Arena D.¹, Giraudo L.¹, Rossato A.², Sarzi L.¹

¹ Rehabilitation Department, CTO, Turin, Italy
² Burn Centre, CTO, Turin

SUMMARY. Recent improvements in surgical therapy and the availability of new covering materials have modified the timing of treatment during the recovery of burn patients. This article proposes a detailed scheme that considers all the possible variations and will be of use to treatment specialists.

Introduction

In the past few years, the burn patient’s clinical course has been modified by new findings in the surgical field and by advanced medications.

The various surgical options, combined with the wide choice of covering materials, create a vast range of possibilities.

The choice of surgical technique and of the type of covering material in each single case is made on the basis of the following considerations:

• the degree of the burn
• the percentage of body surface affected by the burn
• the patient’s age
• the patient’s general conditions

With regard to the patient’s recovery, these conditions will affect the timing of our intervention.

It is necessary to remember the general contra-indications of rehabilitation treatment (RT):

• poor general conditions
• risk of causing massive bleeding
• suspected tendon lesions

Let us now consider the different degrees of burns, pointing out the possible differences in medical and surgical treatment and the consequent differences in rehabilitation time.1

First-degree burns

Classic and state-of-the-art topical treatment can overlap. A cortisone cream is applied, alternating this with a base cream in exposed treatment.

Rehabilitation treatment is immediate. There may be problems linked to the presence of oedema or pain.

Second-degree burns

The classic topical treatment requires emptying of the phlyctenae, using a sterile technique and dressing the burn every other day with petroleum jelly gauze, sterile gauze, and non-compressive bandages. If there is a lesion in the roof of a phlyctena, this is removed using a sterile technique, after which an antiseptic is applied, followed by application of petroleum jelly gauze, sterile gauze, and non-compressive bandages.

State-of-the-art medication of second-degree burns can be performed with a variety of different materials:

• hydrofibres
• semipermeable pellicles
• alginates
• hydrocolloids
• amnion

The Turin CTO hospital burn centre mainly uses hydrofibres and alginates.

With regard to timing, rehabilitation treatment is also in this case immediate, and the problems that may limit treatment are again related to oedema and pain.

State-of-the-art medication offers a number of advantages (reduction of pain, better adherence, better handling possibilities) that make it possible to achieve a wider range of movement and therefore more efficient rehabilitation treatment.

Deep second-degree or third-degree burns

The classic topical treatment involves use of an antiseptic and/or an escharolytic preparation for 15/20 days. Cutaneous substitutes are applied when good granulation tissue has been obtained.

State-of-the-art medication makes use of fluid hydrogels, which promote eschar autolysis and hydrate the eschar if it is dry, and collagenase covered with a secondary medication.

The timing of rehabilitation treatment is the same in both cases and is immediate. There may be the problem of premature rigidity.

The classic surgical technique in second-degree deep burns and third-degree burns consists of excision followed by a dermo-epidermic graft (DEG).

Rehabilitation treatment after the operation is suspended for a minimum of 5 days and a maximum of 7-9 days. The surgeon evaluates the prospects of recovery on the basis of DEG take; this evaluation is performed during baths after the surgical operation (on days 5, 7, and 9).

The problems that need to be dealt with, on resumption of RT, are rigidity, pain, and the patient’s degree of collaboration (if he is no longer under sedation).

Innovations in covering materials make it possible to treat deep second- and third-degree burns also with an excision followed by application of a temporary covering (e.g. xenografts and glycerolized allografts).

RT can be resumed immediately, though cautiously, bearing in mind the presence of metal sutures (at least during the first 5 days, and especially in articular areas) and the patient’s pain.

The state-of-the-art surgical techniques that we have considered are those of Alexander2 and Cuono;3 we have also considered INTEGRA®.4

In Alexander’s technique (excision and sandwich), RT is suspended for 5, or 7, or 9 days, depending on the take evaluated during the post-operative baths.

The Cuono technique is performed in two stages. After the first stage (excision and application of frozen allografts), RT is suspended until the first post-operative baths (5 days), or, at the plastic surgeon’s discretion, for 2 or 4 more days (second and third post-operative baths) and can continue until the second stage is performed after about 21 days.

The second surgical stage (excision and application of cultivated keratinocytes) requires suspension of rehabilitation until day 10, if take has occurred; if it has not, until day 14-18.

The application of INTEGRA® (after the excision) requires a suspension of rehabilitation treatment for 15-19 days, i.e. until the silicon detaches.

During a second stage, a thin DEG is applied. This makes it necessary to suspend treatment for 5-9 days (depending on the evaluation of the degree of take performed during post-operative baths) (Table I).

Conclusion

In conclusion, it is of fundamental importance for the rehabilitation therapist to be aware of latest developments in surgical techniques and in dressings. In this way it will be possible to avoid unnecessary post-operative delay, which may be the cause of articular limitations.

RESUME. Les améliorations récentes dans la thérapie chirurgicale et la disponibilité de nouveaux matériaux de couverture ont modifié les temps du traitement des patients brûlés. Les Auteurs proposent un procédé détaillé qui considère toutes les variations possibles et sera utile pour le spécialiste du traitement.

Bibliography

1. Arena D., Giraudo L.: L’allineamento posturale e la mobilizzazione del paziente ustionato in fase acuta In: “La cicatrice patologica”, G. De Nicola Editore, 1998.
2. Alexander J.W., Macmillan B.G., Law E., Kittur D.S.: Treatment of severe burns with widely meshed skin autograft and meshed skin allograft overlay. J. Trauma, 21: 434, 1981.
3. Cuono C.B., Langdon R., Berdall N.: Composite autologous-allogenic skin replacement. Development and clinical application. Plast. Reconstr. Surg., 80: 626-7, 1987.
4. Burke S.F., Yannas I.V., Quinby W.C.: Successful use of a physiologically acceptable artificial skin in the treatment of extensive burn injury Ann. Surg., 194: 41.