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Case

Shoulders, upper arm and back

This case features a young boy with extensive burn injuries, including a circular burn on his right upper arm. The parents quickly brought him to the hospital where an emergency escharotomy was performed. Effective treatment for severe burns requires a strong foundation of knowledge within the family and community on how to respond to burn incidents. Timeliness of treatment is also determined by factors such as proximity to a hospital and availability of transportation.

Medical history

The boy was carrying burning charcoal with flames. It dropped on his back and arm and his clothes kept burning for some time. The father applied traditional medicine on the wound: ashes mixed with eggs and herbs. The parents wanted to take the patient directly to the hospital but had to wait two hours for transport. They arrived 5 hours after the burn accident happened (Photo 1).

Physical examination

He presented with a dry mouth and reduced urine production. The wound was covered with a traditional mixture of ashes, eggs and herbs. Wounds were therefore difficult to assess in the emergency department (Photo 2). He had an estimated TBSA of 20%.

A circumferential burn of the right upper arm was suspected, with edema in the lower arm and hand. The patient was not able to confirm sensation in the right hand. The team decided that an emergency escharotomy was indicated.

Conservative management

The patient received fluid resuscitation and maintenance fluids via a peripheral intravenous line.

Urine output was monitored. He was prepared for theatre.

Wound inspection under general anesthesia revealed dry, leathery skin which was black and whitish appearance. 

Estimated TBSA burned 15-20%. Functional areas: posterior head, shoulders and an almost circular full thickness burn of the right upper arm (Photo 3).

Surgery

The patient received fluid resuscitation and maintenance fluids via a peripheral intravenous line.

Urine output was monitored. He was prepared for theatre.

Wound inspection under general anesthesia revealed dry, leathery skin which was black and whitish appearance. 

Estimated TBSA burned 15-20%. Functional areas: posterior head, shoulders and an almost circular full thickness burn of the right upper arm (Photo 3).

Postoperative care

Post-operative care 1

The boy underwent daily soaking and dressings (Photo 5).

One unit of blood was given in the first week to maintain a Hb above 10 gr/dl. 

In this setting a delayed staged grafting approach was chosen. 

Post-operative care 2 and 3 

Tetracycline ointment with one single layer of Vaseline gauze was placed on both the donor and acceptor sites. Dry gauzes were applied on top and fixed with a circular bandage. 

The wound was inspected after 3-4 days. In a tropical setting, thick layers of bandages are avoided to prevent infection underneath. Both the patient and parents should be carefully instructed that friction is a major cause of skin graft loss. After both sessions of skin grafting the take of the grafts was good (Photo 9).

Outcome

Hand function was fully preserved, probably thanks to a timely escharotomy.

Availability of physiotherapy was limited to the time the patient was hospitalized.

The boy and his parents were instructed to perform exercises to improve shoulder and elbow function. 

However, a contracture of the axilla and elbow could not be prevented (Photo 10).

Over time the function improved slightly but a contracture remained after four and five months (Photo 11 and 12).

Lessons learned

The doctors involved in the case drew several important conclusions:

Performing Escharotomy: The doctors recognized the significance of performing an escharotomy, a procedure that involves releasing constricted burned tissue. They learned that this skill is essential in preventing amputations and improving blood flow to the affected area.

Delayed Staged Skin Grafting: In low-resource settings, the doctors found that delayed staged skin grafting is a safe and suitable approach. This method involves a step-by-step process of grafting, allowing for better wound healing and positive outcomes.

Importance of Follow-Up: The medical professionals emphasized the importance of proper follow-up. Regular evaluations are necessary to assess the functional outcome of the patient's recovery over time. These follow-up visits enable doctors to monitor progress, address potential complications, and optimize long-term outcomes.

Treatment of Contractures: The doctors acknowledged that contractures, a tightening of the skin and underlying tissues, may develop as a consequence of the burn injury. However, they highlighted that contractures can be treated effectively through various interventions.

The patient and his parents expressed their thoughts and emotions throughout the treatment process:

Initial Fear and Concerns: In the first few weeks following the incident, the family experienced intense fear and concerns about potentially losing their child. The severity of the burn injury understandably caused great distress.

Apprehension about Skin Grafting: The family expressed particular apprehension about the skin grafting procedure, especially because it involved creating new wounds on the legs. This fear stemmed from the anticipation of additional pain and the unknowns associated with the treatment.

Hope for Contracture Release: The family expressed hope that contracture release procedures would be possible in the future. They recognized the potential impact of such interventions in further improving the patient's functional abilities and quality of life.

Case

Shoulders, upper arm and back