Acute hand burns in children: management and long-term outcome based on a 10-year experience with 698 injured hands.

OBJECTIVE: To document long-term results associated with an coordinated plan of care for acutely burned hands in children. SUMMARY AND BACKGROUND DATA: Optimal hand function is a crucial component of a high-quality survival after burn injury. This can be achieved only with a coordinated approach to the injuries. Long-term outcomes associated with such a plan of care have not been previously reported. METHODS: Over a 10-year period, 495 children with 698 acutely burned hands were managed at a regional pediatric burn facility; 219 children with 395 injured hands were followed in the authors' outpatient clinic for at least 1 year and an average of >5 years. The authors' approach to the acutely burned hand emphasizes ranging and splinting throughout the hospital stay, prompt sheet autograft wound closure as soon as practical, and the selective use of axial pin fixation and flaps. Long-term follow-up, hand therapy, and reconstructive surgery are emphasized. RESULTS: Normal functional results were seen in 97% of second-degree and 85% of third-degree injuries; in children with burns involving underlying tendon and bone, 70% could perform activities of daily living and 20% had normal function. Reconstructive hand surgery was required in 4.4% of second-degree burns, 32% of third-degree burns, and 65% of those with injuries involving underlying bone and tendon. CONCLUSIONS: When managed in a coordinated long-term program, the large majority of children with serious hand burns can be expected to have excellent functional results.

Impact of childhood brain injury on work and family finances.

Parents of children who suffer brain injuries are often surprised by the extent to which work and family finances are disrupted. In this paper, work and financial problems are described, predictors are identified, and ways to minimize problems are discussed. Eighty-two children treated at two Massachusetts trauma centres were given an extensive battery of medical, functional, and psychosocial tests during hospitalization. At 1 and 6 months post-discharge they were retested and their parents were surveyed about work and financial difficulties. Trouble maintaining regular work schedules and injury-related financial problems were common. At highest risk for work and financial problems were families of children with severe injuries who had four to nine impairments, along with children hospitalized > 2 weeks who were not discharged to home. Surprisingly, families with HMO coverage reported significantly fewer financial problems, and this relationship was not due to differences in socioeconomic status or injury severity. Health-care providers need to pay more attention to the potential impact of injury on work and family finances. Providers can help at-risk families muster child-care services, deal effectively with employers and insurance companies, and plan for the future.

The Vancouver Scar Scale: an administration tool and its interrater reliability.

The Burn Scar Index, often called the Vancouver Scar Scale, is widely used in clinical practice and research to document change in scar appearance. Several sections of the Index require equipment to accurately score the items. Additionally, the numeric scores are difficult to remember. We recently devised a pocket-sized tool to aid in scoring the scar and to increase staff compliance in use of the Index. With this tool interrater reliability is good, which makes the Burn Scar Index a viable measure for research.

Families of children with traumatic injuries identify needs for research and training.

This paper summarizes the survey responses of 67 families with children who were hospitalized after traumatic injuries. The survey was conducted during the pre-planning phase of a major research proposal on the rehabilitation of children who had been injured. The purpose of the survey was to involve families in the identification of needs and determination of priorities for research and training in childhood injuries. The first part of the survey focused on direct services that children and their families received through medical, psychosocial, educational and vocational interventions and providers. The second part concerned the immediate and long-term effects of a child's injury upon the family. Families were asked to indicate: (1) the direct care services they considered most important in their child's recovery; (2) areas needing more research and study; (3) training needed by professionals; and (4) information needed by families. Major findings were the importance to families of emergency room treatment and the quality of hospital care; concerns about communication between professionals and parents; the uncertainty of expectations for the future; and lack of information on community resources. Written comments emphasized the emotional impact of physical trauma upon families and the need for longitudinal research, with pediatric rehabilitation viewed as a broad spectrum of care starting with emergency room care and hospitalization and continuing through school and community programs. As a result of this survey several projects were initiated. They include: revision of head sheets distributed by emergency rooms, physician training in communication skills, preparation of families as service coordinators, and development of materials and programs specifically for families.

Functional performance of young children after traumatic brain injury: a 6-month follow-up study.

OBJECTIVES: A follow-up study is reported of 40 children between the ages of 1 month and 5.6 years who had sustained a brain injury either with (n = 11) or without (n = 29) additional injuries. METHOD: Children and their families were assessed at both 1 and 6 months after hospital discharge with standardized measures of functional performance and family functioning, including the Child Behavior Checklist, the Pediatric Evaluation of Disability Inventory, and the Impact on Family Scale. In addition to within-group analyses, functional outcome was compared to that of a group of 17 children who had sustained non-central nervous system injuries. RESULTS: Mean scores for both groups of injured children were within the average range at both 1-month and 6-month follow-up testing. There was a general trend toward improved performance across the follow-up period, although only a few of these changes reached statistical significance. The effect of the injury as reported by the family was significantly associated with children's function as reflected by number of behavior problems and increased need for caregiver assistance. CONCLUSION: Results point to the need for systematic follow-up of young children after brain injury using sensitive measures to enable early identification of children whose further development may be at risk and to provide support to families whose children are displaying changes in functional behavior.

Use of the Children's Orientation and Amnesia Test at hospital discharge for children with neurological and non-neurological traumatic injuries.

The measurement of post-traumatic amnesia in children is a common clinical index of the extent of brain injury. The only published paediatric test, the Children's Orientation and Amnesia Test (COAT), has been standardized on a sample of children in a school setting who had not been injured or hospitalized. Two questions arise in the use of this test: are the published norms valid for hospitalized children with non-neurological trauma? and does the COAT offer better discriminative power or clinical utility over the adult test, the Galveston Orientation and Amnesia Test (GOAT)? This paper describes scores on the COAT for 28 children hospitalized with non-neurological injuries and compares them with the published scores. The hospitalized children scored within normal limits when compared with the school sample. In addition, 23 children with neurological traumatic injuries were given both the COAT and the GOAT. Failure rate was higher for the COAT. Some implications for the use of the COAT in paediatric trauma are discussed.