"Proximal to distal" sequence of the release of the upper extremity post-burn contracture: Rule or case-based approach?

Post-burn contractures are common entities seen in developing countries. There are multiple reasons for the development of contractures, most are preventable. In extensive contractures, a strategic plan is necessary to release all contractures and yet not antagonize post-operative positions. It is also necessary to be cost-effective and minimize the number of surgeries needed. Conventionally the release sequence in extensive burn contractures is proximal to distal. In this case report, we discuss an unusual sequence where we released distal contractures before the proximal to achieve optimum results. A 3-year-old child with post-burn contracture of hand, wrist, elbow, and axilla was treated in 2 stages, with the release of wrist contracture and cover with pedicled abdominal flap in the first stage and division of pedicled flap with the release of axilla and elbow contracture in the second stage. Thus, the release of all contractures was achieved without antagonizing post-operative positions and minimized the number of surgeries. A case-based approach may be crucial in making a strategic surgical plan to minimize the rehabilitation phase, rather than following known dictums.

Abdominal Wall Reconstruction in Adults With Exstrophy of the Bladder.

INTRODUCTION: Abdominal wall reconstruction in an adult patient with exstrophy bladder is challenging. A variety of local and regional flaps are described. We describe our experience with a 3-layer technique with the differential reconstruction of the fascial and cutaneous layer. PATIENT AND METHODS: Three adult patients with untreated bladder exstrophy were included in the study period from 2017 and 2019. The surgical technique involved 3-layer abdominal reconstruction involving closure with unilateral anterior rectus sheath turnover and a pedicled anterolateral thigh flap for skin cover reinforced with a mesh between the two. RESULTS: All three were male patients with an average age of 22.3 years. The average size of the defect was 10 × 9 cm. The mean period of follow-up was 6 months (range, 2-18 months). In all 3 patients, the flaps settled well with no complications. CONCLUSIONS: Although rare as they may be, the management of untreated bladder exstrophy presenting in adulthood has evolved over the years. The goals of the management have changed from simple defect closure to the dynamic reconstruction of the abdominal wall covering a continent neobladder. Our technique of a 3-layer closure can provide good functional integrity to the abdominal wall even in large defects.

Effectiveness of Parkland formula in the estimation of resuscitation fluid volume in adult thermal burns / 中华创伤杂志(英文版)

PURPOSE@#Acute burn resuscitation in initial 24 h remains a challenge to plastic surgeons. Though various formulae for fluid infusion are available but consensus is still lacking, resulting in under resuscitation or over resuscitation. Parkland formula is widely used but recently its adequacy is questioned in studies. This study was conducted to see how closely the actual volume of fluid given in our center matches with that of calculated volume by Parkland formula.@*METHODS@#All patients admitted with more than 20% flame burn injury and within 8 h of incident were included in this study. Crystalloid solution for infusion was calculated as per Parkland formula; however, it was titrated according to the urine output. Data on fluid infusion were collected from patient's inpatient records and analyzed.@*RESULTS@#The study included a total of 90 patients, about 86.7% (n = 78) of the patients received fluid less than the calculated Parkland formula. Rate of fluid administered over 24 h in our study was 3.149 mL/kg/h. Mean hourly urine output was found to be 0.993 mL/kg/h. The mean difference between fluid administered and fluid calculated by Parkland formula was 3431.825 mL which was significant (p < 0.001).@*CONCLUSION@#The study showed a significant difference in the fluid infused based on urine output and the fluid calculated by Parkland formula. This probably is because fluid infused based on end point of resuscitation was more physiological than fluid calculated based on formulae.

A prospective randomized controlled trial comparing negative pressure dressing and conventional dressing methods on split-thickness skin grafts in burned patients.

INTRODUCTION: Split-thickness skin grafting (SSG) is a technique used extensively in the care of burn patients and is fraught with suboptimal graft take when there is a less-than-ideal graft bed and/or grafting conditions. The technique of Negative Pressure Dressing (NPD), initially used for better wound healing has been tried on skin-grafts and has shown to increase the graft take rates. However, comparative studies between the conventional dressing and vacuum assisted closure on skin grafts in burn patients are unavailable. The present study was undertaken to find out if NPD improves graft take as compared to conventional dressing in burns patients. MATERIALS AND METHODS: Consecutive burn patients undergoing split-skin grafting were randomized to receive either a conventional dressing consisting of Vaseline gauze and cotton pads or to have a NPD of 80 mm Hg for four days over the freshly laid SSG. The results in terms of amount of graft take, duration of dressings for the grafted area and the cost of treatment of wound were compared between the two groups. RESULTS: A total of 40 split-skin grafts were put on 30 patients. The grafted wounds included acute and chronic burns wounds and surgically created raw areas during burn reconstruction. Twenty-one of them received NPD and 19 served as controls. Patient profiles and average size of the grafts were comparable between the two groups. The vacuum closure assembly was well tolerated by all patients. Final graft take at nine days in the study group ranged from 90 to 100 per cent with an average of 96.7 per cent (SD: 3.55). The control group showed a graft take ranging between 70 and 100 percent with an average graft take of 87.5 percent (SD: 8.73). Mean duration of continued dressings on the grafted area was 8 days in cases (SD: 1.48) and 11 days in controls (SD: 2.2) after surgery. Each of these differences was found to be statistically significant (p<0.001). CONCLUSION: Negative pressure dressing improves graft take in burns patients and can particularly be considered when wound bed and grafting conditions seem less-than-ideal. The negative pressure can also be effectively assembled using locally available materials thus significantly reducing the cost of treatment.