Randomized Controlled Trial of Compression Interventions for Managing Hand Burn Edema, as Measured by Bioimpedance Spectroscopy.

Compression, a common treatment of choice for the management of edema, is one intervention that is applied with little objective understanding of the optimal parameters of application or efficacy in acute burn wounds. The aim of this study was to determine the effectiveness of different methods of compression for the management of hand edema following burn injury. The primary hypothesis tested was that in acute hand burn injury, the application of cohesive bandage will reduce edema faster than a generic compression glove. It is a randomized controlled study of 100 patients presenting with hand burn injury. Compression was randomized to one of the three methods of application: 1) spiral application of Coban to fingers, figure of eight to hand and wrist; 2) pinch application of Coban to fingers, spiral application to hand and wrist; or 3) a generic compression glove (control condition). Bioimpedance spectroscopy was used to measure hand volumes. Hand and wrist range of movement, pain scores, and QuickDASH were recorded. One hundred patients (68 males) demonstrated significant reductions in hand volumes, using all compression methods. Both methods of applying Coban resulted in significantly greater reductions in edema compared to the generic compression glove. Notwithstanding compression method, all range of movement measures improved, with significant improvement in thumb opposition (P = .046), hand span (P = .020), and wrist flexion (P = .020). QuickDASH decreased between sessions (P < .001). Different methods of applying Coban are superior to generic compression gloves for managing acute hand burn edema.

Bioimpedance Spectroscopy Is a Valid and Reliable Measure of Edema Following Hand Burn Injury (Part 1-Method Validation).

The assessment of swelling following burn injury is complicated by the presence of wounds and dressings and due to patients experiencing significant pain and impaired movement. There remains a lack of sensitive objective measures for edema in patients presenting with hand burn injury. Bioimpedance spectroscopy (BIS) is a measure of body composition that has been demonstrated by our group to be reliable for measuring whole body and limb edema during resuscitation and to be sensitive to edema changes within healing wounds. The aim of this study was to determine the reliability and validity of BIS as a measure of edema following hand burn injury specifically. One hundred patients presenting with burn injury including a portion of a hand were recruited to this trial. Repeated measures of the hand were recorded using a novel application of BIS and in parallel with water displacement volumetry (WDV). The results were analyzed using mixed-effects regressions. Paired repeated measures were obtained for 195 hands, using four electrode configurations. BIS demonstrated high reliability in measuring hand BIS-Intraclass Correlation Coefficient 0.995 to 0.999 (95% CI 0.992-1.000) and sensitivity-Minimum Detectable Difference 0.74 to 3.86 Ω (0.09-0.48 Ω/cm). A strong correlation was shown with WDV, Pearson's r = -0.831 to -0.798 (P < .001). BIS is a sensitive and reliable measure of edema following acute hand burn injury.

Alternate Electrode Positions for the Measurement of Hand Volumes Using Bioimpedance Spectroscopy.

Background: Bioimpedance spectroscopy (BIS) is a tool that can be used to measure body composition in a variety of populations. Previous studies have investigated novel applications to utilize BIS to measure localized body composition, including in the hand. According to BIS guidelines, there should be no skin wounds at the site of electrodes, and that electrode positions may be modified in specific circumstances, as our group has validated previously in burn wound populations. Methods and Results: To determine in noninjured participants, whether BIS measurements recorded using alternate electrode positions on the palm of the hand and forearm, or a combination of electrodes on the dorsum and volar surface of the hand and forearm, were comparable with electrode positions on the dorsum of the hand and forearm. The study demonstrated that drive and sense electrodes on the palm of the hand and volar forearm, and a combination of electrodes on the palm of the hand and dorsum of the forearm, resulted in comparable measures of impedance of extracellular water (difference from reference position: 1.26%-4.75%, p = 0.411-0.558) and total water (difference from reference: 2.15%-2.40%, p = 0.258-0.781). Electrodes on the dorsum of the hand and volar forearm resulted in significantly different measures for the same BIS variables (percentage difference range 4.66%-6.15%, p < 0.001-0.003). Conclusion: Electrode positions on the palm of the hand and volar forearm, or on the palm of the hand and dorsum of the forearm, are interchangeable as clinical measures of hand lymphedema and total water impedance.

An Intraoperative Template Technique for Hemi-Hamate Bone Grafts in Reconstruction of the Proximal Interphalangeal Joint.

The surgical management of proximal interphalangeal joint fracture subluxations is challenging. The hemi-hamate autograft is a useful but technically challenging technique for these injuries. We describe a simple technical note, using a bone wax template to help guide the harvest of a geometrically accurate hemi-hamate graft to facilitate accurate proximal interphalangeal joint reconstruction, while reducing donor site morbidity.

Extended Posterior Auricular Artery Flap for Temporo-Parietal Scalp Defect in Previously Irradiated Scalp.

BACKGROUND: Temperoparietal scalp defects are fairly common resulting from varied array of etiology. Various reconstructive options exisit, but the aim was to achieve a reliable and simple solution keeping in mind the principle of replacing "like with like." METHODS: The authors present a 83-year-old lady who had a fall at her home and was lying unconscious for quite some time on her right side of her temple, leading to full thickness necrosis of overlying scalp. She had received surgery and prior radiotherapy for her basal cell carcinoma of the scalp at the same site of her present injury. She was treated with single stage debridement and reconstruction using extended posterior auricalar artery flap. She had no issues with wound healing. DISCUSSION: Extended posterior auricular artery flap for tempero-parietal scalp defects is a reliable local option as it has the several advantages over the traditional scalp flaps. It preserves the direction of hair follicles, no long scalping incisions, no unsightly dog ears, no need for donor area grafts. In this scenario, the robustness of this flap was truly tested as it was raised from a previously irradiated site and did not have any issues of necrosis. To the best of our knowledge, this is the first report confirming the safety of this reliable local option postirradiation.

A Previously Discounted Flap Now Reconsidered: MatriDerm and Split-Thickness Skin Grafting for Tendon Cover Following Dorsalis Pedis Fasciocutaneous Flap in Lower Limb Trauma.

OBJECTIVE: The dorsalis pedis flap has reliable vascularity; however, its use is limited by reports of donor site morbidity including infection, delayed healing, exposure of tendons, and later contractures. The purpose of this study was to demonstrate its continued role in lower limb trauma when the donor site is reconstructed with MatriDerm to avoid complications. METHODS: A 65-year-old man presented with a displaced, Gustilo 3b open transverse fracture of his left distal fibula. He had a 2 cm(2) open wound over his lateral malleolus. RESULTS: Following review of possible local options, a dorsalis pedis fasciocutaneous flap was deemed best for coverage, and the donor site was closed with 1-mm MatriDerm dermal matrix and a 6/1000 inch split-thickness skin graft (STSG) in a single stage. Three months postoperatively, the foot had excellent function and cosmesis, with toes in a neutral position and a full range of movement. CONCLUSIONS: The dorsalis pedis flap is a valuable reconstructive option for defects of the foot and ankle. Its major limitation donor site morbidity can be overcome by the additional application of a dermal substitute such as MatriDerm under the STSG.

First impressions last A survey of knowledge of first aid in burn-related injuries amongst hospital workers.

RATIONALE: The administration of first aid in burns has been shown to have a significant influence on the ultimate severity of the burn. We wanted to assess in-hospital healthcare (HCW), and non-healthcare workers' (nHCW) knowledge of first aid in burns. METHODS: A purpose-designed questionnaire, including information about previous attendance at a first aid course and four clinical scenarios of burns, was distributed to HCWs in the local hospitals and non-medical students in the Universities of Leeds and Sheffield. RESULTS: 697 questionnaires were completed - 397 (57%) from HCW and 300 (43%) from nHCW. 59% of HCW had attended a first aid course, 68% of these courses included teaching on first aid in burns. HCW who had completed a first aid course generally did better than those who had not. Only 16% of HCW achieved correct answers in all questions compared to 30% nHCW. CONCLUSIONS: We show that the knowledge of first aid in burns is relatively poor amongst HCW and that attendance at a burns first aid course improves knowledge (although perhaps not as much as one might hope). We recommend that the burns content of first aid courses be reviewed, and that there is a requirement for ALL hospital healthcare workers to undertake a first aid course, which includes appropriate burns first aid.

Complex chemical burns following a mass casualty chemical plant incident: how optimal planning and organisation can make a difference.

INTRODUCTION: Four employees at a chemical plant sustained extensive chemical burns following the explosion of a pipeline containing 100% sulphuric acid. We describe the management of these patients from the initial ED triage through to discharge from hospital in life and limb threatening chemical burns. METHODS: Four patients who sustained chemical burns to the torso and extremities are reviewed. Data was retrieved from patient case notes and operating theatre logbooks. RESULTS: Four patients sustained chemical burns during the blast and were immediately transferred to a local ED where a prompt referral was made to the burns service. All patients were male aged 25-59 years (mean 46.5). Burn size was 2-50% BSA (mean 22.5). Following RFDS transfer to the state burns service two patients required immediate excisional surgery. In these patients the chemical burn involved full thickness skin loss with extensive underlying muscle and neurovascular damage. One patient required immediate above knee amputation of one leg and fascial burn excision of the other. The other patient required fascial burn excision of both legs followed by Integra placement 24h later. Both patients had prolonged hospital stays due to the complex nature of their injuries requiring multiple trips to theatre and lengthy rehabilitation. The two patients with smaller burns had straightforward surgery and an unremarkable recovery. CONCLUSION: Early communication following this mass casualty incident allowed for organisation of tertiary services and early radical surgery which was life saving. Management lessons were learnt following this mass casualty chemical burn incident.

Burn patients, parents and doctors; are we in agreement?

BACKGROUND: Burns in children present a serious challenge for patients, parents and doctors. This study aimed to investigate differences in desire for burn reconstruction in paediatric patient, parent and surgeon groups. METHODS: This study is a case series (n=21). Questionnaires were administered to patients, their parents and surgeons. Medical records were also reviewed. Data were analysed to ascertain how different factors affected desire for reconstruction between parents, patients and surgeons. RESULTS: Surgeons and parents were more likely to desire surgery than paediatric patients (76.2 vs 61.9 vs 52.4% respectively). Surgeons were more likely to recommend surgery for pre-pubescent patients (81.8 vs 70%). All groups were more likely to desire surgery for female patients. Patients and parents desired surgery more for hidden scars. Higher VSS scores were associated with a higher desire for surgery in all groups. Agreement between patients and parents was highest (Kappa=0.81) with poor-moderate agreement between surgeons, patients and parents (Kappa=0.12-0.24). CONCLUSIONS: This study suggests that paediatric patients are less likely to want burn reconstruction compared to parents and surgeons. Gender and age may impact on desire for surgery. Opportunities for improving patient, parent and surgeon agreement may exist. Further research is warranted to validate these results.

Epidemiology and outcome analysis of 208 children with burns attending an emergency department.

OBJECTIVE: The purpose of this study was to prospectively study all burns attending a single inner city emergency department (ED) to establish epidemiological burn patterns and final outcomes for thermal injuries affecting children. DESIGN AND SETTING: A 12-month prospective study of all burns involving children (ages, 0-16 years) presenting to a single ED serving approximately 500,000 people. RESULTS: Two hundred eight children with burns attended the ED. The average patient age was 5 years, with most cases involving infants and young children. Fifty one percent of injuries were scalds, and 36% were contact burns. Burn size varied from 1% body surface area to 23% body surface area. First aid had not been administered in one third of cases before attendance, and 87% of patients had received no analgesia. Final outcomes were as follows: 5% of patients were discharged from the ED with no further follow-up. Twenty three percent of patients were instructed to attend their general practitioner for follow-up, and 58% were instructed to attend the ED clinic for review. Four percent of patients were reviewed in the plastic surgery dressing clinic, 7% were admitted to the plastic surgery ward, and 3% of patients were transferred to a burn center. In total, 3% of patients required burn excision and skin grafting for their burns. There were no deaths. CONCLUSIONS: Many pediatric burns are appropriately managed in the ED without the need for burn center care. Although the mortality from burn injury in children may have fallen in recent decades, problems persist in terms of small burns that can be associated with long-standing morbidity. Education and prevention programs are still required at all levels to help address the problem of childhood burns.