skin including: • disruption of the skin's sensation, • ability to prevent water loss through evaporation, and • ability to control body temperature. • Disruption of cell membranes causes cells to lose K+ to the spaces outside the cell and to take up water and Na+. Burn wound healing: pathophysiology and injury management In burns > 30% of the total body surface area: significant inflammatory response → results in increased leakage of fluid from the capillaries, and subsequent tissue edema: this causes overall blood volume loss, with the remaining blood suffering significant plasma loss, making the blood more concentrated. Poor blood flow to organs such as the kidneys and GI tract may result in renal failure + stomach ulcers. Increased levels of catecholamines and cortisol can cause a hypermetabolic state that can last for years → associated with increased cardiac output, metabolism, a fast heart rate, & poor immune function. Type Layers involved Appearance Sensation Healing Time Prognosis Epidermis Redness in the skin. No blisters Painful 5–10 days Heals well. Repeated sunburns increase the risk of skin cancer later in life. Superficial partial thickness (second-degree) Extends into superficial dermis Redness + blister. Blanches with pressure. Very painful 2–3 weeks Local infection (cellulitis) but no scarring typically Deep partial thickness (second-degree) Extends into deep dermis Yellow or white. Less blanching. Bistering Pressure and discomfort 3–8 weeks Scarring, contractures ( require excision and skin grafting) Full thickness (third-degree) Extends through entire dermis Stiff and white/brown. No blanching. Painless Prolonged (months) and incomplete Scarring, contractures, amputation (early excision recommended) Fourth-degree Extends through entire skin, and into underlying fat, muscle and bone Black; charred with eschar Painless Requires excision Amputation, significant functional impairment and in some cases, death. Superficial (first-degree) Diagnosis: classified by depth, mechanism of injury, extent, and associated injuries. Classification of burn is based on the depth of injury. The depth of a burn is determined via examination +/- biopsy → difficult to accurately determine the depth of a burn on a single examination (may need repeated examinations over a few days to determine). If headache/dizzy present in a fire-related burn: may suspect carbon monoxide poisoning +/cyanide poisoning. Size: to determine Burn severity: assess a percentage of Total Body Surface Area (TBSA) affected by partial thickness or full thickness burns. • First-degree burns: only red in color and no blister. • 70% of burns involve less than 10% of the TBSA. Assessment Methods: Wallace rule of nines, Lund and Browder chart, and estimations based on a person's palm size. Assessment of Burn Size: Rules of Nine • The rule of nines: only accurate in people over 16 years of age. • Lund and Browder charts: The size of a person's handprint (including the palm and fingers) is approximately 1% of their TBSA. • To determine the need for referral: assessed based on a number of factors including TBSA affected, the involvement of specific anatomical zones, the age of the person, and associated injuries. • Moderate burns are managed in hospital, and major burns are managed by a burn center. • Mixed degree burn is common (1st + 2nd + 3rd). • Prone to develop contracture after a burn, and causing lost of function affect an individual’s ADL. American Burn Association severity classification Minor Moderate Major Adult <10% TBSA Adult 10–20% TBSA Adult >20% TBSA Young or old < 5% TBSA Young or old 5–10% TBSA Young or old >10% TBSA <2% full thickness burn 2–5% full thickness burn >5% full thickness burn High voltage injury High voltage burn Possible inhalation injury Known inhalation injury Circumferential burn Significant burn to face, joints, hands or feet Other health problems Associated injuries Prevention • 50% of all burns were deemed preventable, via education, regulations & code of practice. • Prevention programs decreased rates of serious burns: by limiting hot water temperatures, smoke alarms, sprinkler systems, proper construction of buildings, and fire-resistant clothing. e.g. 1. set water heaters below 48.8 °C (119.8 °F). 2. To prevent scalds: use a thermometer to measure bath water temperatures, 3. To install splash guards on stoves. 4. Limit the sale of fireworks to children. First Aid Management: DRABC + 3B + 3C • Burning Stopped • Breathing Maintained • Body examined • Cool • Cover • Carry General Management • If inhalation injury is suspected: O2 therapy +/- early intubation to maintain the airway open + patent. • Care of the burn wound: extensive burns may be wrapped in clean sheets until they arrive at a hospital. • Burn wounds are prone to infection: a tetanus booster shot (if not been immunized within the last 5 years). • Nutrition to major burns patient: early feeding (for conscious)/IV feeding (for unconscious) with increased protein intake + trace elements + vitamins. • Hyperbaric oxygenation: in addition to traditional treatments. • IV fluids: in patients with poor tissue perfusion + boluses of isotonic crystalloid solution. • Children > 10–20% TBSA burns, and adults > 15% TBSA burns: fluid resuscitation + monitoring (those with burns greater than 25% TBSA: begun treatment from prehospital state). • The Parkland formula determines the volume of IV fluids required over the first 24 hours (based on the affected individual's TBSA and weight): 50% is administered over the first 8/24 + remaining 50% over the following 16/24 (time is calculated from when the burn occurred, and not from the time that fluid resuscitation began). • Children require additional maintenance fluid that includes glucose (D5 or D10) . • Those with inhalation injuries require more fluid (inadequate fluid resuscitation may cause problems, and too much fluid may cause pulmonary edema). • The formulas give a guide for an ideal infusions tailored to a urinary output of >30 mL/h in adults or >1mL/kg in children + mean arterial pressure > 60 mmHg. • Lactated Ringer's solution or normal saline are used. (Note: crystalloid fluids appear just as good as colloid fluids). • Blood transfusions are only if the hemoglobin level < 60-80 g/L (6-8 g/dL). • IV catheters may be placed through burned skin if needed or intraosseous infusions may be used. Principles in Wound care in Burn victims • Early cooling (within 30 minutes of the burn) reduces burn depth and pain • Avoid over-cooling to cause hypothermia. • Performed with cool water 10–25 °C and not ice water as the latter can cause further injury. • Chemical burns may require extensive irrigation. • Cleaning with soap and water, removal of dead tissue, and application of dressings are important aspects of wound care. • If intact blisters are present (leaving them intact) • Second-degree burns should be reevaluated after 2 days. • Symptomatic + Supportive therapy • Superficial burns: usually without dressings +/- topical antibiotics. • Partial thickness burn: topical antibiotics + plastic bags to keep the skin moisture. • Some studies showed that silver sulfadiazine may prolong healing time. • Some doctor may use dressings containing silver or negative-pressure wound therapy. • Silver sulfadiazine does not appear to differ from silver containing foam dressings with respect to healing. • Clean partial thickness burn: DuoDERM • Contaminated wound: topical antibiotic +/- oral/IV antibiotics. • The use of steroid: unclear evidence. Burns are preventable! Burn Treatment varies depending on the severity: Superficial burns: simple pain medication. • Cooling with tap water may help pain and decrease damage & prolonged cooling may result in hypothermia (low body temperature, <35 degree Celsius). • Blisters: leave them intact if small and drain them if large. Major burns: require prolonged treatment in specialized burn centers. • Partial-thickness burns: require cleaning and wound dressings. • Full-thickness burns: require surgical treatments, e.g. skin grafting. • Extensive burns: require large amounts of intravenous fluid, due to capillary fluid leakage and tissue swelling. • Common complications: wound infection, septicemia, scar formation, renal failure, chest infection and limitation in mobility with reduced functional activities. • Tetanus toxoid should be given if not up to date. Medications: analgesics (e.g. ibuprofen and acetaminophen) and morphine for managing pain. Benzodiazepines may be used in addition to analgesics to help with anxiety. During the healing process: antihistamines, massage, or transcutaneous nerve stimulation to aid with itching (antihistamines are effective in 20% of people, use gabapentin if not improve with antihistamines). IV antibiotics before surgery for those with extensive burns (>60% TBSA) (improve survival rates in those with large and severe burns). (Note: prolonged use may increase antibiotic resistance and the increased risk of fungal infections). Erythropoietin usually not effective to prevent or treat anemia in burn cases. In burns caused by hydrofluoric acid, calcium gluconate is a specific antidote and may be used intravenously and/or topically. Recombinant human growth hormone (rhGH) in burns > 40% of their body appears to speed healing without affecting the risk of death. Surgery • Full thickness burns: surgical closure with skin grafts or flaps as early as possible. • Circumferential burns of the limbs or chest: need escharotomy (urgent surgical release of the skin) → to treat/prevent problems with distal circulation, or ventilation. • Fasciotomies may be required for electrical burns. • Skin grafts: skin substitute from human donor or pig skin or synthesized, to cover the wound as a dressing, preventing infection and fluid loss, but will eventually need to be removed except the human skin. Alternative medicine: Honey to aid wound healing of partial thickness burns. The evidence for aloe vera is of poor quality, but might be beneficial in reducing pain. Vitamin E: helps with keloids or scarring. Butter is not recommended. In low-income countries: burns are treated up to one-third of the time with traditional medicine, including applications of eggs, mud, leaves or cow dung. Surgical management is limited in some cases due to insufficient financial resources and availability (part of the Operation Concern to take care of burn cases in NE China from 1970s to 2000). Virtual reality therapy, hypnosis, and behavioral approaches such as distraction techniques helps to reduce pain and anxiety. Prognosis: worse in with larger burns, older, and females. • The presence of a smoke inhalation injury, long bone #, heart disease, diabetes, psychiatric illness, and suicidal intent influence prognosis. • Burn areas < 10% TBSA: mortality rate of < 1% • Burns over 90% TBSA: mortality rate of 85%. • The Baux score has been used to determine prognosis of major burns: determined by adding the size of the burn (% TBSA) to the age of the person, and taking that to be more or less equal to the risk of death. • No longer very accurate with improved care standards in burns. Prognosis in the USA TBSA Mortality 0–9% 0.6% 10–19% 2.9% 20–29% 8.6% 30–39% 16% 40–49% 25% 50–59% 37% 60–69% 43% 70–79% 57% 80–89% 73% 90–100% 85% Inhalation 23% Burn Complications: • Infections (Bacterial +/- fungal) • Pneumonia, cellulitis, urinary tract infections and respiratory failure. • Risk factors for infection: burns > 30% TBSA, full-thickness burns, extremes of age (young or old), or burns involving the legs or perineum. • Pneumonia occurs in those with inhalation injuries. • Anemia secondary to full thickness burns of >10% TBSA is common. • Electrical burns may lead to compartment syndrome or rhabdomyolysis due to muscle breakdown. • Blood clotting in the veins of the legs is estimated to occur in 6 to 25% of people. • The hypermetabolic state that may persist for years after a major burn can result in a decrease in bone density and a loss of muscle mass. • Keloids scars may form subsequent to a burn, particularly in those who are young and dark skinned, including Asians → cause significant psychological trauma + post-traumatic stress disorder especially in children + disturbance in body image + limiting ROM and limb functions. • Social isolation, extreme poverty and child abandonment. Cheng S1, Chan A, Fong S, Lam M, Leung A, Lee P, Tsang J, Wong J, Wu A. “Outcome Hong Kong: patients' satisfaction”, Burns. 1996 Dec;22(8):623-6. studies for burn patients in Introduction: With advances in burns treatment in Hong Kong, many more survive the burn to experience pain, scarring, physical deformity, loss of function and psychological trauma. Pressure therapy prescribed by OT > 20 years in HK proved its effectiveness in treating the visible scars. Rationale of study: The inconvenience and impaired appearance that is brought about by these garments during the long phase of therapy bears some weight in worsening patients' social acceptance and happiness in life, and their families especially in children. Objective of study: To measure the subjective rating of the effectiveness of pressure therapy through patients' satisfaction towards treatment effectiveness and its effect on daily life. Methodology: 70 burn cases with > 1 year previously were selected randomly among for the survey. The scale used was ordinal from 1 - 6. Eleven items concerning treatment effectiveness, life at home, work and leisure aspects were questioned. Results were analysed into two streams-satisfaction towards pressure therapy and change of life satisfaction pre- and post-injury. Analysis: Non-parametric tests were used for data analysis, using the Wilcoxon Sign Rank Test and Cluster analysis, major determinants were identified. Association and correlation were done with the demographic data. Conclusion: OT programmes for burn patients to reintegrate the patient into normal living + scars management with pressure garment: 1. To turn pressure garments into ‘pleasure garments’ by exploring different garment properties, their relation to patients changes of daily routine and their acceptance. 2. To expand the scope of services for individual needs, e.g. using the life-satisfaction checklist for burn patients as part of a routine assessment. 3. Develop work rehabilitation for burn patients. 4. Involve team support, especially from a social worker or clinical psychologist in handling family and sexual problems. 5. More help is needed for patients with low educational level since they correlated most strongly with financial difficulties. 6. Continue to educate patients on burns outcomes and how pressure therapy or other treatment modalities can help and gain their maximum compliance for therapy. Eschar formation • An eschar is a slough or piece of dead tissue that is cast off from the surface of the skin, particularly after a burn injury, but also seen in gangrene, ulcer, fungal infections, necrotizing spider bite wounds, tick bites associated with spotted fevers, and exposure to cutaneous anthrax. • An eschar contains necrotic tissue. • Eschar is also called a black wound because the wound is covered with thick, dry, black necrotic tissue. • Eschar may be allowed to slough off naturally, or it may require surgical removal (debridement) to prevent infection, especially in immunocompromised patients (e.g. if a skin graft is to be conducted). • If eschar is on a limb, it is important to assess peripheral pulses of the affected limb to make sure blood and lymphatic circulation is not compromised. • If circulation is compromised, an escharotomy, or surgical incision through the eschar, may be indicated. Scars Active scars may be red, firm, thick, or raised and can feel sensitive or even limit motion and function. The eventual appearance of the scar is dependent on multiple factors including the cause of the wound, the wound size and depth, the part of the body that was wounded, and the wound care received. Types of scars: 1. Cicatrix: Appearance is flat or slightly raised with a pink or reddish color, although it may also be paler or darker than surrounding skin. It may feel itchy or painful. Proper wound care increases the chances that the scar will become flat rather than raised. 2. Hypertrophic: Appearance is raised and firm, and it may feel painful or restrict movement. These scars most frequently form from wounds sustained on the chest, upper back, or shoulder, although they can appear anywhere on the body. 3. Keloid: These scars are raised and grow to be larger than the wound that caused the scar. They can appear up to a year after an injury was sustained and can be itchy or painful. 4. Contracture: Scars that form when the scar tissue is tighter and thicker than the surrounding skin. They can restrict movement, particularly if the scar is near a major joint, such as a knee. Keloidal scar • Formation of scar depends on its maturity, and its composition: type III (early) or type I (late) collagen, i.e. an overgrowth of granulation tissue (collagen type 3) at the site of a healed skin injury which is then slowly replaced by collagen type 1. • Keloids are firm, rubbery lesions or shiny, fibrous nodules, and can vary from pink to the color of the person's skin or red to dark brown in color. • A keloid scar is benign and not contagious, accompanied by severe itchiness, pain, and changes in texture. In severe cases, it can affect movement of skin. • Keloid scars are seen 15 times more frequently in people of sub-Saharan African descent than in people of European descent. • Keloids should not be confused with hypertrophic scars (e.g. after healing from an incised wound), which are raised scars that do not grow beyond the boundaries of the original wound. Scar Management • Scar formation is part of the last phase of wound healing, the maturation or remodeling phase. This phase can last from 21 days to two years, and it occurs only in full-thickness wounds (e.g. in a burn). • Cellular activities include collagen remodeling, capillary regression, and increasing tensile strength. • Scar formation involves collagen cross-linking and replacement of the disorganized type III collagen by organized type I collagen. • Other clinical observations include continued contraction, shrinking, thinning, and paling of the scar. It results in the restoration of normal dermal composition and an increase in the tensile strength of the wound over time to a maximum of 80% of the original tensile strength, 50% of which is restored by six weeks. • Wound care has a direct impact on how your skin heals. With adequate wound care, it is possible to minimize scarring and in some cases even prevent a scar entirely. Risk Factors • • • • • • • • Genetic variations that may be associated with scar formation Age Bacterial colonization Tension on the wound (scars often develop on body areas with high skin tension) Systemic inflammation, which can increase the risk of developing hypertrophic scars or keloids Hypertension (associated with increased keloid severity). The presence of skin diseases(e.g. epidermolysis bullosa) makes skin extremely fragile and results in blistering that forms scars upon healing, or hidradenitis suppurativa (causes deep wounds in the skin). The extent to which scarring occurs can largely, although not entirely, be controlled by treatment. Interventions and Treatment • Pressure therapy/pressure garment: applying pressure with a pressure dressing to a wound while it is healing to reduce a scar or prevent a keloid from forming or returning. • Silicone gel, sheet, or ointment: are applied after a wound closes and can be used for several months to reduce the scar’s size, hardness, redness, itching, or stiffness. They can also prevent a scar from becoming raised. • Polyurethane dressing: These dressings are moist and flexible and can be worn to reduce scarring or reduce the color, hardness, and size of a raised scar. • Lasers or other light treatment: are becoming increasingly common because they can prevent raised scars and keloids, reduce the appearance of a scar, decrease scarring after surgery, lessen the color, and reduce the pain, hardness, itch, and swelling of a scar. • Corticosteroid, 5-fluorouracil, or bleomycin injections: are administered directly into the scar to reduce the size of it and ease itchiness and pain, although they generally require multiple treatments. • Cryosurgery: freezes the scar to destroy scar tissue, which reduces the size, pain, itchiness, hardness, and discoloration of the scar. • Scar surgery: surgically to reduce the size of a keloid or increase mobility if the scar is limiting it. • Radiation: reduce raised scars and ease some of the itchiness and discomfort. • Other treatments: onion extract, vitamin A, and vitamin E (their efficacy is limited). Skin Graft/Skin transplant • A type of graft surgery to transplant the skin. The transplanted tissue is called a skin graft. Use to treat: • Extensive wound / trauma • Burns • Areas of extensive skin loss due to infection (e.g. necrotizing fasciitis or purpura fulminans). • For healing to occur, e.g. after removal of skin cancers • After serious injuries when some of the body's skin is damaged. • Follow a surgical excision or debridement of the damaged skin . Serves 2 purposes: 1. Reduce the course of treatment needed (and time in the hospital), and 2. Improve the function and appearance of the area of the body which receives the skin graft. 2 types of skin grafts: i). Partial thickness skin graft: a thin layer is removed from a healthy part of the body (the donor section) like peeling a potato. ii). Full thickness skin graft: involves pinching and cutting skin away from the donor section. More risky in terms of the body accepting the skin, yet it leaves only a scar line on the donor section, similar to a Cesarean section scar. The donor section will often heal much more quickly than the injury, and is less painful than a partial thickness skin graft. Classification by types • Autologous: The donor skin is taken from a different site on the same individual's body (autograft). • Isogeneic: The donor and recipient individuals are genetically identical (e.g., monozygotic twins, animals of a single inbred strain; isograft or syngraft). • Allogeneic: The donor and recipient are of the same species (human→human, dog→dog; allograft). • Xenogeneic: The donor and recipient are of different species (e.g., bovine cartilage; pig skin; xenograft or heterograft). • Prosthetic: Lost tissue is replaced with synthetic materials such as metal, plastic, or ceramic (prosthetic implants). • Allografts, xenografts, and prosthetic grafts are usually used as temporary skin substitutes, that is a wound dressing for preventing infection and fluid loss. They will eventually need to be removed as the body starts to reject it. • Autologous grafts and some forms of treated allografts can be left on permanently without rejection. • Genetically modified pigs can produce allograft-equivalent skin material, and tilapia skin is used as an experimental cheap xenograft in places where porcine skin is unavailable and in veterinary medicine. Classification by thickness: i) A split-thickness skin graft (STSG) is a skin graft including the epidermis and part of the dermis. Its thickness depends on the donor site and the needs of the person receiving the graft. It can be processed through a skin mesher which makes apertures onto the graft, allowing it to expand up to 9 times its size. Frequently used as they can cover large areas and the rate of auto-rejection is low. The same site can be harvested again after 6 weeks. The donor site heals by re-epithelialisation from the dermis and surrounding skin and requires dressings. ii). A full-thickness skin graft consists of the epidermis and the entire thickness of the dermis. The donor site is either sutured closed directly or covered by a split-thickness skin graft. iii). A composite graft is a small graft containing skin and underlying cartilage or other tissue. Donor sites include, for example, ear skin and cartilage to reconstruct nasal alar rim defects. Donor selection • Heterografts or xenografts: when grafts are taken from other animals: they are temporary biologic dressings which the body will reject within days to a few weeks; useful in reducing the bacterial concentration of an open wound, and reducing fluid loss. • A full-thickness skin graft for more extensive tissue loss. Often performed for defects of the face and hand where contraction of the graft should be minimized. The thicker the graft, the less the contraction and deformity. • Cell cultured epithelial autograft (CEA) procedures take skin cells from the person needing the graft to grow new skin cells in sheets in a laboratory. These sheets are very thin (only a few cell layers thick) they do not stand up to trauma, and the "take" is often < 100%. • To remove the thin and well preserved skin slices and strips from the donor, surgeons use a special surgical instrument called a dermatome (produces a split-thickness skin graft that contains the epidermis with only a portion of the dermis). The dermis left behind at the donor site contains hair follicles and sebaceous glands, both of which contain epidermal cells which gradually proliferate out to form a new layer of epidermis. The donor site may be extremely painful and vulnerable to infection. • To treat donor site pain: subcutaneous anesthetic agents, topical anesthetic agents, and certain types of wound dressings. • The graft is carefully spread on the bare area to be covered, and is held in place by a few small stitches or surgical staples. The graft is initially nourished by plasmatic imbibition in which the graft "drinks plasma". New blood vessels begin growing from the recipient area into the transplanted skin within 36 hours in a process called capillary inosculation. • To prevent the accumulation of fluid under the graft which can prevent its attachment and revascularization, the graft is frequently meshed by making lengthwise rows of short, interrupted cuts, each a few millimeters long, with each row offset by half a cut length like bricks in a wall. • This allows the graft to both stretch + cover a larger area + to more closely approximate the contours of the recipient area. • Results in a rather pebbled appearance upon healing that may ultimately look less aesthetically pleasing. • To aid both pre-operative wound maintenance and post-operative graft healing, the negative pressure wound therapy (NPWT) is by placing a section of foam cut to size over the wound, then laying a perforated tube onto the foam. • The arrangement is then secured with bandages. • A vacuum unit then creates –ve pressure, sealing the edges of the wound to the foam, and drawing out excess blood and fluids. • This process helps to maintain cleanliness in the graft site, promotes the development of new blood vessels, and increases the chances of the graft successfully taking. NPWT can also be used between debridement and graft operations to assist an infected wound in remaining clean for a period of time before new skin is applied. • Skin grafting can also be seen as a skin transplant. Risks for the skin graft surgery are: • Bleeding • Infection • Loss of grafted skin • Nerve damage • Graft-versus-host disease • Rejection may occur in xenografts. To prevent this, the person receiving the graft usually must be treated with long-term immunosuppressant drugs. Prognosis • Most skin grafts are successful, but in some cases grafts do not heal well and may require repeat grafting. The graft should also be monitored for good circulation. • Recovery time from skin grafting can be long. • Graft recipients wear compression garments for several months and are at risk for depression and anxiety consequent to longterm pain and loss of function. Wound Management The basic principles for the management of a wound or laceration are: • Haemostasis • Cleaning the wound • Analgesia • Skin closure • Dressing and follow-up advice • Personal protection when assessing a wound: gloves, apron or gown, and goggles/visors 1. Haemostasis is the process that causes bleeding to stop. In most wounds, haemostasis will be spontaneous. In cases of significant injury or laceration of vessels, steps include direct pressure, elevation, tourniquet, or suturing. 2. Wound cleaning is important for reducing infection and promoting healing. 5 aspects of wound cleaning: i). Disinfect the skin around the wound with antiseptic ii). Avoid getting alcohol or detergents inside the wound iii). Decontaminate the wound by manually removing any foreign bodies iv). Debride any devitalised tissue where possible v). Irrigate the wound with saline If no obvious contamination present: low pressure irrigation is sufficient* (pouring normal saline from a sterile container into the wound) Antibiotics for high-risk wounds or signs of infection (follow local antibiotic guidelines) Risk factors for wound infection: foreign body present or heavily soiled wounds, bites (including human), puncture wounds, and open #. *If the wound is clearly contaminated, it must be irrigated at high pressure to remove any visible debris present 3. Analgesia: allow for a humane and easier closure of the wound. Infiltration with a local anaesthetic (e.g. lidocaine) is the most common form of analgesia used + systemic analgesia (e.g. paracetamol) used as an adjunct. • The maximum level of lidocaine is 3mg/kg and the addition of adrenaline allows for up to 7mg/kg (a 1% solution equates to 10mg/ml). Remember to not use adrenaline with local anaesthetic if administering in or near appendages (e.g. a finger) 4. Skin Closure: the edges of the wound can be manually opposed. 4 main methods: • Skin adhesive strips (e.g. Steri-StripsTM) are suitable if no risk factors for infection are present • Tissue adhesive glue (e.g. Indermil®) can be used for small lacerations with easily opposable edges (a popular choice in paediatrics) • Sutures are typically used for any laceration greater than 5cm, deep dermal wounds, or in locations that are prone to flexion, tension, or wetting • Staples can be used for some scalp wounds Dressing the Wound and Follow-Up • Correct dressing of the wound will reduce infection and contamination. • When applying a wound dressing to a non-infected laceration, the first layer should be non-adherent (such as a saline-soaked gauze), followed by an absorbent material to attract any wound exudate, and finally soft gauze tape to secure the dressing in place. • Tetanus prophylaxis is required for any individual not up to date with (or unsure of) their tetanus immunisation status. Following initial wound management, advise patients to: • Seek medical attention for any signs of infection • Take simple analgesia (e.g. paracetamol) • Keep the wound dry as much as possible, even if wearing a waterproof dressing • Any sutures or adhesive strips should be removed 10-14 days after initial would closure (or 3-5 days if on the head); tissue adhesive glue will naturally slough off after 1-2 weeks. Remove dressings at the same time as the sutures or adhesive strips. Wound Management: Foot ulcer, DM Foot Amputation • Amputation is the removal of a limb surgically, with aim to control pain or a disease process, such as malignancy or gangrene, in trauma, medical illness, or surgery cases. • May preform sometimes as a preventative surgery for such problems. • Congenital amputation: in cases fetal limbs have been cut off by constrictive bands. • The amputated person is called an amputee. • Majority of new amputations occur due to complications of the vascular system (the blood vessels), especially from diabetes; or from RTA, trauma, war injuries. Stump length for prosthesis consideration Above Knee (common: 12 cm above Knee joint) Below Knee: (common: 14 cm from Knee Joint) Below Elbow: (Common 18 cm from Elbow joint) Above Elbow: (common 20 cm from the Shoulder joint) Types of amputations in leg include: • partial foot amputation: amputation of the lower limb (LL) distal to the ankle joint • ankle disarticulation: amputation of the LL at the ankle joint • trans-tibial amputation: amputation of the LL between the knee joint and the ankle joint: also called below-knee amputation • knee disarticulation: amputation of the LL at the knee joint • trans-femoral amputation: amputation of the lower limb between the hip joint and the knee joint: above-knee amputation • hip disarticulation: amputation of the lower limb at the hip joint • trans-pelvic disarticulation: amputation of the whole LL + all/part of the pelvis: hemipelvectomy/hindquarter amputation Types of upper extremity amputations include • partial hand amputation • wrist disarticulation • trans-radial amputation: below-elbow or forearm amputation • elbow disarticulation • trans-humeral amputation: aboveelbow amputation • shoulder disarticulation • forequarter amputation • trans-radial amputation/Krukenberg procedure: the radius + ulna are used to create a stump capable of a pincer action. Consider: • How much is enough cutting? • the length of the stump end for fitting the prosthesis. • Sensation • Muscle strength • Health status • Circulation status • Phamtom pain • Family support • Financial support Causes: • Circulatory disorders: e.g. Diabetic vasculopathy, Sepsis with peripheral necrosis. • Neoplasm: e.g. osteosarcoma, chondrosarcoma, fibrosarcoma, epithelioid sarcoma, Ewing's sarcoma, synovial sarcoma, sacrococcygeal teratoma, liposarcoma, melanoma, etc. • Trauma: Severe limb injuries in which the limb cannot be saved or efforts to save the limb fail in traumatic amputation (e.g. RTA, IOD, War and conflict victims) • Amputation in utero (e.g. Amniotic band) • Congenital anomalies: Deformities of digits and limbs (e.g., proximal femoral focal deficiency, Fibular hemimelia, polydactyly). • Infection: Bone infection (osteomyelitis) and diabetic foot infections • Frostbite • Few athletes choose to have a non-essential digit amputated to relieve chronic pain and impaired performance (e.g. Australian Rules footballer Daniel Chick had his left ring finger amputated; Rugby union player Jone Tawake had a finger removed; National Football League Ronnie Lott had the tip of his little finger removed) to improve their athletic performance . References 1. Blom, A., Warwick, DJ, & Whitehouse, M.. (2018). Apley & Solomon’s System Of Orthopaedics And Trauma. (10th ed.). Florida, CRC Press. 2. Frontera, W. R., Silver, J. K., & Rizzo, T. D. (2018). Essentials of Physical Medicine and Rehabilitation: Musculoskeletal Disorders, Pain and Rehabilitation. (4th ed.). Philadelphia: W.B. Saaunders Company. 3. Goodman, CC, & Fuller, KS. (2015). Pathology: implications for the physical therapist. St. Louis, MO: Elsevier Saunders. 4. Porter, S. (2013), Tidy's Physiotherapy, 15e (Physiotherapy Essentials). 5. Porter, R. (2018), The Merck Manual of Diagnosis & Therapy (20th edition), Weiley 6. Photos from Google web pages.