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Case

Groin and upper leg

A 5-year-old girl was presented at the emergency department of the Haydom Lutheran Hospital in Tanzania, after a fire-related burn injury involving the groins, extending to the abdomen and lower extremities.

The picture shows how difficult it can be to estimate the extent of the burn by inspection shortly after the burn injury. As seen on pictures taken at a later stage, the burn deepens and a larger area is affected a few days later.

Medical history

The patient had been playing in the kitchen, when her clothes had caught fire. Since her grandmother was babysitting but unable to help due to “being mentally unwell”, she had run outside. Her neighbours had helped her extinguish the fire. There was no history of inhaling hot air. She had no known comorbidities. Tetanus status was not noted in the file. No first aid had been administered and instead she had been taken straight to the hospital. Since she lived in a nearby village, she arrived 3 hours after sustaining the burn injury. Her caregivers earned wages below the poverty line, but at Haydom Hospital they were enrolled in a poor patient fund which offered them support to cover the costs.

Physical examination

An alert, young girl was seen, clinically suspected to be in a state of dehydration. Inhalation injury was not clinically suspected. There were no clinical signs of malnutrition, and her weight-for-length ratio was between -1 and -2 SD. Her temperature was 36.4 degrees Celsius. A large, continuous burn wound was seen, involving the abdomen, left flank and both lower extremities, including the vulvae. The burn wound visible on the left thigh appears almost circular, however distal pulses and capillary refill were normal. The left axilla and upper arm were also affected. The burn depth was estimated to be mainly full thickness, due to absent capillary refill and loss of sensation, with patches of deep dermal and superficial dermal burns. The TBSA affected was estimated to be 36%. Hemoglobin level was 16.9g/dL. (Photo 1)

Conservative management

Because of the TBSA burned being over 10%, the patient was given resuscitation and maintenance fluids according to the ISBI guidelines. Ampiclox and metronidazole were started, as was routinely done for burn patients in this hospital.

Intramuscular tramadol was provided for pain relief, and Silver Sulfadiazine was applied to the burn wounds. The wounds were dressed daily in closed fashion with Vaseline dressings (Photo 2).

Surgery

Surgical considerations

Given the large size of the burn, a delayed staged approach was chosen to cover the wounds. After stabilization of the patient, a debridement would be done because of an infection, followed by multiple skin graft surgeries. This allowed the donor sites of the body (legs, back) to heal and be used again.

Preoperative care

One blood transfusion was given, due to moderately severe anemia and expected blood loss.

Surgical procedures

Debridement: infected eschar with pus removed (Photo 3)

SSG 1 after 47 days. Left thigh circular 8%, 90% graft take (Photo 4).

SSG 2 after 60 days. Left buttocks 3% + right anterior thigh 4%, 60% graft take, partial graft necrosis due to graft site infection (Photo 5).

Postoperative care

Postoperatively, the grafts were covered with tetracycline-coated Vaseline gauzes, with a layer of dry gauzes on top. In the ward, a bed cage was placed to prevent the bed sheets from damaging the grafts. The patient and caregivers were instructed not to touch the dressings. After five days, the dressings were removed to inspect the graft site. The grafts healed little by little, recurrent colonization with a purulent discharge delayed the healing process but finally almost all wounds closed with only a small granulating wound on her left buttock remaining (Photo 6).

Outcome

The patient was discharged after being hospitalized for 4 months. Despite the surgical treatment, she had developed a contracture involving both groins, limiting abduction and extension of the legs (Photo 7). Her caregivers were counseled about reconstructive surgery at a later stage, to which they agreed.

Lessons learned

At first glance, it can be difficult to ascertain the size and depth of an acute burn wound. It is vital to keep reassessing these features during the first days of admission, and adjusting the treatment plan accordingly.

With large burn wounds, especially those involving possible donor sites, a staged approach is often required, with 2-week intervals between skin grafting. This allows for re-epithelialization and thus repeated use of the donor sites, limiting iatrogenic discoloring of the unaffected skin.

Another lesson that the doctors learned looking back over the file of this patient was not to forget the tetanus injection in burn victims. They had experienced tetanus in previous burn patients and were reminded that such an important yet simple action is easily overlooked.

From the patient’s perspective, the father expressed that he was happy with the patience of the nurses during the daily soaking sessions. He also understood that the contractures had been difficult to prevent and the communication about the possibility for contracture release surgery in the future had given him hope.

Case

Groin and upper leg