BURN MORBIDITY (SCARS AND CONTRACTURES)

Burn injury is a very severe kind of trauma because it can lead to mortality or permanent scarring and on many occasions functional disabilities in survivors. Burn injury may be caused due to Flames (heat), Scalds (moist heat), Steam, Frost bite (Cold), Electrical injury, Chemicals and Radiation. In other words it can be caused due to clothes catching fire, contact with hot objects, spillage of hot fluids, inhalation of hot smoke, acids or alkali spillage and passage of electric current through body parts.

Burn survivors are disadvantaged in many ways. They are physically scarred, often financially drained, psychologically affected, and due to deformities may be vocationally challenged and socially ostracized.

When a person gets a Burn it is necessary to meet the right surgeon - a plastic surgeon or a general surgeon who is specialized in Burns. Primary treatment by the right doctor will help keep the deformities and scarring to a minimum.

There are many factors which affect the end result of a Burn injury. These are the depth of the burn, the percentage of body area affected, special areas affected like face, hands etc, the cause of burn like flame/ scald/ electric shock etc and most importantly the treatment provided to the patient during management of the acute burn.

A small burn in an important special area like the face, hands, fingers, feet, perineum (private parts), eyes, ears etc needs special attention as deformities in these areas will affect the survivors life to a large extent. For such burns do visit a Burn specialist or visit a large public hospital which will more often than not have the specialists attached.

Superficial burn injuries are more painful but may heal spontaneously with or without scarring. But as the depth of burn increases, the ability of skin to heal itself decreases. If left to themselves, wounds in the human body heal by contracting. Therefore, in case of deeper and larger area burns, if not managed surgically, the wounds take a long time to heal and form thick, dark and tight scars. These are called hypertrophic scars. When these occur across the joints and force them to stay in unnatural positions they are called post burn contractures. These are functionally disabling.

To reduce post burn scarring and to avoid contracture formation particular attention is required during primary treatment of the acute Burn.

As FIRST AID, whenever a person gets burnt, the most important and simplest step towards reducing the depth of Burn is to pour water over the burnt area for at least 20 -30 minutes. This will reduce the temperature of the skin and help reduce the depth of the burns and consequently the resultant scarring. Do not use ice / ice packs as it causes further injury to skin. In cold places make sure that the patient does not go into hypothermia (body becoming too cold). To stop the burning process / extinguish the flames, pour water or pat the flames off to extinguish the flames. Do not let the victim run around at it fuels the flames of a loose flowing dress.  Always remove the smoldering clothes else they will continue to cause more burning of skin. Make sure you remove all rings, watches, jewellery, belts etc. which retain heat and continue the burning process of skin as also have a tourniquet effect and cause reduced blood flow in the limbs / fingers. Even in cases of scalds, remove the soaked clothing, or it will act as a continuous source of heat. Remember to wrap the burnt area / victim with a clean sheet while transporting to the hospital.

When the patient is brought to a Burn center / hospital, the initial immediate management is aimed towards saving life by providing adequate fluids, nutrition, avoidance of infection and wound coverage.

Along with that starts the management aimed at avoidance of post burn sequelae of scarring and contractures.

This multi disciplinary management is very important. Positioning and movement of joints by therapists helps in reducing the post burn sequel. Mobilization is very important to keep the joint function normal and though initially painful, all patients are exhorted to gradually increase their mobility to be able to meet the requirements of activities of daily living. This needs to be continued even after the wounds heal and the patient is discharged and up to a minimum of 6 months, when the changes in skin begin to settle and the danger of the contracture occurring or relapsing is not imminent. During acute management patients are given dressings and over them they are given splints which will counteract the tendency of skin and joints to contract. These contractile forces start almost immediately and therefore it is important that splintage starts without delay. The patient is also advised to lie in particular positions (e.g. with a pillow below the shoulder, arms outstretched etc) which again counteract the contractile forces. Though they sound very simple, the use of splintage and positioning are the two most important steps to avoid post burn contractures in later stage and also to improve quality of life after burns.

In case patients have deep burns, they are counselled for a surgery called excision of dead and burnt skin and coverage by skin graft. It is a basic surgical principle that any dead tissue from the body needs to be removed. This is made difficult by the fact that the patient may not be haemodynamically stable and may lose some blood during surgery. The surgical decision is therefore a carefully thought of one, done on case to case basis, and balances between the risk and benefit of the surgery in the given patient. Coverage of deep wounds with skin grafts also helps reduce scarring as compared to patients who are allowed to heal secondarily over a long period of time.

Patients who have developed contractures or excessive scarring following burns need to visit a Plastic Surgeon.

Depending on the severity of the affliction, the surgeon may decide to do surgery or manage with conservative management like silicone gel sheets, pressure garments, splints exercise and massage therapy. Occasionally steroid injections may be given in hypertrophic scars. The contractures which are soft and stretchable may be opened up to a degree after which they are surgically released, while a few may do well even without the need of surgery.

Surgery of a Post Burn Contracture involves releasing the scar at its tightest point and covering the resultant wound with either thin skin (called as skin graft) or a skin flap, depending on the underlying structures. Skin grafts take up to 2 weeks to settle completely and patients may expect to be discharged after such time. Again the use of splints and positioning is imperative and needs to be continued for 6 months to a year to prevent re-contracture.

Finally, the foremost step in prevention of post burn scars and contractures is the prevention of burn itself. Each one of us needs to keep our eyes open and keep a lookout for possible reasons of burn injuries. Safe habits in work environment, homes, supervision of children and avoidance of unsafe electrical connections are a few such things which will go a long way in eradicating the bane of burns from our society.