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Case

Lower leg

The patient's burn injury occurred as a result of a seizure episode, during which she fell into an open fire. The incident resulted in burns on her left elbow, abdomen, thigh, and lower extremity (Photo 2). Initially, she sought treatment at a local dispensary, where conservative measures were applied. However, due to a worsening of her condition, she was subsequently referred to Haydom Lutheran Hospital. It took her six days to reach the hospital from the time of the burn injury.


The patient had a long-standing history of epilepsy, which began in childhood. She had been prescribed phenobarbital to manage her condition, but her epilepsy was poorly controlled. Apart from epilepsy, she did not have any other significant medical conditions. She was married but did not have any children.

Medical history

The patient's burn injury occurred as a result of a seizure episode, during which she fell into an open fire. The incident resulted in burns on her left elbow, abdomen, thigh, and lower extremity (Photo 1). Initially, she sought treatment at a local dispensary, where conservative measures were applied. However, due to a worsening of her condition, she was subsequently referred to Haydom Lutheran Hospital. It took her six days to reach the hospital from the time of the burn injury.

The patient had a long-standing history of epilepsy, which began in childhood. She had been prescribed phenobarbital to manage her condition, but her epilepsy was poorly controlled. Apart from epilepsy, she did not have any other significant medical conditions. She was married but did not have any children.

Physical examination

Upon arrival at the emergency room, the patient appeared unwell but conscious and alert. Her body temperature was measured at 39°C, and she exhibited tachycardia. With a BMI of 14.7, she was underweight.

The patient had four deep burn wounds on her left side, affecting an estimated total body surface area (TBSA) of 10%. Specifically, the burns were located on her elbow, thigh, abdomen, and lower leg. In this example, we focus on the fourth-degree burn on her left ankle. The burn site exhibited eschar formation and showed signs of herbal treatment, as well as indications of infection with the presence of pus (Photo 2). Additionally, a previous burn scar was observed.

Conservative management

Since the patient arrived at the hospital six days after the burn injury, the Parkland formula for fluid resuscitation was no longer applicable. However, rehydration and a protein-rich diet remained crucial. Intravenous fluids were administered to address fluid loss and prevent secondary sepsis. To combat infection, Ampiclox was administered intravenously. Pain relief was provided through intramuscular tramadol and oral paracetamol. The patient's regular medication of phenobarbital for epilepsy was continued. The burn wounds were dressed using a closed technique with Vaseline/tetracycline while she awaited surgery. Attention was given to ensure the patient's nutritional needs were met.

Surgery

Surgical considerations

In a septic patient with evident infection originating from the burn wounds, prompt debridement becomes essential once the patient's condition is stable enough for surgery.

Managing a wound with exposed bone presents significant challenges. To ensure the viability of the bone, it is crucial to maintain an aseptic and moist environment. This can be achieved using advanced wound dressings such as vacuum-assisted therapy or through repeated wetting of regular dressings.

Given the limited resources in this setting, several surgical options are available:

Local or free flap: This is the preferred option as it promotes rapid healing, although it requires advanced surgical techniques.

Healing by secondary intention: This method is time-consuming but can be aided by bone fenestration. Bone fenestration involves drilling small holes across the exposed bone to facilitate epithelialization from the marrow. Once the bone is covered, split skin grafting can be performed to close the defect.

Surgical amputation: In extreme cases where other methods fail, amputation may be necessary.

In this particular case, due to limited flap options and equipment to perform a free flap, the surgical team chose bone fenestration as the treatment approach for the patient's left ankle.

Surgical procedures

After a two-day period, the left ankle was debrided, and fibula fenestration was performed using a drill (Photos 3 and 4). During this procedure, the remaining sides of the wound were closed using flaps and/or split-thickness skin grafts (SSGs).

After 30 days, granulation tissue was observed covering the fibula, indicating that the wound was ready for split skin grafting (Photo 5).

Postoperative care

Following the bone fenestration procedure, the nursing team, along with the patient and their family, received instructions on the importance of regularly soaking the dressing. Dressings were changed on a daily basis to maintain a clean and moist environment.

After the skin grafting procedure, the grafts were covered with tetracycline-coated Vaseline gauzes, with a layer of dry gauzes placed on top. To protect the grafts from damage, a bed cage was positioned in the ward to prevent contact with the bed sheets. The patient and caregivers were specifically instructed not to touch the dressings.

After five days, the dressings were removed to assess the graft site. Subsequently, the wound was covered with a protective gauze, and gradual improvements were observed over time (Photo 6).

Outcome

The patient was discharged from the hospital after 39 days of admission. At the time of discharge, there were still small wounds present on the fibula and calcaneus, covered with crusts. Due to financial constraints, surgical secondary closure could not be performed, and the patient received further treatment as an outpatient.

Over the following years, the patient received regular follow-up care. The wound continued to heal gradually, although she experienced pain in her ankle when walking long distances. She continued to live with her parents, as her relationship with her husband had ended after 2.5 years. Her epilepsy remained relatively stable with the use of phenobarbital, with an occurrence of one epileptic attack per month. However, her mood was affected by her circumstances, and she was offered psychological support to help cope with the emotional challenges (Photos 7, 8, and 9).

Lessons learned

Epilepsy and Burn Injuries: The case highlights the heightened susceptibility of individuals with epilepsy, particularly in lower-to-middle income countries, due to their vulnerability during seizures. Raising awareness about this risk and implementing preventive measures are crucial steps to mitigate burn injuries in this population.

Complexity of Managing Fourth Degree Burns: Managing fourth degree burns involving bone exposure poses significant challenges, necessitating reconstructive surgery, continuous wound care, and substantial time for proper healing. The choice of reconstructive options depends on factors such as burn location and available resources. In this case, considering alternatives like the cross-leg flap, though considered outdated, could have been beneficial. Extending the hospitalization period, possibly to six weeks, might have led to improved and expedited outcomes.

Comprehensive Follow-Up Care: Comprehensive follow-up care is paramount for burn patients, involving regular monitoring, complication management, and ongoing support throughout the recovery process. However, maintaining contact with patients poses challenges, often requiring reliance on community leaders and relatives to facilitate communication. By ensuring consistent communication and tracking progress, healthcare professionals can deliver tailored care and address evolving needs or challenges encountered during recovery.

Case

Lower leg