Arm
This case study focuses on a 5-year-old boy who suffered burn injuries to his arm, face, and chest. While the treatment for his facial burns has been covered separately, this example highlights the approach taken for the burn wounds on his right arm. Specifically, we will explore the implementation of a delayed grafting strategy at Haydom Hospital in Tanzania.
To learn more about the treatment of this patient's facial burns, see Face, 5 year old.
Medical history
The patient sustained burn injuries while trying to remove his clothes that caught fire while he was playing near a traditional wood stove. He was brought to the hospital two days after the injury. The patient's initial caretaker was his grandmother, but she left shortly after admission. The patient's uncle was then contacted and agreed to take on the role of caretaker after being counseled. Due to living 250 kilometres away from the hospital, the uncle did not arrive until two weeks after the initial phone call (Photos 1a and 1b).
Physical examination
Upon admission, dry and leathery burn wounds were observed on the right arm, including the elbow and wrist. These wounds exhibited signs of deep burns. The affected skin showed no capillary refill and lacked sensation. Although the burns were nearly circular, there were no indications of constriction. Over time, careful observation of the hand did not suggest the need for an escharotomy (Photo 2).
Conservative management
During the initial days of admission, the patient received supportive treatment, including fluid administration monitored by urinary output. Pain relief was provided through the administration of paracetamol and diclofenac. The burn wounds on the arm were treated by daily soaking and dressings using silver sulfadiazine (SSD) for a week.
On the eighth day after the burn, most of the eschar (dead tissue) was removed, thanks to the softening effect of SSD (Photo 3). After two weeks, the patient's condition stabilized, and the wounds were deemed ready for surgery (Photo 4).
Surgery
On the fifteenth day, prior to placing split skin grafts, the burn wounds were cleansed. Surgical removal of all granulation tissue was performed to achieve hemostasis, using a gauze soaked in an adrenaline solution. The lateral thigh was selected as the donor site, and the graft was harvested using an electric dermatome. The split-thickness skin graft (SSG) was meshed using a scalpel (Photo 5). To secure the grafts, small, rapid absorbable sutures were utilized (Photos 6 & 7).
Postoperative care
Following surgery, the grafts were covered with a single layer of Vaseline gauze with tetracycline ointment, followed by a single layer of dry gauze and a circular bandage (Photo 8). The patient and their caretaker were instructed to prevent friction to avoid graft failure. On the fourth day after surgery, the grafts were inspected and showed successful adherence (Photo 9). As a result, the grafts were left undressed since they did not produce any exudate.
Outcome
After six weeks, the skin grafts had fully healed, and the patient exhibited no impaired range of motion in the wrist and elbow. Remarkably, despite not having received physiotherapy, the patient experienced no functional limitations even after one year (Photos 11 & 12).
Lessons learned
This case taught us that delayed grafting for a large deep burn wound affecting the elbow and wrist can yield positive outcomes, including a full range of motion in low-resource settings. This approach offers valuable insights for managing similar cases in similar settings, highlighting the potential for successful outcomes without extensive resources or specialized interventions.