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A B FIGURE6 The laser Doppler scanner (A) is helpful for the diagnosis of burn wound depth cheap ginette-35 2 mg without prescription. Its sensitivity and specificity are best between 48 and 72 h after the injury 2 mg ginette-35 amex. It is placed over the area to be scanned (B) ginette-35 2mg mastercard, and in few seconds it produces a digitized image of the burn wound discount ginette-35 2 mg with mastercard. Typical ap- pearance is that of a hyperemic area with severe discomfort and hyperestesia. Such burns do not blister, and they generally desquamate between 4 and 7 days after injury. Initial Management and Resuscitation 19 A B FIGURE 8 Second-degree burn injuries (or partial-thickness burns) present with different degrees of damage to the dermis. They usually blach with pressure and do not usually leave any permanent scarring. Deep portions of the dermis have been damaged and they tend to leave permanent changes on the skin (C, D). Initial Management and Resuscitation 21 In contrast to the former injuries, third degree burns or full-thickness burns never heal spontaneously, and treatment involves excision of all injured tissue (Fig. In these injuries, epidermis, dermis, and different depths of subcutaneous and deep tissues have been damaged. Pain involved is very low (usually with marginal partial-thickness burns) or absent. In infants and patients with immersion scalds, the burns may appear cherry red, and they may be misleading in nonexperienced hands. Burns that affect deep structures, such as bones and internal organs, are categorized as fourth-degree burns. These injuries are typical of high-voltage electrical injuries and flammable agents, and have a high mortality rate. Some partial-thickness burns, however, present with a mixture of depths, with areas that are very difficult to categorize either as superficial or deep partial-thickness. Management of these injuries has been conservative treatment for 10–14 days followed by a second assessment and definitive diagnosis. Burns that then have the potential to heal in less than 3 weeks do not require skin grafting. In contrast, burns that will not heal at that point within 3 weeks are then operated on and skin grafted. We do know that burns that heal in less than 3 weeks do so without scarring or with minimal changes in pigmentation. With the aid of laser Doppler scanning, however, most of these burns can be categorized at 48 h after the injury as either superficial or deep, and definitive treatment can be begun without much delay. After a definitive diagnosis has been made regarding size and depth, burns can be classified as minor, moderate, or major injuries (see Table 6). A major burn injury is defined as greater than 25% BSA involvement (15% in children) or more than 10% BSA full-thickness involvement. Major burns require aggressive resuscitation, hospitalization, and appropriate burn care. Additional criteria for major burns include deep burns of the hands, feet, eyes, ears, face, or perineum; inhalation injuries; associated medical conditions; extreme age; and electrical burns. Moderate thermal burns of 15–25% BSA or 3–10% BSA full-thickness often require hospi- talization to ensure optimal patient care. Other criteria for admission include concomitant trauma, significant pre-existing disease, and suspicion of child abuse. LABORATORY AND COMPLEMENTARY TESTS Routine admission laboratory evaluations should include the following: Complete blood count Coagulation tests, including D-dimmers and fibrinogen Blood group type and screen 22 Barret A B FIGURE 9 Third-degree burns present with complete destruction of the skin and different degrees of soft tissues (A). Their appearance ranges from white, non- blanching, and leathery (B) to nonblanching, red discoloration due to hemoglobin denaturation Initial Management and Resuscitation 23 C D FIGURE 9 (Cont. A charred leathery dry eschar is typical of flame burns, more obvious in burns caused by ignited liquid flammables. Superficial partial-thickness burns of the head, hands, feet, or perineum 4. Burn surface involvement of more than 25% body surface area (15% in children) 2.
The sa- crum is the resting point about which this erect posture is achieved purchase ginette-35 2mg without a prescription. The development of the upright posture requires a specially-shaped spinal column cheap ginette-35 2 mg mastercard. The double-S-shaped human spine differs from the single-S-shaped spine of Postural development from the fetus order ginette-35 2mg, via the infant and toddler ginette-35 2mg visa, to the quadruped in its additional lumbar lordosis. Flexion contractures of up to 30° are held by the head and feet, the opposite side can be made physiological. Resolving infantile scoliosis used to be much extensors are the first to be strengthened, providing the more common in the past, and is rarely encountered infant with head control. This is possibly attributable to the trend (after is also capable of sitting up, albeit with total kyphosis of 1970) of placing the infant in the prone position. At this stage the lumbar lordosis is still lacking, recently (since approximately 1992), the prone position is which is a physiological finding during this period before being abandoned following the discovery that sudden in- 3 the start of walking. But this process does not fully par- seen an increase in resolving infantile scoliosis since then. In toddlers this hyperlordosis is often not The prognosis for resolving infantile scoliosis is very compensated by a hyperkyphosis of the thoracic spine, good, as almost all of these curvatures disappear during resulting in the scenario of the »hollow back«. This did not always used to be the posture in the toddler is characterized by the physiologi- case. Some cases of apparently resolving infantile scoliosis cal weakness of the muscles and the general laxity of the persisted and developed into progressive idiopathic in- ligaments that is typical of the constitution at this stage. The observation that the shape shortly before puberty, although this shape is still difference between the angle made by the ribs and the dependent on the state of the muscles. In the elderly, the spine when seen from the side is greater in the progressive spine again resembles the kyphotic picture of the infant forms than in cases that spontaneously resolve themselves (⊡ Fig. The persistence of The condition of progressive infantile scoliosis has this reflex can lead to an asymmetrical development of almost disappeared even in Scotland, where the condition the muscles and the condition known as resolving infan- was particularly common. Resolving infantile scoliosis is a single arc- the disease has an extremely poor prognosis, resolving shaped curvature of the whole spine resulting from the infantile scoliosis is not associated with any long-term se- asymmetrical tone of the muscles. It is completely unrelated to idiopathic adolescent ciated with little rotation and occurs with a left- or right- scoliosis, and patients with a history of resolving infantile sided convex curve with equal frequency. If the child is scoliosis show no increased risk of developing idiopathic adolescent scoliosis in later life. Postural types in the adolescent Posture is influenced by the following factors: ▬ The shape of the bony skeleton The shape is determined by genetic factors (the moth- er: »His father has exactly the same crooked back«). The position of the sacrum, which in turn is depen- dent on the pelvic tilt, also plays an important role. The steeper the sacrum, the less pronounced the sagit- tal curvatures (lordosis and kyphosis). If our muscles are not activated, then we simply »hang« from our ligaments. Such a posture can best be adopted by overstretching the hips, sticking out the tummy, positioning the lum- bar spine in hyperlordosis and tilting the upper body backward to offset the forward shifting of the center of gravity. If the center of gravity is shifted forward or backward we talk of a ventral or dorsal overhang ( Chapter 3. Postural cycle (the old man returns to the kyphotic pos- sively, however, since it is unstable and must be com- ture of the fetus) pensated for by muscle activity. Strong muscles with good tone can maintain an actively erect posture throughout the day. The condition of the muscles depends partly on constitutional factors and partly on the training status. But one other factor needs to be taken into account in relation to the growing body: The muscles, together with the skeleton, undergo substantial length growth but are unable to increase in width to the same extent. Consequently, a certain muscle weakness is physi- ological in the growing child. Only on completion of the growth phase can the »muscle corset« be trained and built up in the optimal way.
This produces less ditional transverse strap can prevent the distraction from pronounced abduction but greater flexion than standard exceeding 60° buy ginette-35 2 mg free shipping. It is easy to handle and its size can be This repositioning of the dislocated hip can take a adjusted to fit the infant buy cheap ginette-35 2 mg on-line. Since it is made from plastic cheap 2mg ginette-35 with visa, few days in some children cheap ginette-35 2 mg line, but may require several weeks hygiene is less of a problem than with the Pavlik harness, in others. The dislocated hips reduce themselves spon- for example, which is made of fabric. Naturally, this Reduction methods assumes that the infant possesses normal motor skills. We differentiate between the following options: The use of this harness beyond the age of 9 months is not ▬ manual reduction methods, recommended. In the hands of skilled practitioners, ▬ braces for reduction, reduction with the Pavlik harness is a reliable method ▬ traction methods. Child with a Pavlik harness: The harness straps can be and holds the hips in over 90° flexion and an abduction of approx. Reduction with overhead trac- On the one hand, these findings were very prob- tion must be followed by immobilization, for which ably the result of inadequate compliance on the part we use the Fettweis spica cast (⊡ Fig. The Pavlik harness is relatively com- improves the chances of a successful closed reduction plicated and the numerous straps can be confusing for and reduces the risk of avascular necrosis of the femoral the parents. The main problem is that the harness Immobilization very easily becomes soiled by the child and cannot then The following can be used for immobilization: simply be wiped down like a plastic splint. Accordingly, plaster casts, one study has shown that plastic splints are much easier splints, to manage. Another study has also reported a relatively high necrosis rate of 33% after reduction with the Pavlik harness. Traction methods We make a basic distinction between two methods: ▬ longitudinal traction, ▬ overhead traction. Longitudinal traction: Longitudinal traction for reducing the hip is the first known therapeutic procedure and was described by Pravaz in 1847. A board placed beneath the feet is designed to avoid pres- sure on the malleoli. The traction weight is initially 1/7 of the infant’s weight, but can subsequently be increased to 1/4 or more. The pulleys are shifted later- else the foot of the bed can be elevated so that the weight ally to increase hip abduction of the body is shifted towards the head. Overhead traction: Overhead traction was introduced in 1955 by Craig, and remains a widely used method even today. This traction can also be employed for older children for whom a Pavlik harness is no longer appropri- ate. Overhead traction requires the fitting of two bars at the side of the bed which are linked together above the bed by a crossbar. The degree of traction should initially be adjusted to produce a flexion of over 90°. The pulleys are then shifted laterally to gradually increase ab- duction (⊡ Fig. We shift the pulleys so as to achieve an abduction of around 70° after 8–l0 days. By this time spontaneous reduction has occurred in most cases, and this can be ⊡ Fig. A sufficiently wide section Hip spica in the Lorenz position: This oldest known is cut out of the cast around the buttocks. Self-adhesive immobilization treatment described by Lorenz in 1895 plastic inserts that prevent soiling of the cast are available fixed the hips in an abduction position of 90° (also on the market. We know from large-scale statistical analyses that very many cases of avascular Splint treatment necrosis of the femoral head have occurred as a com- Various abduction splints are used for immobilization plication of immobilization in this position. These are particularly suitable as follow-up was once assumed that this complication was caused by treatment after immobilization in a Fettweis hip spica. Numerous modifications of the Denis Browne splint, This also explains why femoral head necroses are less with the aim of producing a better position, have been frequent after reductions if the ossification center of the proposed.
Shear can be limited with the use of Biobrane to cover the grafts and hold them in place buy 2mg ginette-35 free shipping. The grafted area is then allowed to dry and the 152 Heimbach and Faucher FIGURE 9 Patient 21 months after excision and grafting using Integra trusted ginette-35 2mg. Note the better appearance of the lower chest and abdomen compared to the upper chest buy cheap ginette-35 2mg online, where Integra was not used generic 2 mg ginette-35 with visa. If wet dressings are desired, the use of a quilt dressing as described by Sheridan and others is also an option. Buttocks Burned buttock can be very difficult to manage because continued fecal soilage facilitates early bacterial invasion of deep burns. We follow the principles listed below: Remove necrotic tissue early to diminish burn wound sepsis. In patients with large burns, allow partial-thickness burns to remain unex- cised. Skin graft take over the inferior gluteal creases is poor as a result of shearing. If fascial excision is required for deep burns to the buttocks, do not excise the fat from the perirectal spaces because the resulting defect is nearly ungraftable. Principles of Burn Surgery 153 Biobrane makes an excellent skin graft dressing because it conforms well. Frequent evaluation is needed: the dressing should be removed if fecal soilage occurs. Preoperative mechanical bowel preparation, followed by a somewhat con- stipating diet, may give up to 5 days of avoidance of fecal soilage. This may be enough time for graft take that is more resistant to infection. Chest and Abdomen We follow these principles in treating patients with burns to the chest and ab- domen: Fascial excision of the chest and abdomen is reserved for char burns and patients with massive burns. Excision in the early postburn course allows easier excision: the fluid under the eschar facilitates sequential excision without the use of clysis. Care must be taken with excision near the umbilicus: many patients have asymptomatic defects in the abdominal wall. Inattentive excision in this area could lead to invasion of the peritoneal cavity that would carry an increased risk of peritoneal infection. Breast The management of the burned breast depends on the total burn size, depth of burn, age of the patient, and occasionally the social circumstances of the patient. The most common burn to the breast we see is a scald burn in a preadoles- cent girl. Deeper burns, if allowed to heal, can lead to significant scarring and later displacement of the breast. When excision is indicated, great care should be taken to avoid excision of the subareolar tissue, as it contains the breast bud. Burns needing excision of the developed female breast are difficult to treat. Extensive burns with limited donor sites and involved breasts are often an indication for simple mastectomy: this will lessen the need for skin to cover the anterior chest. Severe breast burns in the elderly woman most often are caused when a nightgown or bathrobe catches fire and this leads to deep burns. We have a much lower threshold for recommending mastectomy in these patients. This area also tends to contract easily, which leads to functional deficits. Arms are abducted to 90 degrees and splinted in position until graft take, and then range-of-motion exercises are begun. Physical therapy is crucial to achieve adequate arm function and avoid contraction. Perineum The perineum is spared in almost all but the most extensive burns. Scald burns to the genitalia frequently heal without operative intervention. Most of our experience with skin grafts to the perineum is in patients with necrotizing soft tissue infections.