POST BURNS CONTRACTURE – AN AVOIDABLE MORBIDITY
Burns is tissue injury caused by open flames, hot liquids such as water or oil. Other agents such as steam , electric current can cause severe burns. The skin , subcutaneous tissue, muscle, blood vessels and bones could be burnt. Chemical agents in high concentrations such as acids or caustic soda can cause skin and mucosal burns either accidentally or intentionally( suicides). Burns injuries sustained from fire in enclosed spaces can lead to inhalation of noxious fumes injurious to health . Victims can also sustain burns to the respiratory tract leading to oedema and subsequent airway obstruction and death without immediate intervention. Circumferential burns to the neck and chest can compromise ventilation. Circumferential burns to extremities can result in compartment syndrome and threaten limb loss .
The severity of injuries depends on the burnt surface area, concentration of chemical agents, duration of exposure to agent. The elderly and the young are vulnerable to sustaining severe injury as they are not strong enough escape from burning buildings. Epileptics tend to sustain deep burns. They may fall into fire after a seizure attack and burn for prolonged period if relatives are not around to rescue them
The burns patient is at risk of rapid fluid losses leading to acute renal failure. Other complications are sepsis, anaemia, malnutrion. The patient’s lowered immune state predisposes him to opportunistic infections.
In my residency rotation in the burns and reconstructive unit of komfo Anokye Teaching hospital, Kumasi i have come across several patients referred to the unit with post burns contractures. Most of the patients are children aged between 2 and 5 years . The common agents of injury was accidental exposure ( falls) into hot liquids such as soups and hot water. Victims were usually from low income homes . Initial management comprised pouring cold water on the victims after which several agents were applied with the intention to either sooth or aid healing of the wounds. Some of these agents are egg white, bath water, cow dung, herbal mixtures . Late presentation to the primary care facility after such treatment leads to onset of severe sepsis causing patients to succumb to death from infection rather than the degree of burns .Patients were sent to hospitals. parts of the body involved in the body injury were trunk , face , upper and lower limbs. Flexural areas such as neck and groin were usually spared of severe burns.
Agents employed in the care of the wound are silver sulphadiazine, vaseline, gentian violet paints(not advised ) etc. If patient’s wound get healed challenging functional and cosmetic complications may result. Other long term complications of chronic burns wound are osteomyelitis and Marjolin’s ulcer ( Low grade squamous cell carcinoma)
Very severe post burns contractures involving the angle of lips, neck, armpits, elbows, groins , fingers and toes have been documented. Most of these victims pose a great challenge to caregivers who almost always have to augment apparently normal physical activities consistent with the childs age. the social stigma that is associated with the deformities can lead to children either never starting school, or having to drop out.
It is worth nothing that the primary caregivers play an important role in preventing or reducing the incidence of such contractures. It must however be acknowledged that dressing of burns wound does put physical and psychological strain on both the patients and caregivers. The wounds are usually mixed thickness and painfull. Inadequate staff strength may mean that parents have to help in physically restraining their children during change of dressings. This more often than not means that delicate areas such as the fingers and toes which must be dressed seperately may be dressed together causing them to fuse during the healing process. Other notorious deformities are healing of fingers in severe extension or flexion .
Simple but effective steps can be employed to prevent such contractures:
1. Multidisciplinary approach at total care of the burns patients. This involves the plastic surgeon, general nurse, physiotherapist, nutritionist. The best care of the wound that aids in early healing must be chosen since chronic wounds are notorious for forming contractures
2. Dressing of fingers and toes individually with non adhesive sterile packs
3. Application of splints to wounds involving major joints such as elbows , knees
4. Commencement of early physiotherapy to joints and flexural areas. This means that physiotherapist must be involved from the very beginning so that patient care can holistically planned ab initio
It is important to put a high premium on prevention of wound contractures since their effective management is surgically challenging. Scarred tissue has poor blood supply and so may not heal well with elaborate flaps , tissue transfer becoming necessary in such situations. Patients may need several staged reconstructive surgeries which is expensive and exposes patients to anesthesia risks.
The economic burden that victims impose on the immediate caregivers and later the country at large makes it imperative that contractures are prevented . Increased dependence on caregivers leads to job losses . The patients if not properly cared for may become socially withdrawn and unproductive.
DR RICHARD AMETIH,DEPARTMENT OF SURGERY,KATH, KUMASI