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CHAPTER30 Burn contracture surgery
The foot and ankle
Dorsum
Dorsal foot contractures are very common. Hyperextension deformities
of the metatarsophalangeal joints (MTPJs) of the foot result, and if the deformity is chronic, especially in adults, surgery to release the dorsal capsule
of the MTPJ and lengthen the extensor hallucis longus may be necessary.
Minor contractures may be released with Y– Vs for linear bands. Often incisional release and skin grafting is required, because there is very little skin
laxity on the dorsum of the foot.
When planning a release with skin grafting, it is best to place the transverse release incision proximally, about half way up the dorsum of the
foot, so that when release occurs, the distal scarred skin of the dorsum still
covers the MTPJ. This enables these joints to be released surgically and the
extensor longus to be lengthened if required, while still leaving a graftable
defect (rather than exposed joint/ tendon which would need a ap).
Thick skin grafts or dermal substitutes are good options for the dorsum
of the foot.
Occasionally, if extensive bone and joint work is required, a thin free ap
may be necessary, but it can be challenging to obtain ap tissue that is thin
enough to readily t in a shoe (Fig. 30.16).
For major longstanding deformities, it is important to gauge function of
the foot and ankle. Not uncommonly there can be secondary xed deformity and even growth disturbance of the bones. Commonly toes are
hyperextended and the MTPJs may be dislocated. In such circumstances be
aware that skin contracture release alone may not eect a full correction or
a functional foot. Even if full correction is attainable, accommodative orthoses may be necessary to allow weight bearing. Consider X- rays of foot and
ankle to gauge deformity. Further bony surgery and open joint relocations
or fusions may be necessary. If the patient has not been weight bearing at
all for more than two years, then consideration needs to be given to ablative surgery in order to best regain function. Discuss with orthopaedic
surgeons/ orthotists/ prosthetists if possible.
After an extensive incisional release it is often best to excise the skin
edges as these are commonly of poor vascularity on the foot
K wiring in plantar exion is extremely important after release of signicant dorsal contractures. Typically the wires are left until the grafts are
stable (about 4– 5 weeks).
Commonly a broadband contracture of the dorsum of the foot is associated with a linear contraction of the dorsum of the ankle. In this event, a
skin graft release is combined with a proximal Y– V or Z plasty.
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THE FOOT AND ANKLE
Fig.30.16 Diagram showing incision for release of dorsal foot contracture placed
at about mid- foot level so that the MTPJs are covered by intact skin when the release
is carried distally. This allows grafting of the defect. Extensor brevis tendons can be
excised if necessary. Often some skin has to be excised to prevent scar necrosis at
the edges of the skin graft.
Sole and tendo achilles
Fortunately, contractures of the plantar surface of the foot are uncommon.
They can readily be released with full thickness grafts in most cases, but
grafts and marginal scars tend to produce troublesome hyperkeratosis that
needs continuous treatment to alleviate discomfort.
Orthotists and podiatrists are invaluable specialists in looking after patients with post burn sole of foot problems, as surgery commonly does not
satisfactorily resolve symptoms from scars on the sole.
Occasionally, equinus contractures can cause severe problems with mobility. Release with tendon lengthening is likely to require a free ap. An
alternative is an ankle fusion or a ‘pseudo fusion’ with sacrice of the tendo
Achilles in patients with lower demands:this produces improved position of
the foot at the expense of loss of powerful plantar exion.
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CHAPTER30 Burn contracture surgery
Conclusion
• Assess the contracture as well as possible. Remember it is a decit
of skin
• Release through the entire subcutaneous scar
• If the contracture is not releasing well, excise more scar
• If you are skin grafting, excise all subcutaneous scar to make a good bed
• Look after your patients well. They have already suered much and they
may need many more operations
Further reading
Hyakusoku H, Orgill DP, Teot L, etal. Colour atlas of burn reconstructive surgery. Heidelberg:
Springer, 2010.
Shokrollahi K, Whitaker IS, Nahai F. Flaps:practical reconstructive surgery. Stuttgart:Thieme, 2017.
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Chapter31
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Outpatient management
ofminor burns
Introduction to outpatient management of
minor burns 286
Denition of minor burns 286
Assessment and selection of patients for outpatient
management 287
First aid and initial management 289
Local wound treatment 290
Patient education 291
Complications and when to admit 291
Follow- up 292
Further reading 292
Reference 292
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CHAPTER31 Outpatient management ofminor burns
Introduction tooutpatient management
ofminor burns
More than 90% of burns can be managed as outpatients by non- specialists,
eg. emergency departments, minor injury units, and general practice. In
practice, most burns are, at least, discussed with a burn service which
then elects for outpatient management by either the burn service itself or
non-specialists services for the lowest risk injuries. Outpatient management
in supportive home environments aims to reduce unnecessary admissions
and improve cost eectiveness without compromising quality of care.
Although the majority of burns patients can be managed as outpatients,
research has largely focused on burns requiring inpatient resuscitation, reducing high level evidence on which to base recommendations. This chapter
summarizes widely accepted practice and existing evidence for consideration and does not constitute dogmatic recommendations.
Definition ofminor burns
Various denitions of minor burns have been advanced. The following features are generally accepted:
• Limited extent (<3– 5% total body surface area (TBSA)) and not
requiring resuscitation
• Supercial and supercial- partial thickness burns
• ≤1% TBSA full- thickness burns in children or adults without cosmetic
or functional risk to eyes, face, hands, feet, or perineum
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PATIENT ASSESSMENT & SELECTION FOR OUTPATIENT MANAGEMENT
Assessment and selection ofpatients
foroutpatient management
There are no internationally accepted criteria for selecting patients for outpatient management. The criteria in Table 31.1, expanded below, serve
as a guide to features from the history and examination that should be
considered.
• Age:patients at the extremes of age have intrinsically poorer outcomes.
However, outpatient management may be suitable for all ages in
select cases
• Comorbidities:cardiovascular, respiratory, neuropsychiatric, metabolic/
renal, and endocrine systems may complicate outpatient management
• Social circumstances:including employment, distance and access to
clinics should be ascertained. For example:
• Achild or adult who may have sustained their burn injury in
questionable circumstances (eg. non- accidental injury) may be best
managed initially as an inpatient with Social Services input
• Patients managed as outpatients may be required to attend regular
follow up appointments. It is important that selected patients have
access to transport
• An elderly patient living alone may not have family/ friends to assist
with care and may be best managed in hospital
• Severity/ extent of injury:minor burns (see denition above) can usually
be managed successfully as outpatients. However, some patients with
comorbid renal failure, alcohol dependence, and patients in arid climates
may require admission for intravenous uid resuscitation even for
minor burns
• Burn depth:while supercial burns usually heal within 3 weeks, full-
thickness burns usually require admission for skin grafting. However,
operative treatment for small burns can be performed on an outpatient
or day case basis in a burns service. Where supercial partial thickness
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Table31.1 Factors tobe considered whenselecting patients
foroutpatient burn management
Patient factors Age
Burn factors Severity/ extent of injury
Data sourced from Hartford CE, Kealey GP. Care of outpatient burns. In Herndon DN (ed.)
Total burn care, 3rd edn. Edinburgh, UK:W.B. Saunders, pp. 67– 80, Copyright © 2007, and
Warner PM etal. Outpatient burn management. Surgical Clinics of North America 94(4):879– 92,
Copyright © 2014 Elsevier Inc. All rights reserved.
Comorbidities
Social circumstances
Depth
Distribution
Aetiology
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CHAPTER31 Outpatient management ofminor burns
burns are managed as outpatients, these wounds should be regularly
examined to identify conversion to deeper injuries and/or complications
such as infections to allow early treatment
• Distribution:burn wounds on functionally and aesthetically sensitive
areas such as the face, eyes, hands, and perineum may be need to
initially be managed as inpatients because of potential diculties relating
to facial swelling, visual impairment, or diculties in dressings
• Some burns in these anatomical regions, such as full thickness injuries
traversing joint surfaces in the hands hands, may require early surgery to
reduce the risk of debilitating contractures.
• Burn aetiology
• Electrical burns:patients exposed to low voltage (<1 kV, although
most household injuries are 120– 220 V) can be considered for
outpatient management if an electrocardiogram is normal or becomes
normal during observation and if the wounds are small.
• Chemical burns:it may be possible to manage some chemical burns
as outpatients depending on location, extent, and depth. Rarely, large
hydrouoric acid burns necessitate inpatient treatment for monitoring
of serum calcium levels and pain relief (see Chapter19 Chemical
burns). Poisons information services such as Toxbase (http:// www.
toxbase.org/ ) should be consulted
• Flame burns:These are often deeper and can be associated with an
inhalation injury. If the latter is suspected a full respiratory assessment
should be performed and if present the patient should be managed as
an inpatient in conjunction with Intensive Care Physicians.
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FIRST AID AND INITIAL MANAGEMENT
First aid and initial management
• Cooling:cooling the burn wound for up to 20 minutes is an eective
measure to dissipate heat and arrest tissue damage, stabilize mast cells
and thus reduce oedema, and also has an analgesic eect. Cooling is
most eective if commenced within 20–30 minutes of the injury. Cool
tap water or soaks (8– 25°C) may be used.
• Pain management:initial assessment and dressing of burns may require
opioid analgesics. Adjuvants such as paracetamol and non- steroidal antiinammatory (NSAIDs) agents may also be used. Once a burn has been
dressed, pain is usually manageable with oral analgesics such as NSAIDs
or weak opioids. Patients usually require supplementary analgesia during
dressing changes and physical therapy sessions. Patients with narcotic
abuse or chronic pain issues may require specialist input. Anxiolytics
such as benzodiazepines may also be required in certain cases
• Tetanus vaccination:tetanus vaccination status should be ascertained
and boosters administered if required (see Chapter39)
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CHAPTER31 Outpatient management ofminor burns
Local wound treatment
• Management of blisters:there is general agreement that these should
be debrided to allow full assessment of depth and size. Very small, nontense blisters may be left intact. Aspiration is not recommended as it
may introduce infection without the benet of the ability to fully assess
the wound when fully deroofed.
• Cleansing and debridement:wounds may be cleansed with water,
and/ or mild non- irritant soaps. Debridement of wounds reduces the
risk of infection and allows more accurate assessment of burn depth.
• Topical agents:there are a variety of topical agents used to dress
burns. Examples include silver sulfadiazine and chlorhexidine. The latest
Cochrane reviews have shown the evidence for these treatments to
be generally weak, precluding evidence- based recommendations. Silver
sulfadiazine has especially been consistently shown to be associated with
poorer outcomes. The general principle should be to avoid use of these
in clean, uncontaminated burns
• Wound dressings:a wide range of dressings is available including:
• Simple dressings (ne mesh gauze, hydrocolloid, and silicone based)
• Biosynthetic dressings (biobrane, biobrane- like dressings, and
polyhexanide containing bio- cellulose). There is accepted evidence
that Biobrane, when used in children with conuent supercial dermal
burns within 48 hours of the injury, reduces the pain of subsequent
dressing changes thereby enabling outpatient management in this
patient group.
• The 2013 Cochrane review, by Wasiak etal.,1 assessing a range
of dressings found that all 30 eligible studies were at risk of bias,
precluding rm recommendations. In most small supercial burns
simple non- adherent dressings combined with an absorbent layer will
allow the wounds to heal spontaneously if changed every 2– 4days
depending on the amount of exudate. Biologic and biosynthetic
dressings may have some role in special areas such as the hand or in
large burns to allow early movement, reduce exudate and pain, but
are generally very rarely used in the outpatient setting.
• Management of itch:pruritus may aect >90% of burn suerers in the
rst month. Suggested treatments are
• First line:emollients should be used liberally to avoid dry skin, which
may exacerbate pruritus
• Second line:regular H1 receptor antagonists such as cetirizine are
preferred over non- specic antihistamines such as diphenhydramine
• Third line:neuropathic pain blockers such as gabapentin and
pregabalin may be useful
• Others:doxepin, massage therapy, and transcutaneous electrical
nerve stimulation
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COMPLICATIONS AND WHENTO ADMIT
Patient education
Successful outpatient management depends on motivated, informed patients. Patients should particularly be educated on:
• Pain management:patients should be advised to take additional analgesia
during dressing changes and therapy sessions
• Features of infection:including fever, pain, and spreading redness/ erythema.
Parents of children should also be counseled to report any features of toxic
shock syndrome including change in aect, dry nappies, rashes, abdominal
pain, anorexia and any parental concern.
• Maintaining mobility:regular physical exercise of aected area, especially
hands and feet, reduces the risk of stiness or contractures if the burns
are deep
• Elevation to reduce oedema:limbs, especially, should be raised to a level
above the heart
Complications and whento admit
Patients initially managed as outpatients may require admission due to a
number of possible complications including:
• Infection:there is no evidence supporting prophylactic antibiotics in
burns since only 5% of patients managed as outpatients suer infection.
However, local or systemic infections should be treated aggressively
according to local antibiotic policies. Microbiological culture of burn
exudate may guide antibiotic selection. Swabbing of any burn before
treatment for infection is essential. Any suspected cases of toxic
shock syndrome should be managed expediently in collaboration with
the receiving accident and emergency department, paediatricians,
microbiologists, intensivists and the burns service.
• Delayed wound healing:this increases the risk of scarring and poor
function/ cosmesis. Some wounds may have progressed in depth and
may require operative interventions such as skin grafting
• Social:patients failing to cope may require respite or inpatient care
especially if other factors such as pain or dicult dressings are also of
concern
• Uncontrolled or intractable pain
• Dressings:some body parts such as the perineum may be dicult to
apply dressings or patients may have signicant exudate requiring more
frequent dressing changes
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