SUMMARY. Although permanent sequelae of deep burns always persist, they can be very favourably influenced if we start soon after the injury. There are several possibilities: very early rehabilitation by positioning and supports prevents the shortening of tendons and ligaments surrounding the large joints and thus reduces post-traumatic oedema. By selecting the correct surgical technique at the right moment, we achieve an optimal course of healing and scar formation. Great attention must be paid to infection and its prevention. After healing it is important to apply compressive aids soon, preferably in combination with silicone and similar materials. For lubrication it is better to use creams with a high water content. Ensure the optimal mental well-being of affected patients. If the patient communicates well, do not hesitate to use psychoanalytic methods to reduce emotional and verbal blocks related to the injury.
Bewahrte MaBnahmen zur Verminderung der Dauerfolgen von Verbrennungen
Blaha J.
Die Dauerfolgen von tiefen Verbrennungen kann man vermindern, falls die entsprechende Mal3nahmen unmittelbar nach dem Unfall getroffen werden. Es gibt mehrere Moglichkeiten: durch eine fruhzeitige Rehabilitation mittels Lageanderungen and Unterlagen kann man der VerkOrzung der Sehnen in der Umgebung der grossen Gelenke vorbeugen and die posttraumatische Anschwellung vermidern. Optimaler Verlauf der Heilung and Vernarbung kann durch die Wahl der geeigneten Operationstechnik and der Operationszeit erreicht werden. Von grosser Wichtigkeit ist die Vorbeugung gegen einer Infektion. Unverweilt nach der Abheilung sollten die Kompressionsmittel, am besten in Verbindung mit den Silikonen oder ahnlichen Materialien appliziert werden. Die Haut sollte lieber mit den Kremen mit hohem Wassergehalt gesalbt werden. Psychische Behaglichkeit der behinderten Patienten sollte beachtet werden. Bei den gut kommunizierenden Patienten kann die Psychoanalyse verwendet werden, um die mit dem Unfall verbundene Emotionen and Verbalblocke zu reduzieren.
Key words: deep burns, scars, rehabilitation, compressive therapy, lubrication, psychotherapy, psychoanalysis
In the treatment of patients with burns we must be interested from the onset in permanent sequelae of the burns and therapeutic procedures.
The latter accompany the patient in later life and sometimes influence his further existence in a significant way. Serious burns are not such a frequent injury and with regard to the fact that the appearance of the affected areas is influenced not only by the injury proper but also various therapeutic activities leading to its healing, it is advisable that the patient should be treated in a specialized department. According to our experience attempts at conservative or surgical treatment of burns by health professionals who have no practice in this field distort the statistics of successful treatment and are associated with multiple technical complications and frequently with infections of the affected area. Every complication protracts treatment, has a negative impact on the health and mental state of the patients and causes deterioration of the prognosis of permanent sequelae.
Superficial burns, i.e. burns grade I and superficial burns grade II, usually do not leave any permanent sequelae, in the worst case only minor irregularities in the skin pigmentation (Fig. 1). Deeper and deep burns, i.e. those of grade II and III, leave sequelae. In general it may be stated that the deeper the thermal injury or the deeper tissue structures succumb to necrosis, the more serious the permanent sequelae. The appearance of the surface after healing depends on a series of interconnected factors.
The reaction to burn injuries is very individual. The range of resulting scars is so different that in some patients we may speak of hereditary predispositions for the formation of unfavourable external scars, while in others despite complicated treatment only minor or negligible permanent sequelae develop. Regardless of these extreme cases the great majority of patients reacts by visible and obvious scars, which differ as to their character not only in different patients, but in extensive affections we can observe a different development of scarring in different parts of the body. In investigating the causes of this remarkable phenomenon it is important to follow the case-history day by day, the procedures day by day and follow up the course of treatment with all complications that occurred. If we process in this way a sufficient number of cases, we shall obtain data that indicate what benefits patients as regards permanent sequelae and what does not.
As has been already mentioned, we must take into account a certain inborn predisposition for scar formation.' Furthermore, permanent sequelae depend on the amount of thermal energy absorbed by the affected tissue. We cannot simply evaluate the depth of the burn according to the general three-grade classification. The latter serves only to orient and to express the grade of the burn as it appears on macroscopic inspection during the initial evaluation and subsequent development. It provides, however, only limited information on the amount of absorbed heat.
For example, a burn after exposure to an electric arch without concurrent passage of current seems very deep during the first hours (Figs 2, 3). In addition to the charring of the epidermis and contamination of the surface by oxides of dispersed metals from the conductor, it does not display any signs of vitality during tests of so-called capillary return or tactile sensitivity. If, however, we cool such an affected area for a sufficiently long period and treat it subsequently by a suitable conservative technique, we find as a rule that a superficial or grade II burn is involved, although it appeared at first as a deeper burn. Permanent sequelae are as a rule of minor nature despite a temperature of the electric arch of about 3000 °C. The cause is the very short-term action of a very hot flash. Its duration is several seconds or fractions of seconds. The immense energy is exhausted on the superficial skin layers, when the corneal layer gasifies and evaporates, the epithelium carbonizes and loses all cellular water and along with it also a substantial part of the energy of the arc, and the small r emanent of thermal energy more or less damages the surface of the corium and the subpapillary capillary plexus of the corium. (Water has an exceptional capacity to absorb thermal energy during evaporation). From the preserved adnexa the area epithelizes easily, and the superficially damaged corium ensures during the stage of scarring a sufficient firmness; the development of adverse scarring is rare. In the worst case irregular coloration occurs due to impaired pigmentation after healing of the area.
In cases of burning of a patient's hand by water with a temperature of ca 80 °C during an epileptic fit, and where the exposure lasted several minutes, a very serious affection of superficial and deep layers occured (Fig. 4). The scald, which at first appears very favourable, deepens during subsequent days, and after several days it is found that the area will not heal without surgical intervention. The permanent sequelae are as a rule quite serious, and rehabilitation is difficult and prolonged. Thus a detailed history of the injury is very important. From what has been said, it ensues that for the severity of permanent sequelae the extent of tissue damage is important, in particular of the corium and other more deeply situated structures.
Repeatedly we can observe that if, after a burn or surgery during collection of an autograft, a certain borderline of the skin is passed, a hypertrophic scar develops (Fig. 5). This is a very important finding for surgical practice and the prognosis of scars. The cause is the cicatrical loss of firmness of the skin in the area of the corium. From practice it is known that after penetrating 1/2-2/3 of the thickness of the corium when collecting a graft, there is very slow healing of the site and almost. always the development of a hypertrophic scar. The value of taking off a limital graft unfortunately cannot be expressed in mm because the corium is not of equal thickness in all parts of the body surface, and moreover there are great interindividual differences in the reaction of individual patients. If we transplant a small infant during the first months after birth, the skin is so thin that the optimal autotransplant varies as to its thickness at the borderline of the technical possibilities of dermatomas. The same applies to old patients, chronically sick patients or those treated for prolonged periods with corticoids. There we have to take into account natural atrophy of the epidermis, rnoroever influenced by corticotherapy, and the concurrent rapid deterioration of dermal adnexa causes a deterioration of spontaneous epithelization at the donor site. This can be partly avoided by taking primarily a more extensive portion of skin than needed to cover the defect, and the superfluous graft is returned to the donor site, meaning that we transplant it again. The resulting effect is very favourable. The area heals quickly and remains almost smooth, without hypertrophy.
We cannot omit the necessity of correctly estimating when to leave the surface to epithelize spontaneously and when to use a surgical approach. This should be the decision of specialists who are adequately experienced in transplantation technique. Unfortunately, we frequently witness neglected deep burns left to heal spontaneously with subsequent development of a mutilating hypertrophic scar that frequently disintegrates secondarily. In its high, tough fibrous
structure there are very few suppressed immature and non-differentiated vessels that are easily closed, and the whole area which they supplied becomes necrotic. In rare instances we also encounter in these scars a malignant reverse, and an urgent operation is then life saving (Fig. 6). In reconstruction of inveterate scars the whole area must be excised and replaced by a sound autograft as should have been done much earlier. The other extreme are unnecessarily transplanted superficial burns of the deeper grade II to shorten the patient's hospitalization. This ,can be done shortly after admission to treatment when it is already obvious which parts will heal spontaneously and which ones would cause problems, but this has to be done professionally with regard to the depth of the injured tissue and the defect has to be covered by a very thin graft which contains only epithelium and the pars papillaris of the corium. We have to realize that by using a dermoepithelial graft we cover the crevices of vital adnexa in the lower part of the burnt corium, and those will resume activity after 2-3 weeks. If their outlets are covered by a strong and incorporated autograft, the secretion cannot escape freely and retention cysts develop (Figs 7, 8).
The latter are infected secondarily, abscesses develop, treatment becomes complicated an the patients are not satisfied. In the permanent sequelae then the influence of infection and a strong overlapping autograft potentiate each other. The solution is again correction either by adjustment of surfaces or intense compressive therapy during the initial weeks after healing (Fig. 9a).
An adverse aesthetic effect is aroused also by transplants with a coloration markedly different from the surroundings (Fig. 9b). We observed repeatedly that if we take an autograft of the full thickness of the skin from the inguinal area and place it in an area irradiated by sun (face, neck, hands), excessive pigmentation of the graft develops and the patient is stigmatized more by a dark spot at a visible site than by the originally uneven but light scar. (A very useful experience is a visit to a nudist beach where we can see clearly why the groin provides pigmented grafts). It is important to choose carefully from where we select the graft and where we want to transfer it. On the face the most favourable effect is produced by grafts from the inner area of the arm, although their thickness is not quite identical.
As has been already indicated, a serious problem is infection. The loss of the epidermis opens a wide field of action for exogenous (mainly aerogenic) infection (Fig. 10). Although during the first hours the burnt area is sterile due to the release of cellular immunoglobulins, their activity is soon exhausted, and if from the capillary walls sufficient amounts of fibrin effuse into the developing bullae we have to foresee an infection. In addition to aerobic microorganisms - in particular Sapht. aureus - also saprophytic bacteria from skin adnexa are involved, and therefore it is important to perforate in time the bullae which develop and evacuate their contents. If we leave the detached epithelium on the burnt surface as a suitable biological cover we can do so only for a period of 3-5 days after the injury. If we do not remove it after this period, saprophytic infection and deepening of the burn occurs. In extensive burns there is moreover the influence of acute shock due to burns. As a result, intestinal bacteria pass across the endothelial barrier into the circulation and necroses become infected by the haematogenic route from the transitory zone between vital tissue and necrosis. When evaluating scars in deep burns in relation to the early infection during treatment, Staphylococcus pyogenes aureus is most malignant as well as the now rather rare Streptococcus pyogenes beta haemolyticus. Staphylococcus pyogenes is frequently combined with other bacteria which potentiate its adverse effect by their toxins. The latter are particularly bacteria of the intestinal microflora Pseudomonas aeruginosa, enterococci, Enterobacter, Proteus and Escherichia coli. In very deep injuries, in particular after high tension electric current injuries, in exceptional cases the anaerobic flora of Clostridia is also found. Their effect on scarring is difficult to evaluate due to the rare occurrence of the infection and the generally mutilating and frequently loss involving injuries.
Thus if we summarize factors that cause the development of adverse scars after burns, they are as follows:
The latter and hithero not yet discussed circumstances must be elucidated in more detail.
A very important fact is the type of patient who suffered the injury. If he or she is a so-called biophiloriented person with an optimistic approach to serious life events and confidence in the attending staff, the resulting scars will be very acceptable and rehabilitation will cause no problems. The affected patient usually will not need any subsequent surgical operations to optimalize function and appearance; the scars will stabilize rapidly and without complications. Many of these patients do not have to use even special compressive devices although deep injuries with autografts of the skin were involved.
According to our experience, very acceptable permanent sequelae are also seen in patients with social problems, those with a tendency towards chronic alcoholism, in particular if the injury occurred in a state of inebriation, and also patients who regularly take so-called hard drugs. Also in mentally ill patients who caused their injury during a suicide attempt, we usually do not encounter serious problems during scarring and stabilization of scars. As regards permanent sequelae among the group of suicides, those patients are best off who meant their attempt as a demonstration to achieve some objective and were, according to their own opinion, successful in their activity: the target was achieved, the unbearable situation was resolved.
<% immagine "Fig. 1","gr0000001.jpg","The scald on the back was deep, on the shoulder more superficial. The sharp borderline between the different types of affection is of interest - where the magic borderline at the level of the corium was passed. On the shoulder there will not be any permanent sequelae, on the back impaired pigmentation.",230 %>| <% immagine "Fig. 2","gr0000002.jpg","",230 %> | <% immagine "Fig. 3","gr0000003.jpg","",230 %> |
Figs 2 and 3. Burns by an electric arc seem very deep at first, requiring necrectomy and autotransplantation. After correct cooling the condition improved to such an extent that the areas will heal without surgery. Impaired skin pigmentation may be a permanent consequence.
| <% immagine "Fig. 6a","gr0000006.jpg","Older hypertrophic scars necrotize as a result of ischaemisation; they disintegrate and frequently become infected. In the picture: an abscess in the scar with a capillary drain.",230 %> | <% immagine "Fig. 6b","gr0000007.jpg","Repeated disintegrations of hypertrophic scars lead to chronic irritation, which may undergo malignant reversal. In the picture: a carcinoma in the scar after scalding of the skin 50 years previously.",230 %> |
| <% immagine "Fig. 7","gr0000008.jpg","",230 %> | <% immagine "Fig. 8","gr0000009.jpg","",230 %> |
Figs 7 and 8. An originally not very deep scald of the chest,which was unsuitably excised and covered by a very thick autograft. The covered adnexa led to the formation of cysts and abscesses. The borders of the thick graft with epithelium beneath them necrotize and separate.
| <% immagine "Fig. 9a","gr0000010.jpg","Unprofessionally performed autotransplantation of area IIb with a very thick graft, which morover has a coarse network on a visible part of the body. The patient attended the Burns Clinic for a reparative operation: the whole graft was removed and the area was evened out.",230 %> | <% immagine "Fig. 9b","gr0000011.jpg","Markedly hyperpigmented autograft, taken in the groin and inserted after excision and release of scars on the palm. If such a transplant is placed in the face, it is frequently more striking than the scar which it replaces.",230 %> |
Rehabilitation after burns is divided into two basic groups: physical rehabilitation, psychic rehabilitation.
Physical rehabilitation serves the maximum maintenance of the mobility of the patient's joints to preserve muscular function. We can divide it into early and late rehabilitation.
Mental rehabilitation is focused on the possible optimal reintegration of the patient into society with a clear perspective of future work and social integration. And similarly as in physical rehabilitation, we can divide it into early and late rehabilitation.
Early physical rehabilitation
It is started as soon as possible after the injury. In minor burns this is immediately after regression of the painful stage and after termination of the period of cooling of the burnt surfaces (face, neck, hands). In serious burns we start rehabilitation already during the period of the acute stage, i.e. the period of acute burn shock. Its extent depends, however, on the site of the burns and the general condition of the patient.
Minor burns can be treated in a high percentage of cases in out-patient departments. If the burn affects the upper extremities - most frequently the hands - we recommend to position the affected area to facilitate the outflow of venous blood and lymph from the injured area. The position on the vertex of the head or at least in a sling, if the mobility of the extremities is restricted was suitable. As a rule, the patient himself knows the best position according to the painfulness of the affected areas. We recommend to keep the lower extremities in a recumbent position supported by suitable soft material (a cushion) to facilitate the flow of blood and lymph to the heart. Walking should be limited to as little as possible with regard to the greater possibility of infection of injuries of the lower extremity. This applies even more to diabetic patients.
Post-injury oedema causes deterioratibn of the blood and lymph circulation; the removal of metabolic products from the injured area is retarded, and the medium acidifies due to the accumulation mainly of lactic acid and thus irritates the nerve endings in tissues. To this we have to add also the compression of nerve fibres by the oedema and hydrostatic pressure of the blood column. This applies in particular to burns of the lower extremities. In addition to unpleasant painful sensations, oedema also causes the deepening of originally more superficial burns. The slower circulation leads to the formation of microthrombi in the subpapillary plexus and possibly also in the subdermal plexus, and if this weakened tissue is affected by a secondary infection, necrosis develops rapidly, from a superficial burn a deep one develops that can no longer be treated conservatively and it is necessary to make a surgical intervention necrectomy - and possibly a dermal autograft. Permanent sequelae are the rule.
If there are problems with adherence to the suggested regime and if the situation of the patient's family permits, we recommend possible short-term hospitalization.
In burns of the face and neck we adjust the bed into a semi-sitting position with slight back bend of the head. Immediately after the injury we cool the areas by means of compresses for a sufficient time, i. e. as long as they give the patient relief. In grade I burns where there are no bullae it is sufficient to cool the areas for 2-3 hours; in solar dermatitis, however, much longer, sometimes for more than 48 hours. The deeper the burn, the longer the period of cooling it requires. The most frequent affection is grade II a and in hospitalized patients we terminate cooling after 18-24 hours. Concurrent administration of analgesics and antihistamines (promethazine) is suitable for prevention of early post-injury oedema. Facial oedema also has, in addition to possible deepening of the areas, a very important psychological aspect. The face is the "visiting card" of man, and the smaller the oedema and deformity, the more favourably the patient experiences his injury. Oedema of the eyelids and the impossibility to communicate with the environment is another complicating injury and certainly does not promote the course of therapy. Oedema of the lips makes food and fluid intake impossible and also causes discomfort during therapy. Cooling must be done very carefully, respecting principles of asepsis because the open area after removal of the bullae is freely accessible to external infection and the latter deepens the superficial burn and threatens the patient with permanent sequelae. This has again a very important sociological and communicative impact on the patient. This problem will be discussed in detail in the section on mental rehabilitation.
The anterior part of the neck is frequently burnt along with the face. It is important to emphasize to the patient from the first moments of the injury that for the further development of areas at this location, it is extremely important that he should keep the head in a slight backward bend. He will thus prevent maceration of contact areas in the natural folds of the skin on the neck, their deepening by pressure and infectious complications. If the burns are deeper, or deep oedema also affects as a rule the flat m. platysma, its individual fibres necrotize and succumb to fibrotization, scarring and shortening. Rehabilitation after healing of this area is extremely difficult and calls for special procedures, materials and frequently also reconstructive surgery, in particular if the patient's cooperation is not optimal. In this case we recommend to the patient that from the beginning he should not use a head support and in particular that he should not use a soft cushion. The latter due to its consistency adjusts to the shape of the head, and if the pinnae are also affected, it deforms and compresses them. This leads to ischaemic chondritis, sequestration of cartilages and scarred deformities, which again cause marked social stigmatization of the patient.
In hospitalized patients we position burns in the area of the upper extremities in slings made from sterile towels, or we use as support polyurethane blocks packed in sterile towels. In burns of the hands we always ensure a well-shaped bandage and carefully respect basic rules of bandaging technique. The thumb must alway be separated from the other fingers. The fingers are positioned in a physiological position - slight semiflexion in all joints - separated from each other by an adequate layer of bandages to prevent maceration of contact surfaces of individual fingers. The wrist is maintained in slight semiflexion or straight. It proves useful to apply a suitably shaped splint, which moreover maintains the selected position of the hand and also protects it against possible mechanical impacts that are painful for the patient. Already at this stage we can select slightly elastic bandage material that is available in our distribution network under the name PEHA Crepp. It shapes even complicated areas of the body very well, it does not press and tighten, and moreover by slight compression it reduces the development of early posttraumatic oedema. It also makes possible slight mobility of the affected area, which is very important for subsequent rehabilitation procedures. If a patient with burnt hands is able to look after himself at least partially, the psychological effect also plays a part as the patient does not have to rely completely on the assistance of others. This factor is repeatedly emphasized by patients.
If burns of the hands require surgery with necrectomy and subsequent autotransplantation, the above-mentioned positioning after surgery is particularly important. We observed repeatedly that unsuitably bandaged fingers in complete extension or even slight hyperextension (in particular due to incorrect application of the fixation bandage) cause great problems to the patient during rehabilitation after healing (Fig. 11). The local finding then creates an impression as if the affected hand permanently remembered the position immediately after surgery and subconsciously considered it as optimal. It is of no avail to explain logically to the patient how he should rehabilitate and what position the hand and fingers should take. It is a subconscious reaction that recedes very slowly, and in some cases it can be helped only by very vigorous rehabilitation procedures, which of course also involve some pitfalls.
The lower extremities also have some peculiar features, starting with injuries, through surgical procedures and ending with rehabilitation. As mentioned already, immediately after burns we position patients to facilitate the flow of lymph and venous blood from the lower extremities. The same procedures are respected during surgery and the initial stages of rehabilitation. The greatest problems are created by spontaneously healed burns of deep grade II. If the patient starts to walk too soon on the fragile surfaces, serous bullae are formed and the fragile epithelium breaks, the area becomes infected and frequently poorly healing granulation areas develop. The cause is very simple. After removal of the superficial necrosis in burns of grade IIb (surgically or conservatively), the pars papillaris of the corium is also removed. It was destroyed by the burn. After epithelization of the remaining necks of the dermal adnexa, the newly formed epithelium becones attached to a flat, very thin layer of granulation tissue formed by a dense capillary network and free cellular elements with the ample pArticipation of fibroblasts. Because so far the saw-like structure of the papillary layer of the corium has not been created, the epithelium is not fixed to the connective tissue and even minor mechanical strain becomes threatening for it. In the lower extremities, moreover, the hydrostatic pressure of the blood column and poorly drained lymphatic spaces dominate. Minor blood and lymphatic capillaries break, and the emerging sanguinolent fluid breaks away the epithelium. Due to the high protein content, it is also an excellent nutritive medium for ambient bacteria that complete the disaster. In the initial stages, when it is necessary for the patient to start rehabilitation, we resolve this controversial situation by careful application of elastic bandages over a light soft gauze bandage. If the patient is in bed, the bandage need not be applied. When, however, the moment approaches when he should stand up and the hydrostatic pressure will burden the fragile epidermis, the patient applies, either by himself or with the assistance of a nurse, a bandage and reinforces the healed areas. After termination of exercise, he releases the bandages. Important support is also offered by this compression to patients with affections of the superficial or deep venous system, as known from general surgery. There this rule applies even more.
Early rehabilitation is also important from another aspect. Muscular activity releases endorphins, which reduce the threshold of pain. The patient does not perceive pain or pressure in the healed areas and does not require administration of analgesics, sedatives or antihistamines. Because he moves, walks and can partly look after himself, he also becomes mentally better balanced and possible complications are reduced to a minimum. Minor dressings do not require anaesthesia and his immune system is not weakened.
In extensive burns, early positioning of the upper extremities in wide slings made from gauze is used, with a 90° sideways extension of the arms and slight forward extension. The lower extremities are then suspended in a slightly elevated position with the legs 20° apart. The trunk is supported by a polyurethane mattress from the shoulders to the buttocks. The head is maintained in a mild backward tilt to prevent contractures of the anterior area of the neck (Figs 12-14). In burns of the back we place the patient on his stomach or in special air beds (SSI Clinitron).
The same procedures are used during surgery and in the initial stages of rehabilitation. As support we most frequently use polyurethane prisms beneath the knees and legs above the Achilles tendon in slight semiflexion of ca 5° or slings prepared from sterile gauze. In burns of the feet it is necessary to prevent shortening of the triceps of the leg with permanent plantar flexion, which is a very serious complication in rehabiliting the gait after healing of the burn. We insert into the patient's bed a suitable firm support to ensure that the planta is in a standing position. The possibility of early rising from bed and rehabilitation of gait is ideal. Bandaging by means of elastic bandages prevents the development of hypostatic oedema, it hastens the venous and lymphatic circulation in the lower extremities, and by compression it prevents the development of haematomas beneath not yet firm skin transplants or fragile newly formed epithelium of spontaneously healed areas, in particularly in deep burns grade II. There, very frequently serious or sanguinolent bullae are formed, the thin epithelium breaks, the area becomes secondarily infected and poorly healing granulation areas develop. An elastic bandage is also a very important aid after surgical operations, as it prevents blood losses and the development of haematomas beneath autografts: It also prevents their possible shifting after an unsuitable movement.
Late physical rehabilitation
Late rehabilitation is started at the moment when the transplants are firmly incorporated and the donor areas epithelized. We rehabilitate in particular the large joints of the upper extremities and the small joints of the hands. As for the lower extremities, we pay particular attention to restoring an independent gait using elastic bandages or special elastic slipons and stockings,which may be individually made for the patient, or else we select some suitable type produced by commercial firms.
The main impediments to the restoration of normal mobility of the burnt area are:
On the feet there is a tendency towards shortening of the m.triceps surae and ensuing plantar flexion. The latter subsequently makes excercising the gait difficult and must be prevented by support for the soles and by maintaining a rectangular position in the talocrural joint. On the hands there is a special type of deformity - the "swan neck" position. This is characterized by volar flexion in the wrist and dorsal flexion in the MP articulation, and by flexion in the proximal PP joint (sometimes both) and extension of the distal PP joint. The thumb is then usually in adduction and extension. The ideal prevention is careful splinting in the early stages after injury.
| <% immagine "Fig. 13","gr0000015.gif","",230 %> | <% immagine "Fig. 14","gr0000016.jpg","",230 %> |
Figs 12-14. The three presented patterns illustrate optimal positioning of extensively burnt patients already during the first day after injury.
| <% immagine "Fig. 16a","gr0000018.jpg","Rigid-pressure technique with Duracryl splints for dental prostheses. The acrylate material does not irritate; it is easily processed mechanically, and when applied beneath an elastic mask it compresses tough resistant scars.",230 %> | <% immagine "Fig. 16b","gr0000019.jpg","Combined material - polypropylene foam thermally processable and Orthopaedic band age X-Lite made in Belgium. Both materials can be combined well. Polypropylene foam is soft and the X-Lite ensures a stable shape of the splint. Optimal temperature for processing is 110 °C.",230 %> |
Tested rehabilitation techniques
Pressure massage
It serves the expression of deep post-traumatic oedema in the area of the joints and prevents the development of hypertrophying scars. It is implemented as follows: we press with the finger tip the particular site for 30 seconds, and then we expel a deep oedema from the scar or rehabilitated area (Fig. 15). Then we shift a finger width to a neighbouring area and repeat the same technique. We always proceed from the periphery towards the heart and thus shift the oedema back into the circulation. When the oedema is reduced we start with rehabilitation of the joints, articular capsules and tendons and the appropriate muscle groups.
Elastic compression
Pressure massage is very effective but time consuming, and thus it is only used in areas with a particularly adverse course of scarring. In other parts of the burnt area we use compression by a special elastic aids prepared from elastic non-irritating materials such as elastic bandages, elastic tubular aids with a width corresponding to the compressed area (Lastogrip, Raucopress) or individually prepared elastic aids, Tshirts, slips, gloves etc. made to measure for individual patients. The material must be sufficiently pervious, nonirritating, and easily laundered (processed crepe polyamides etc.).
Rigid compression
On sites with a complicated shape or those with very tough and prominent scars, resistant to simple elastic compression, we place suitably shaped compression splints (Figs 16a,b). They are prepared from nonallergenic plate thermoplasts (acrylates, polypropylene, polyurethane, Sanplast) that are precisely shaped for certain minor areas, or we select casting polymers used in the health services (acrylates etc.).
Special materials
Very recent scars, shortly after epithelization of the burn, can be positively influenced by silicone materials (Sil-K, Topi-gel...). Frequently, even elastic compression is not necessary, never theless a combination of both potentiates their effects and the results are much better. A similar effect is also exerted by the gel material Medigel or Silipost. The elastic jelly-like material contains mineral oils that are nonaggressive to the skin surface and do not cause allergic reactions. They influence the surface of the scars similarly as silicone materials (Figs 17, 18). They optimize gas exchange and modify the exchange of water vapours on the surface of the recent scar, they pacify the surface of the newly formed epithelium and mitigate the inflammatory reparative reaction in deep burns, Silicone and gel materials exert a favourable effect by their physical properties on the surface of recent scars where there is not yet a functional keratin layer and the preserved skin adnexa do not yet fulfill their function. Due to this the epithelium and superficial part of the recent scar suffers from dehydration and is easily damaged mechanically (Fig. 19). This leads as a rule to minor rhagads or eczema, and the areas are then secondarily infected and disintegrate. The mentioned materials replace the function of the immature keratin layer, and then pacification of the scar does not display an inadequate tendency of hypertrophy. The range of similar materials is steadily being extended and at present covers the entire mentioned problem. However, none of the lastmentioned preparations should be applied to an unhealed area or a secondary abrasion. They do not allow penetration of early secretion and encapsulate possible infection. This leads to the development of deep defects and secondary disintegration of the healed area by infection in the wound.
In some instances physical techniques do not suffice and pharmaceutical treatment .must be used. We found the administration of the corticosteroid Kenalog into extremely hypertrophic scars useful (Fig. 20). There are essentially two forms of administration. Either the selected dose of the preparation is administered in a mixture with a local anaesthetic, as a rule at a ratio of 1:1, or else after local anaesthesia of the particular area from another syringe, Kenalog is administered into the scar (best subepidermally) to create a small whitish depot which then exerts a longterm effect on the scar and dissolves deep fibrous structures. The patient must be regularly monitored to prevent excessive resorption of the corium, thus weakening the mechanical firmness of the scar. As a rule the scar is absorbed within 2-3 months, but the reactions are very individual. If the scar does not respond to the corticoid administration its character can be altered by cryodestruction under local anaesthesia. The scar does not disappear completely but is reduced by ca 30 % and then after healing usually responds to the administration of Kenalog.
| <% immagine "Fig. 17","gr0000020.jpg","",230 %> | <% immagine "Fig. 18","gr0000021.jpg","",230 %> |
Figs 17 and 18. On fresh, well-healed hypertrophic scars,silicone elastomer foils or gel containing mineral oils can be applied. They have a favourable effect on the reparative inflammatory process, and hasten the differentiation of the scar beneath the immature epithelium.
Stretching
Physical rehabilitation must not be painful and must not interfere with basic surgical stages in the treatment of deep burns, i.e. the period of necrectomies (risk of haemorrhage) and the period of skin autografts (movement interferes with the connection of vessels to the transplanted skin graft, haemorrhage from the donor areas). Active movement and an adequate physical load release muscular endorphins, and the course of treatment is then less painful and better tolerated. Among the techniques that remedy cicatricial contractures, stretching proved very useful. It is used in many sports in which elasticity is emphasized as well as joint mobility (gymnastics, material arts, aerobics). The principle involves gradual and patient stretching of shortened areas of the body. Rapid movements have no effect on releasing contractures. The scar consists of spirally wound collagen fibres, in which the individual bends have to be removed from each other by systematic exercise and thus prolong the tough strip. It is important to stretch the scar slowly at the borderline of pain and carefully to avoid ruptures on the surface of the scar, with a duration more over 30 seconds per exercise. Only then does the scar slowly begin to protract. Exercise must be repeated many times per day for short periods. The patient needs psychic support during exercise because the result that he achieved on the previous day is almost gone the next morning, and he has to start without the effect of the previous day. Nevertheless, after a certain time the results are manifested and persist. Then progress from day to day is more marked, and the efficiency with which favourable results are achieved increases rapidly. According to our experience, the worst period of contracting scars is about 3-4 months after the injury. If the patient successfully overcomes this period and does not espair, the results are usually very good. The great majority of patients resolves the motor restrictions by this technique and surgical correction is not necessary. If the position is very difficult, in cooperative patients a minor resistant remnant of the scar is released, but most of the release is due to correct rehabilitation.
Lubrication
Deep burns lead to functional or anatomical loss of skin adnexa, in particular sweat and sebaceous glands. Both types of adnexa are of basic importance for the optimal function of the recent scar and freshly healed area of the burn (Fig. 21). In deep grade II burns it is a temporary condition before adnexa from the preserved basal parts regenerate and start to fulfill their important function, i.e. to maintain a moist and elastic body surface and to create on the surface of the keratin layer a thin protective film that prevents the penetration of bacteria. When dermoepidermal grafts are used, the basal parts of adnexa are not transferred but after some time some functional glands develop (Fig. 22). If we use autografts in their full thickness, they are already completely functional after 1-2 months following incorporation, and it is not necessary to lubricate them.
After many years of experimenting we elaborated the technique of combining light superficial massage with the application of creams containing as much as 50 % water. Mere lubrication only substitutes for the function of the sebaceous glands and omits the sweat glands. It is possible to use a whole ointment base such as Ambiderman, Synderman or Leniens, including complicated creams that contain disinfectants and regenerating substances. Ointment bases are particularly very useful in allergic patients who are sensitive to aromatic or other constituents of commercially available creams. During the last 15 years we did not have a favourable experience with lard. After its application the surface of the scars is polished, tense and obviously dehydrated, and long-term application led to the development of allergies and eczemas. It is useful to check patients regularly, in particular during the initial period of healing when the use of a particular cream may prove unsuitable after 3-4 weeks and local irritation may develop. It is necessary to change the preparation and follow-up its effects.
Immediately after application to the area, the patient should have a plesant sensation without burning or irritation of the scar surface. It is not possible to provide exact advice on the period of lubrication; in some patients 2-3 months are sufficient, in others a year does not suffice. An individual procedure must be selected after examination of the skin surface and the degree f maturity of the scar, based on deep local oedema and the loss of red coloration. Colour balance with the environment is a signal that the capillaries of the granulation tissue in the scar have completely differentiated into functioning arteries and veins and that the lymphatic system has also regenerated.
| <% immagine "Fig. 21","gr0000024.jpg","Inadequately lubricated spontaneously epithelized grade IIb burns on the back itch considerably, are scaly and the oedema persists for a long time before preserved skin adnexa start",230 %> | <% immagine "Fig. 22","gr0000025.jpg","Lubrication in healed and epithelized granulation areas in the vicinity of grafts is particularly important.Adnexa are not present here and practically never regenerate. If the area is not properly lubricated, it becomes too dry and the surface desquamates. Beneath the scales rhagads are formed that may become secondarily infected and result in the disintegration of the scar.",230 %> |
Psychic rehabilitation
This focuses on the reduction or complete elimination of disorders that developed by psychological means as a result of the burn injury. The disorders may pertain to psychic as well as somatic functions. The main emotion in people with extensive burns is fear of death. The impossibility of resolving the situation by oneself leads to depression. Both these conditions must already be handled at an early stage, shortly after the injury. It is possible to use suitable preparations (alpha-blockers, antihistamines, antiphobic drugs, antidepressants) that eliminate the action of high levels of mediators released by the injury into the circulation and reduce the period of acute shock.
If the patient is willing to communicate, the use of psychotherapy is very effective. It should be focused on recollecting the circumstances of the injury, recognition of the cause of injury and a final evaluation, i.e. recognition must be achieved by the patient.
In a similar way, in cases of very complicated rehabilitation, we can relieve the patient when we observe psychic blocks even in simple and non-pretentious procedures. We found repeatedly that the problem arises in the first moments after injury, when the patient is faced for the first time with his injury and also the environment expresses its opinion (possibly saviours etc., either laymen or professionals). Opinions expressed during the period shortly after the injury have a fundamental impact on further treatment and later also on rehabilitation. If sentences are used such as "It is very bad", or "You will look awful", "That arm is fit for amputation" , "With this nothing can be done" the therapeutic procedure is severely blocked and rehabilitation proceeds slowly. Permanent sequelae are marked, and the patient has difficulties to become reconciled with them. Subconsciously he is guided by the primary information, which frequently is unsuitable. If the patient is capable of psychoanalysis and after a guided conversation he is able to repeat these sentences and thus to eliminate them, the advance in treatment is incredible. During these conversations, the patients sometimes repeat even rash conclusions of the attending staff during hospital treatment or in the surgical theatre. It does not matter that he is under anaesthesia. He hears and perceives emphasized sentences as reflections on him. If they contain negative information it ~ burdens his biophil orientation and causes a deterioration of the prognosis. Nevertheless, it must be emphasized that this is treatment for communicative patients and that it is very time consuming. A primary talk immediately after injury usually takes 2-3 hours before a satisfactory result is reached. Conversations in the stage of rehabilitation last 6 and more hours, and they must be divided into several parts with approximately two-day intervals between individual visits. Occasionally it happens that after elimination of a substantial mass of emotions associated with the injury, the patient recollects another event that occurred previously, sometimes very long ago. Sometimes it is an experience that he could not have had in this life; the intensity is sometimes immense, and after repeated experience the patient gets rid of many complaints; sometimes he even changes his hitherto unsuitable lifestyle. This, however, does not occur frequently. It is also possible that after the introductory talk when the patient is not yet able to eliminate the main emotional block, he is invited to attend further therapy after two days. When he comes he may say that he experienced his traumatic experience during the night in a dream, and during the controlled return to the moment of the injury, we find that the blocking emotional charge s released and the patient is quite relaxed.
As has been mentioned, this is therapy only for very communicative patients. Others must be treated with regard to the extent of cooperation. We focus attention on detailed information on the state of the treatment, possible complications and necessary further procedures. We elucidate the unpleasant aspects of surgical operations. We carefully reduce pain by administration of analgesics. During the rehabilitation period we focus on the prognosis of the patient's social and work integration. We make use of the positive effect of different members of the family or the patient's good friends. Special care is required in patients with affections that are visible and are located on obvious parts of the body., i.e. face, neck and hands. These patients are threatened by the DF-syndrome (disfigured face syndrome).
In psychotic patients and decompensated delirious alcoholics, the intervention of a psychiatrist with appropriate pharmaceutical treatment is necessary. Regular check-ups and changes of treatment go without saying. Also relatively frequent are suicide attempts with an inflammable liquid. These patients need extra care from the nursing staff and a psychologist and psychiatric supervision. We can never rule out the danger of repeated suicide attempts by another technique.
I would like to apologize for my unintentional oversight in failing to obtain to list the names of surgeons who operated on patients presented in the figures that are part of the article ,Brest Reconstruction as an Integral Part of Brest Carcinoma Therapy (a selfpresent final report of a research project IGA MZ CR)" published in Acta Chirurgiae Plasticae, 43, 2, 2001, pp. 4253. The surgeons were M. Duskova (Figs 5, 7, 9A, 10), J. M6Stak (Fig. 6), M. Tvrdek (Fig. 8), A. Nejedly (Fig. 9B) and K. Dlabal (Fig. 11). The main reason for the oversight was that investigation of the results of the surgeries was not the objective of the project and did not form the contents of the published article. The figures served above all as illustrations of the methods used.
Therefore, I would like to express at the same time my sincere thanks also to all my other colleagues from the Clinic of Plastic Surgery, as an investigation with sufficient numbers assembled within a short period of time called for inclusion of all patients with the mentioned diagnosis treated at the Clinic of Plastic Surgery in Prague in 1993-1996, regardless of the surgeon who performed the operation.
Prague July 25,2001 - Markéta Duskovŕ, M.D., Ph.D.