INTERNATIONAL ABSTRACTS

FREE FLAP NECROSIS: A SELF-INFLICTED BURN

This unusual case, thought to be the first of its kind reported in the literature, concerns a sequence of selfinflicted thermal injuries which affected the elbow joint and later led to thermal necrosis of a reparative free flap. The patient, a 23-year-old man with a history of self-mutilating injuries, was treated successively for self-inflicted razor wounds in the arm, cigarette lighter burns, and further burns from a gas stove. The injuries were usually in the left arm. The inability of the medical profession to stop this young patient from mutilating his left arm resulted in a charred free scapular flap, which serves a reminder of the difficulties in interdisciplinary management of "the deliberate self-harm syndrome" in psychiatrically disturbed patients.

Vanstraelen P.M., Sonneborn C.K., Dickson W.A. Bums, 19: 244-245, 1993.

This report calls attention to the possible causes of injuries to peripheral nerves in critically ill burn patients. A description is given of two patients suffering from mixed deep partial- and full-skin thickness flame burns covering 45 and 95% of the total body surface area respectively. Both patients, following sepsis and multisystem failure, developed unilateral peroneal nerve palsy. There is a discussion of the possible aetiology of isolated injury to the peroneal nerve in burned and critically ill trauma patients.

Lippin Y., Shvoron A., Yaffé B., Zwas S.T., Tsur H. Burns, 19: 246-248, 1993.

The Koebner or isomorphic phenomenon is a term used to describe the induction of skin changes (psoriasis, verrucae, lichen planus, eczema, vitiligo, etc.) when skin is injured to a degree which in most people would not produce more than a temporary wound but in predisposed individuals results in a recognizable form of skin disease. A simple scratch or pressure point may result in the emergence of a Koebner reaction. This report describes the emergence of viral warts on the hand of a 2-year-old child six months after a superficial scald. The aetiology and immunological implications are considered. It is noted that as standard burn dressings and skin preparations do not contain antiviral chemicals it is hardly surprising that viruses are forming a new challenge in post-burn care.

Khan J1, Frame J.D. Burns, 19: 249-250, 1993.

A retrospective medical record-based study of all 88 patients aged over 65 years of age admitted to the Royal Brisbane Hospital Burns Unit (Australia) between July 1981 and June 1990 was undertaken. It was found that more males than females were admitted (51/37). Burns did not occur predominantly on any particular day of the week or period of the year. Flame burns and scalds were the commonest injuries, usually associated with cooking and bathing adivities respectively. The elderly burn population presents certain predisposing factors and special prevention programmes should be conducted to reduce burn risk in the kitchen and bathroom. Mortality rates, which were well predicted by the Bum Severity Index, were related to the percentage T13SA burned and inhalation injury. Pneumonia and venous thrombosis were the commonest complications. Good nutrition is essential, as well as meticulous wound care to prevent infection. Early wound coverage is recommended in order to prevent sepsis. This should be postponed only if the patient's general condition deteriorates. It was not possible to establish whether early or late surgery was more valid because of the unstable condition of many of these elderly patients.

Lewandowski R., Pegg S., Fortier K., Skimmings A. Burns, 19: 513-5, 1993.

This study concentrates on chemical burns. One hundred and fifty-five patients with chemical burns were admitted to a Burns and Surgery Department at the Guangzhou Red Cross Hospital (People's Republic of China) in the 5-year period 1986-1991. Of these patients, 109 (70.3%) were between 20 and 40 years old, i.e. of active working age. The age and sex of the patients, the scene of injury and the type of chemical agent involved are identified, and an account is given of the diagnostic and management experience. The patients were given the same physical therapy, but it was found that early tangential or full-thickness excision was more successful than conservative treatment. It also shortened hospital stay.

Li Y-Y., Liu Y. Burns, 19: 516-8, 1993.

A report is presented regarding the use of Silastic foam in 15 children with full-thickness hand burns over a 3-year period in a hospital in Manchester (UK). Silastic foam (Dow Corning) proved to be safe, easy to use and effective as a hand dressing following surgery. Successful results were obtained in all 15 patients. The foam is rigid enough to act as a splint, but at the same time it is deformable and accommodates post-operative swelling.

Watson S.B., Miller J.G. Burns, 19: 519-21, 1993.

With the gradual increase of the elderly population in many countries, more persons are exposed to the risk of bums because of age-related physical or mental infirnrities. The residents of nursing homes for the elderly may fall out of bed and come into contact with a hot radiator, without being able to call for help. Five such cases, one fatal, are described in this article. The current guidelines for nursing homes in relation to heating surfaces are considered and some recommendations are made as to how this hazard can be avoided.

Huffen J.S., Dunn K.W. Burns, 19: 522-3, 1993.

It is always difficult to predict blood loss and the requirements for cross-matched blood in burns surgery. This prospective study in a Welsh hospital was performed to assess the variability of blood loss during early layered excision and late excision and grafting and, if possible, to produce a formula or simple nomogram for calculation of cross-matched blood requirements. It was found that operative blood loss during burns surgery in 142 patients showed no significant difference as regards the loss seen during layered excision and grafting up to seven days after thermal injury and that observed during formal (scalpel) incision and grafting from eight days onwards. The data obtained were used to construct a graphical "tariff" for children and adults for the ordering of cross-matched blood for peri-operative transfusion. Use of this tariff could help to strike a balance between wasteful overprovision and dangerous underprovision of cross-matched blood required in burns surgery.

Dye D.J. Bums, 19: 524-8, 1993.

In view of the finding that recurrent abscess formation sometimes occurs on the dense scar after burn injury, it was decided to study the concentration of orally administered ofloxacin in scar tissue, granulation tissue, normal skin and serum. High performance liquid chromotography was used to measure the concentration levels. From 56 patients who received 200 mg of ofloxacin before surgery, 103 specimens (48 of serum, 32 of scar tissue, 18 of normal skin and five of granulation tissue) were harvested between 2 and 3 hours after administration. The ofloxacin values were 1798.6 ± 1125.5 ng/g in the granulation tissue, 1525.5 ± 1002.7 ng/g in the serum, 1450.0 ± 1011.3 ng/g in the scar tissue and 1092.8 ± 593.3 ng/g in normal skin. The ANOVA test did not show any significant difference between the ofloxacin concentrations in these four specimens. It is concluded that orally administered ofloxacin appears to be effective in preventing certain infections.

Sawada Y., Ohkubo T., Kudo M., Sugawara K. Burns, 19: 529-30, 1993.

The Americans with Disabilities Act (ADA) effectively became law in the USA in 1992. The purpose of the ADA is to "bar discrimination against the disabled". This article discusses the ADA in relation to burn survivors. Each of the five major provisions of the act is discussed in detail. A number of case studies are presented in order to demonstrate the ways in which knowledge of the ADA can be used to anticipate and deal with potential complications of re-entry after hospitalization.

Gammon E.A., Abrams Y.A. Bums, 19: 531-4, 1993.

Three cases are described of burns caused to fishermen whose highly conductive carbon fibre fishing rods came into contact with high-voltage overhead cables. It is recommended that persons indulging in this very common sport should be made more aware of this potential danger by means of special warning leaflets and by stickers to be attached to fishing rods.

Logan M.A. Bums, 19: 535-537, 1993.

This report describes a patient with serious burns who developed acute colonic pseudo-obstruction, also known as the Ogilvie syndrome (it was first described by Ogilvie in 1948), and died as a result of septic shock caused by a seconda"ry abdominal perforation of the caecum. Acute colonic pseudo-obstruction is characterized by colonic dilatation without any mechanical cause that affects critically ill patients. As a result the prognosis worsens. Treatment includes decompression via rectal and nasogastric probes, colonoscopy and caecostomy.

Valero Gasalla J_ Vazquez-11arro A_ Pousa Real F., Martelo Vilar F.
Bums, 19: 5 3 8-540, 1993.

Mucormycosis is an acute and rapidly developing infecdon caused by members of various genera of the Mucorales order of Zygomycetes. A case is described in which ischaemic necrosis of the upper extremities caused by invasive mucormycosis developed in a patient with soil contamination of severe bum wounds. There was complete obstruction of blood flow in the forearm. Histological specimens showed nonseptate branching hyphae obliterating the arterial lumens. Cutaneous mucormycosis affects immunocompromised patients, including burn victims. Because of its lethal nature mucormycosis in a patient with bums must be treated with aggressive surgical debridement, including amputation if necessary, and with parenteral amphotericin B at the first dign of cutaneous presence. This case provides a previously undescribed clinical presentation in a patient with major bums.

Kraut E.J., Jordan M.H., Steiner C.R. J. Bum Care Rehabil., 14: 552-6, 1993.

The scrotum is not often used as a donor site because of technical difficulties associated with its harvest. A procedure is described that simplifies scrotal harvest and facilitates the procurement of clinically useful amounts of split-thickness skin. As the scrotum is often spared from burning because of its protected position, this a potentially useful donor site in male patients with otherwise extensive burns.

Sheridan R.L., Ryan C.M., Tompkins R.G. J. Bum Care Rehabil., 14: 557-8, 1993.

This article focuses on some of the effects of aging that may have some impact on the therapist's intervention with the elderly burned patient. The elderly have a tendency towards greater depth and size of bum because of thinner skin, slower reaction times, reduced mobility, iminished sensation, and impaired vision, smell and hearing. The various body systems are considered in relation to the elderly burned patient. It is stressed that appropriate phys ' ical training programmes should: a) counterbalance age associated decline in work capacity and physical performance; b) maintain and improve range of motion, strength, flexibility, balance and endurance; and c) reduce the disability of the cardiovascular, respiratory and musculoskeletal systems.

Staley M., Richard R. J. Burn Care Rehabil., 14: 559-65, 1993.

This is a case study describing major conceptual and methodological problems that emerged in a research project comparing a newly developed home-based treatment modality with standard hospital-based care. The problems considered include those of conceptualization, measurement, patient sampling, follow-up, data collection and analysis. There is a discussion of the causes of the problems and their effects on the implementation of the project. A number of solutions are proposed for the various problems.

Coombs D.W., Dimick A., Bronstein J.M., Potts L.H., Bowens B.
J. Burn Care Rehabil., 14: 568-71, 1993.