|Year : 2021 | Volume
| Issue : 1 | Page : 57-62
Treatment delayed is treatment denied: A review of late burn care in patients presenting with post burn contractures to a tertiary hospital
Harsha Vardhan1, Vishal Lodhi2, Brijesh Mishra1, Divya Narayan Upadhyay1, Vijay Kumar1, Sandesh Singh1
1 Department of Plastic Surgery, King George Medical University, Lucknow, Uttar Pradesh, India
2 MBBS Student, King George Medical University, Lucknow, Uttar Pradesh, India
|Date of Submission||07-Jan-2021|
|Date of Acceptance||23-Nov-2021|
|Date of Web Publication||08-Jun-2022|
Dr. Harsha Vardhan
Department of Plastic Surgery, King George Medical University, Lucknow - 226 003, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: The primary care of a burn victim focuses on the resuscitation. The burns wound draws the attention, with interest of the provider as well as the patient waning after the healing of the wound. “Late burn care” is an important part of burns management that, if delayed, results in the formation of contractures. Simple methods suh as early skin grafting, splintage, and physical therapy prevent the development of these debilitating contractures. Despite this, postburns contractures are a common sequelae.
Aims and Objectives: The aim of this paper is to identify the lacunae in late primary care, provided to patients presenting to us with postburn contractures. Materials: A review of all patients admitted with postburns contractures from January 2016 to December 2018, was done.
Results: A total of 427 patients were admitted in this period out of which 254 responded for the interviews. The epidemiology of postburn contractures has been described. The lacunae in late primary burn care have been identified.
Conclusion: Critical contracture areas are areas, which although innocuous in terms of body surface area burnt, have a high propensity to form contractures and require special care. Public health programs, effective in combating diseases like polio and tuberculosis, can also help preventing burn contractures. Spreading awareness about the basic tenets of contracture prevention will drastically reduce the burden of burn contractures.
Keywords: Burns, contractures, critical contracture areas, epidemiology, late burn care
|How to cite this article:|
Vardhan H, Lodhi V, Mishra B, Upadhyay DN, Kumar V, Singh S. Treatment delayed is treatment denied: A review of late burn care in patients presenting with post burn contractures to a tertiary hospital. Indian J Burns 2021;29:57-62
|How to cite this URL:|
Vardhan H, Lodhi V, Mishra B, Upadhyay DN, Kumar V, Singh S. Treatment delayed is treatment denied: A review of late burn care in patients presenting with post burn contractures to a tertiary hospital. Indian J Burns [serial online] 2021 [cited 2022 Jul 5];29:57-62. Available from: https://www.ijburns.com/text.asp?2021/29/1/57/346898
| Introduction|| |
The primary care of a burn victim is concentrated on the resuscitation of the patient. “Late burn care” refers to the management of the patient once the burn wound has healed. Delayed or improper treatment at this stage can be detrimental for the patient, with contracture being a common sequelae. Early cover of the wound, within 3 weeks, adequate splintage and physical therapy limits the formation of these contractures. Despite these simple steps, postburn contractures are commonly seen in our region. A study by Puri et al., in a tertiary referral center in Mumbai, India, reported 486 patients with burn contractures, operated in a 6-year period. In this study, we aim to describe the epidemiology of postburn contractures in our patient sample and to investigate the lacunae of the “late burn care”, in patients who presented to our institute with postburn contractures.
| Materials and Methods|| |
This is a retrospective observational study. Ethical clearance was taken from the institutional ethical committee. A review of patients admitted between January 2016 and December 2018 with postburn contractures was undertaken. A questionnaire was prepared and patients admitted during the aforementioned period were interviewed. The interviews were conducted, either in person or through telephone. The data were tabulated in spreadsheets and frequency tables were created.
| Results|| |
A total of 427 patients with postburn contractures were operated in the department in the study period. The details of these patients were taken and the patients were contacted. We were able to interview 254 patients with a response rate of 59.5%.
The patients were almost equally distributed in terms of gender. Forty-nine percent (124) of the patients were females and 51% (130) of patients were males. The most common mode of burns was flame burns with 62.6% of patients sustaining burns by this modality.
The average age of patients in our study was 17.3 years. The average duration of presentation postburns was 5.63 ± 0.4 years. This can be further broken down into two groups. One group of patients present within 4 years of burns (158 patients) while another present more than 10 years after burns (72 patients). Most of the patients had the involvement of a single area of contractures [Figure 1]. We enquired regarding the extent of burns in patients presented with contractures. The most common region burnt is the hand. This was followed by the neck, axilla, elbow, and face. Contractures also occurred more frequently in the hand and the neck [Figure 2]. Only a third of the patients reported healing of the initial burn wound within the 1st month. The average distance traveled from their homes to our hospital was about 140 km. Only 100 of the 254 patients responded that they were able to resume a “productive” life. The average duration of resumption, in this patient population, was 4.16 months. None of the patients in our study received their primary care in a burns center. Independent practitioners, in small “nursing home” setups, provided the bulk of the care [Figure 3].
|Figure 1: Top left – Mode of burns in our patient sample, with flame burns being the most common, followed by scalds and electrical burns Top right – Histogram depicting the age distribution of our patient population Lower left – Histogram depicting the time duration since injury Lower right – diagram depicting the number of contractures in our patients|
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|Figure 2: Diagrammatic representation of the areas affected by contractures (top left) and the areas affected by the initial burns in the same patients (bottom right)|
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|Figure 3: Top left – Diagram depicting the time required for the initial burn wound to heal Top right – Diagram depicting the distance traveled by the patient to reach our institute Lower left – Pie diagram depicting the time at which patients were able to resume productive activity (jobs, household work) Lower right – histogram depicting the place of receiving initial care|
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Postburns wound therapy is probably the most important aspect of burn contracture prevention. Only two patients had received any form of splintage following burns. These were in the form of soft cervical collars, given for neck burns. None of the patients were given pressure garments once the wounds healed. Massage with coconut oil was prescribed to 52 patients and massage with emollients was prescribed to 27 patients. Thirty-five patients responded that they were asked to exercise the affected region. We enquired about the awareness of the patients and the education, which they received during their treatment period [Figure 4]. Only six patients responded as “yes” to any of the given questions regarding postburn contractures and their prevention.
|Figure 4: Questions asked to the patients assessing their awareness regarding burn contractures|
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| Discussion|| |
It is clear that there are a large number of patients presenting with contractures over the period of 35 months. However, this is not surprising given the routine flow of burns patients at our center. Postburns contracture is a significant issue and it is apparent that work needs to be done to address this problem. Our study shows that it particularly affects younger people, which means that these patients may have life-long functional issues. More than 90% of patients were in their first three decades of life with an average age of 17.3 years, which is lower than what is reported in studies on burn demographics., This disproportionately affects the productive or the dependent population with the whole family bearing the brunt of the morbidity. Although epidemiological studies for burn patients show a male preponderance, the gender distribution in our patient sample was uniform. In this part of the world burns in the household, both accidental and intentional, are commoner, which may explain the higher proportion of females in our patient population. As expected from literature, flame was the most common etiology, followed by electrical and scald burns. The patients traveled an average of about 140 km from their hometown to our institute. This depicts the poor penetration of facilities for burn contracture correction. There is a need for reducing this distance drastically.
Certain areas of the body like the hands and neck are prone for the formation of contractures, while others such as the face, elbow, and the axilla are slightly more forgiving [Figure 5]. The reason may be that these areas form a small percentage area of burn wound and hence do not get the necessary attention, as compared to other areas that are more important in calculating the total body surface area burnt. Thus these burns may get classified as minor burns as far as resuscitation is concerned, by have a high functional impact. The wounds here may heal relatively quickly but the subsequent remodeling requires continuous treatment in the form of splintage and physical therapy, to prevent the formation of contractures. These areas are critical areas as far as contractures are concerned. The primary treatment provider must understand the problem these small and insignificant burns may give rise to. Involvement of any of these critical areas should prompt the treatment providers to give special care in late burns care.
|Figure 5: Diagram depicting the areas of burns (bars) and the areas of contractures (lines). Neck and hands are less forgiving than face, axilla and elbow as far as contractures are concerned, thus being the critical care areas|
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The late burn care provided to our patient population is poor. Very few received early surgery and a negligible few received splintage or physical therapy. Despite suffering from the deformity, the awareness of the patients regarding contractures was nonexistent. It is not surprising that 60% of patients deemed themselves “unproductive” following burns. None of these patients received primary care in burns center. Medical practitioners, running small clinics, usually treated these victims primarily. They were referred to our institute once the primary wounds had healed. The delay in proper late burn care is a widespread problem, affecting rural population as well as metropolitan cities. There is a clear contrast here with that seen in a multi-centric study performed in the United States, which offers a higher standard of late burn care. In this study, data were collected from thirteen centers managing burns. Eighty percent of their patients underwent split-thickness skin grafting for their burn wounds. This is after the authors excluded the severe burns, which were life-threatening, from the study. Thirty-seven percent of their patients were given splintage and received almost 60 min of rehabilitative therapy per day. The effect of this was that they reported contractures in around 2% of their patients only. In a study from Ghana, a developing third world nation, only 6% of the 650 pediatric burns patients treated at their institute subsequently developed contractures. Thus even in resource-constrained settings, simple measures like rapid wound healing and splinting reduce the rate of contractures.
Prevention of deformities requires a series of simple steps, not requiring a plastic surgeon. The outcome, in a similar area of burn may be vastly different, depending upon the early care that has been provided. Correction of the damage caused by lack of intervention and a delay to presentation to secondary scar reconstruction is frequently intractable. Contractures affect the tissue beyond the area burnt [Figure 6], [Figure 7], [Figure 8]. The tragedy lies in the simplicity of prevention. An early cover will prevent the formation of contractures. Any practitioner can provide splintage and physiotherapy, provided the awareness is there. It is imperative to provide training to the healthcare providers at the primary level and educate the general population about postburn contractures. With this study, we have identified the centers that have managed the most number of primary burns in our patient population and plan to impart training to the healthcare providers in those centers. Public health programs have been eradicating diseases suh as smallpox and polio. A similar program for burn contractures is the need of the hour. This would be more effective in terms of preventing contractures than actual burn centers. As per the website of the National Association of Burns in India, there are 67 centers in India which provide treatment for burn, 37 in the private sector and the 30 in the government sector. This comes to about 1400 beds and around 300 intensive care beds in the country. This for a population of about 1.4 billion is grossly inadequate. The availability of a formal burns center is even sparser. There is an urgent need to upgrade the existing infrastructure for burn management. Formal burn centers need to be established, in all parts of the country.
|Figure 6: Photograph depicting the impact of early grafting, healing without contractures, both extrinsic and intrinsic|
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|Figure 7: Photograph depicting a patient who had burns similar to figure 6. Improper late burn care resulting in contractures of the neck and axilla|
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|Figure 8: Photograph depicting the ravages of contractures, with deformities persisting despite surgical release of contractures|
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| Conclusion|| |
For the policymaker, a burn victim may be a statistic, one that either succumbed or survived. But for a victim, survival is not the only goal. Proper treatment, only if provided in a timely manner, allows the victim to reprise their role as a productive member of the society. Late burn care consists of simple measures that can be provided by any health practitioner. Critical burn areas for contractures require special care. Awareness regarding the prevention of contractures through training and public health programs will help reduce the morbidity of contractures.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]