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Orthopaedic Surgery Board Review Manual
Statement of
Editorial Purpose
The Hospital Physician Orthopaedic Surgery
Board Review Manual is a study guide for train­
ees and practicing physicians preparing for
board examinations in orthopaedic surgery.
Each manual reviews a topic essential to the
current practice of orthopaedic surgery.
PUBLISHING STAFF
PRESIDENT, Group PUBLISHER
Bruce M. White
Senior EDITOR
Robert Litchkofski
Thermal Injuries to the
Extremities
Series Editor:
Pedro K. Beredjiklian, MD
Associate Professor of Orthopaedic Surgery, Thomas Jefferson
University Hospital, Philadelphia, PA; Chief, Division of Hand
Surgery, The Rothman Institute, Philadelphia, PA
Contributors:
Michael Rivlin, MD
Instructor, Thomas Jefferson University Hospital, Philadelphia, PA
Annamaria Tiba, MD
Assistant Professor, Department of Dermatology and Allergology,
University of Szeged, Hungary
Jonas L. Matzon, MD
Instructor, Rothman Institute, Thomas Jefferson University Hospital,
Philadelphia, PA
executive vice president
Barbara T. White
executive director
of operations
Jean M. Gaul
Table of Contents
NOTE FROM THE PUBLISHER:
This publication has been developed with­
out involvement of or review by the Amer­
ican Board of Orthopaedic Surgery.
6 Hospital Physician Board Review Manual
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Burn Injuries . . . . . . . . . . .. . . . . . . . . . . . . . . . . 7
Freezing Injuries . . . . . . . . . . . . . . . . . . . . . . . . 18
Electrical Injury . . . . . . . . . . . . . . . . . . . . . . . . . 21
Chemical Burns . . . . . . . . . . . . . . . . . . . . . . . . . 23
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
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Thermal Injuries to the Extremities
OrthopAedic SurgEry Board Review Manual
Thermal Injuries to the Extremities
Michael Rivlin, MD, Annamaria Tiba, MD, and Jonas L. Matzon, MD
Introduction
The skin is the organ through which we interact
with our environment. This resilient and incredibly
adaptive structure can often maintain its integrity
through harsh internal and external physical insults, but exposure to thermal extremes can rapidly damage healthy skin. The acral surfaces in
particular are at risk from injury due to exposure to
the elements encountered during recreational and
vocational activities or simply during everyday life.
These thermal injuries have a wide spectrum of
presentations, physiologic effects, and patient outcomes. Minor burns are frequent occurrences that
often have little lasting morbidity, while major thermal injuries can be life-threatening, with an overall
mortality rate of 4%.1 This manual discusses the
body’s reaction to the damaging effects of extreme
temperatures and agents that may have a burn-like
effect on the skin, and also reviews the presentation and management of thermal injuries seen in
orthopaedic practice.
Burn Injuries
Burn injuries to the extremities are frequently
encountered, as people often come into contact
with hot surfaces or materials when interacting
with the environment. It is not surprising that
common household burns comprise the majority
of burn injuries seen by health care providers,
since most burns occur at home.1 These include
kitchen injuries, such as those caused by spilled
boiling liquids and contact with cookware or
cooking surfaces, as well as house fires, which
account for a lesser proportion of patients presenting with burns but often involve a larger portion of the body’s surface area.
Burns can cause a wide spectrum of effects,
from a minor skin irritation, such as mild sunburn,
to a life- and limb-threatening injury from a high
temperature burn. The severity of burns depends
on a multitude of host and heat-source factors. Host factors include the body’s vulnerability
and adaptability. Patients at the extremes of age
often have little physiologic reserve, and therefore
smaller insults may create more devastating outcomes.2 Comorbid conditions, associated injuries,
and resuscitation delays exaggerate the morbidity
associated with burns.3,4 However, the major determinant of burn severity is depth and extent.5 These
variables are dependent on heat-source factors,
including temperature, heat capacity, surface area,
and duration of contact.
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Orthopaedic Surgery Volume 8, Part 5 7
Thermal Injuries to the Extremities
Table 1. Classification of Burn Wounds
First degree
Second degree
Third degree
Fourth degree
Classification
Depth
Characteristics
Healing
Superficial
Epidermis
Erythema, mild edema
2–3 days
Superficial partialthickness
Epidermis and superficial dermis
Blisters, marked edema, erythema
5–21 days
Deep partial-thickness
Epidermis and deep dermis
Thick-walled blisters, blanched skin
3 weeks
Full-thickness
All layers of skin
Deep tissue involvement
Blue-gray discoloration, hemorrhagic blisters
Deep necrosis to muscle, tendon, bone
None
None
Pathophysiology
Following contact with a heat source, the skin and
subcutaneous tissues undergo physiologic changes
on the cellular level. Jackson6 described 3 zones
of injuries that propagate following thermal injury.
From the center of the insult to the periphery, they
are the central contact area, the inner ring, and the
outer ring. At the central contact area, coagulation
necrosis begins with rapid cell death secondary to
the physical insult. This area may appear white,
yellow-brown, or charred, and tissue damage is irreversible. The inner ring in the concentric pattern of
cell injury is initially hyperemic but progresses to an
avascular, pale border, which eventually becomes
necrotic. This area is characterized by vascular stasis and is referred to as the zone of ischemia. Here,
early apoptosis and delayed necrosis occur due to
multiple factors, such as free radical damage, tenuous tissue perfusion and oxygenation, microthrombosis, and cytokine changes. Eventually, this leads
to progression of the necrotic margin.7 The damage
in this area is hypothesized to be reversible, and
therefore much recent research has focused on how
to prevent further tissue injury.8 Finally, the outer ring
of erythema is a highly vascular and edematous
region, where healing tissue begins to form and to
expand towards the center of the injury.
Healing of burns depends on the depth of tissue involvement. Superficial burns involving the epidermis
8 Hospital Physician Board Review Manual
and papillary epithelium regenerate from the intact
epithelial appendages, which allows normal healing
with minimal scarring.9 Deep partial-thickness burns
have variable healing response. These wounds may
undergo re-epithelialization from progenitor cells that
were spared in the deep areas of the papillae of the
dermis. If the burn involves deeper layers where
there are no cell lines that can aid in regeneration, or
if the tissue damage is full-thickness, healing potential is minimal without surgical intervention.
Diagnosis
When treating burns, proper wound evaluation
and characterization are required. Tissue damage
is a constantly evolving process. Frequent reexamination is necessary, and reclassification of wound
injuries helps the physician tailor the treatments
and interventions to the needs of the patient.
Classification by Depth
A common way of describing burn wounds is
based on the depth of the injury and relates to the
tissue layers affected. Dupuytren was one of the
first clinicians who classified burn wounds in terms
of depth of tissue injury, and his work is the basis
of today’s wound evaluation in burn patients.10
The most widely used current classification has
4 grades, expressed as degrees, and is based
on clinical evaluation (Table 1). However, most
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A
B
C
D
E
Figure 1. Four grades of burn injury classified by depth of
injury. (A) First-degree burn surrounding second-degree burn
blister formation. (B) Second-degree, superficial partialthickness burn, ruptured bulla. (C) Second-degree, deep
partial-thickness burn. (D) Third-degree burn. (E) Fourthdegree burn over distal interphalangeal joints with burned
joint exposed over the long finger. (Images courtesy of Professor Lajos Kemeny, MD, PhD, DSc.)
burns have areas of variable depth of involvement
and have a combination of several grades. When
describing burn injuries, the highest degree takes
priority and is used in the classification.
First-degree burns (combustio erythematosa)
are characterized by superficial tissue damage
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and involve only the epidermis (Figure 1). The
most common form of first-degree burn is sunburn,
which appears as erythematous discoloration of
the skin without blister formation or desquamation.
Mild edema of the skin is noted. The involved areas
are tender and very sensitive, but the skin barrier is
Orthopaedic Surgery Volume 8, Part 5 9
Thermal Injuries to the Extremities
uninterrupted. Therefore, first-degree burns do not
predispose patients to infections. Some superficial
sloughing may occur, but these burns will usually
heal without scar in less than a week. Sensory
modalities are unaffected long term.
Second-degree burns (combustio bullosa) are
more extensive with deeper tissue involvement
than first-degree burns. The involved areas are
exquisitely tender, red, wet, and markedly edematous. Second-degree burns are further subclassified as superficial partial-thickness and deep
partial-thickness. Superficial partial-thickness
burns produce a characteristic blistering appearance (Figure 1B). The blisters are covered with
a thin layer and contain initially clear and later
cloudy fluid. The blisters form from fluid collecting between the dermal-epidermal junction,
which has been damaged by the heat. As the
epidermis separates and lifts off, high colloid
pressure exudates accumulate. This draws additional fluid by osmotic gradient and enlarges
the collection.
Deep partial-thickness burns involve the deeper dermis (reticular dermis; Figure 1C). These
wounds appear white and pink with thick-walled,
usually ruptured bullae, and there is blanching of
the superficial layers. Pressure sensation is intact,
whereas pinprick sensation and two-point discrimination may be absent. Healing is variable but usually takes around 3 weeks.
Third-degree burns (combustio escharotica) are
characterized by complete disruption of the epidermis and dermis. These areas often appear charred
or white (Figure 1D) and are completely insensate,
dry, and hardened. With time, the edges of the
burns demarcate and the eschar separates. Recovery proceeds with contraction of the surrounding tissues without actual healing of the areas of
full-thickness burn.
10 Hospital Physician Board Review Manual
Fourth-degree burns involve both the skin and
the underlying tissues, such as fat, fascia, muscle,
tendons, bones, or joint (Figure 1E). The irreversible damage is extensive and difficult to assess initially. Since spontaneous recovery does not occur,
extensive debridement and reconstructive efforts
are required to reduce the serious morbidity that
these injuries carry.
A similar classification system by burn depth that
is based on more descriptive anatomy is sometimes preferred. Superficial partial-thickness burns
include first-degree and superficial second-degree
burns, which involve the epidermal and possibly
the upper dermal layers of skin. Deep partialthickness burns are equivalent to deep seconddegree burn and involve the epidermis and part
of the dermal layer. Full-thickness burns are thirdand fourth-degree burns, and they involve the entire epidermis and dermal layers.
It is important to keep in mind that clothing and
other melted materials can make the characterization of wounds extremely difficult (Figure 2).
Classification by Severity
Other than depth, burns can be classified by
severity (Table 2).11 Burn injury is referred to as
minor when less than 15% of total body surface
area (TBSA) is involved in adults and less than
10% of TBSA in children. Less than 2% of TBSA
can be full-thickness burns. Sensitive areas that
would produce major morbidity (ie, face, hand,
foot, genitalia) are not involved. If no comorbid
exacerbating factors exist, these injuries are generally safe to manage on an outpatient basis.
Patients with moderate burns have partial-thickness wounds involving between 15% and 25% of
TBSA. In children under 10 years old and adults
over 40 years old, involvement is between 10%
and 20% of TBSA. Less than 10% of TBSA can be
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Thermal Injuries to the Extremities
Table 2. Classification of Burn Severity
Category of Burn Injury
Total Body Surface Area
Age 10–40 years
Age <10 or >40 years
Full-thickness (all ages)
Minor
<15%
<10%
<2%
Moderate
15%–25%
10%–20%
2%–10%
Major
>25%
>20%
>10%
full-thickness burn. These patients do not have any
involvement of their hands, feet, face, or genitals,
and do not otherwise qualify for transfer criteria to
a burn center according to the American Burn Association (Table 3).12 Moderate burn injuries are
generally more serious and require inpatient medical care. Care for these burns should be provided
by physicians who routinely treat these types of
injuries. Although patients with moderate burns
may need additional medical resources, they do
not always require transfer to a burn center.
Major or critical burns are when adults have
partial-thickness burn involving more than 25% of
TBSA or full-thickness burn involving more than
10% of TBSA (more than 20% partial-thickness
burn in children under 10 years old and adults over
40 years old). These patients require burn center
care. Patients that fulfill the American Burn Association transfer criteria are automatically considered to be major burn victims. This category also
includes patients with electrical burns, chemical
burns, major trauma, inhalation injury, and serious
comorbid conditions.
Classification by Size
Although there are multiple schematic illustrations and guides to approximate TBSA involvement, many shorthand ways of approximating
wound size exist. The Lund-Browder diagram is an
accurate way to classify injuries by size.13 For quick
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Figure 2. Patient with clothing burned on skin. (Image courtesy of Professor Lajos Kemeny, MD, PhD, DSc.)
Orthopaedic Surgery Volume 8, Part 5 11
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Table 3. The American Burn Association Burn Center Transfer Criteria
•>10% total body surface area (TBSA) of second- or third-degree burns in patients younger than 10 years or older than 50 years
•> 20% TBSA second- or third-degree burns in persons of other age-groups
•> 5% TBSA of third-degree burns in persons of any age-group
•Second- or third-degree burns that involve the hands, feet, face, perineum or genitalia, or major joints
•Electrical burns, lightning victims
•Chemical burns
•Inhalational injury
•Medical comorbidities that would impact burn care
•Major trauma or fractures
•System requirements are not met at the present facility (ie, availability of pediatrician in a pediatric burn, long-term rehabilitative resources
not available, complicating social circumstances like cases of substance abuse or child abuse)
approximation, Wallace14 developed a scheme that
adds a proportion-value to areas of the body, commonly referred to as “The Rule of 9’s” (Figure 3).
As a rough estimate, the palm is approximately
1% of the body surface area. These methods are
quickly and easily applied, but they are not precise.
Therefore, for longitudinal follow-up of evolving tissue involvement, more detailed maps of individual
wounds are recommended.
Inhalation Injury
Inhalation injury is caused by thermal and particulate (soot) damage to the upper airway. The
physiologic effect of this type of injury profoundly
affects survival and morbidity in burn patients. A
high index of suspicion is required to diagnose and
properly manage these insults early. An almost
30% increase in mortality is attributed to inhalation
injury in the setting of burns.15
External clues such as coughing, black sputum,
or soot/singeing of the mouth, nose, hair, and/or
face can aid in diagnosing the underlying upper
airway damage. Heat can disrupt the fine lining of
mucous areas of the oropharynx and the ciliated
lining in the upper to lower airways. In addition,
combusted particulate matter (soot) may serve as
12 Hospital Physician Board Review Manual
a mechanical irritant causing bronchospasm or
congestion of the lower airways. Noxious gasses
(eg, carbon monoxide, cyanide, chloride gas, fluorocarbons) released by the combustive reaction
further exaggerate the hypoxic state.
Most patients with inhalational injuries do not
present in distress but rather develop it over the
course of the next several hours as edema of damaged tissue develops. Anticipating these events
through proper airway evaluation can minimize the
significant comorbidity.
Management
The management of burn patients is very complex. In the past few decades, the primary goal for
minimizing burns has shifted toward prevention.
Sophisticated fire-resistant building materials, firesafe architecture, sprinkler and alarm systems, escape protocols, and improved 911 response have
all been instrumental in minimizing fire risk.
If a victim is exposed to a heat source with the
potential for injury, extrication and efforts to minimize exposure must be undertaken while keeping
rescuers protected. Once the patient is in a safe
environment or transferred to a hospital setting, a
primary survey is initiated according to the current
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Thermal Injuries to the Extremities
BLS (Basic Life Support), ACLS (Advanced Cardiac Life Support), ATLS (Advanced Trauma Life
Support), and ABLS (Advanced Burn Life Support)
protocols, in order of escalation. Proper resuscitation and nutritional support are essential for a successful recovery. A thorough evaluation for inhalation injury is paramount as the presence of such
an injury significantly increases mortality. In these
settings, meticulous pulmonary toilet, continued
oxygen therapy, and a low threshold for intubation
are recommended to minimize these risks. A burnspecific secondary survey must include the evaluation of all wounds and affected areas. Clear and
detailed documentation of burn location, size, and
severity is required. All wounds have to be sized
and evaluated and a map must be created detailing the patient’s injuries and stages of the wounds
according to the classifications discussed above.
Palm
1%
9%*
Ant: 9%
Post: 9%
9%
Ant: 9%
Post: 9%
9%
1%
18%*
18%*
*Children:
Head 18%
Leg 14%
Transfer to a Burn Center
Upon initial evaluation and resuscitation, an
important decision has to be made determining
where the patient’s definitive care should take
place. Proper facilities and qualified specialists
are required to guide the often complex and
resource-heavy care of burn victims. Burn patient
care is very complex and should be managed by
physicians who routinely treat these injuries. Burn
severity classification, discussed above, aids in
determining the appropriate setting required in
treating the burn victim. The American Burn Association set forth guidelines that help with decision
making around which patients need transfer to a
burn center (Table 3).12 In the orthopaedic practice,
it is necessary to know specific presenting signs
that would require transfer. These include wounds
that are at least partial-thickness and involve the
hands or feet. Furthermore, patients who have a
fracture, open joint injury, burn over a major joint,
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Figure 3. Rule of 9’s.
traumatic injury, or medical comorbidities should
be transferred to a burn center.
Initial Treatment
The key in burn wound management is continuous reevaluation and interventions tailored to the
individual patient. The guiding principle of surgical
management is the depth of burn wounds. Goals
of wound management and burn surgery are to
achieve rapid wound healing with a cosmetically
appealing result, while avoiding infection, contracture formation, and excessive scarring.5
Orthopaedic Surgery Volume 8, Part 5 13
Thermal Injuries to the Extremities
Localized minor burns are often self-treated or
managed by primary caregivers, such as emergency room physicians and general practitioners.
Initial cooling of the affected area decreases
inflammation, erythema, and swelling. Evidence
suggests that tap water or saline at 8ºC (46ºF)
is as effective as any other means of dissipating
heat from the burn area.16 Thorough cleaning of
the contaminated wound is recommended to remove dirt, debris of clothing, or burned on textiles.
This may be accomplished with room-temperature
water or saline with mild soap or chlorhexidine
gluconate solution. Other substances and surfactants have been used for initial decontamination,
such as Poloxamer 188 and Medi-Sol Adhesive
Remover.
Blister management has long been a controversial area in the treatment of second-degree burns.
Proponents of blister debridement argue that the
toxic and procoagulant milieu of these blisters
exerts an unfavorable effect on the recovering tissues while creating a harboring medium for pathogens that may lead to infection.17 On the other
hand, many physicians, including the authors,
argue that intact blisters serve as biological dressings. Leaving the bullae intact aids in pain control
by providing coverage to an open wound, and also
keeps bacteria walled off in the outside environment.18,19 If blisters are tense, confluent, and large,
such that they restrict range of motion or constrict
distal blood supply, needle decompression will decrease their size while still providing pain relief and
retaining the biological dressing.
Since even minor burns are susceptible to
tetanus, the patient should have the appropriate
standard immunologic coverage or confirmation
of immunization status. In general, antibiotic prophylaxis is currently not recommended for patients
with severe burns.20,21 Wound surveillance and
14 Hospital Physician Board Review Manual
serial examination is the most sensitive way of
diagnosing wound infections.
Wound Sepsis
Due to the disruption of the patient’s normal
barrier to the external environment, infection and
septicemia are the most common complications in
hospitalized burn patients.1 Wounds should be evaluated and followed closely. Signs of wound infection
may be subtle. Pigmentation, exudates, erythema,
and conversion of partial-thickness to full-thickness
burns may all be signs of infection. Swabbing and
culturing open wounds should be avoided as it is
likely to yield misleading results that may represent
normal flora or a contaminant. If infection is suspected, biopsy should be obtained using surgical
principles. A finding of 105 organisms per gram of
specimen is indicative of infection. Concurrent positive blood cultures with the same organism further
increase the specificity of the biopsy. The common
organisms that colonize burns and lead to infections are Staphylococcus aureus (including methicillin-resistant Staphylococcus aureus [MRSA]),
Streptococcus pyogenes, Acinetobacter baumanniicalcoaceticus complex, Pseudomonas aeruginosa,
and Klebsiella species. Several of these organisms,
specifically Streptococcus and Pseudomonas, produce toxins that can cause toxic shock syndrome.
Fungal infection of the burn wounds is also prevalent, especially if topical antimicrobials that do not
have antifungal coverage are used.
Wound Care and Dressings
Exposed wounds should be kept sterile and
moist, preventing fluid loss and infection. Dressing changes should continue until healing has
progressed to the point when the patients’ own
skin is able to provide adequate protection from
the environment. If wound closure does not occur
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with conservative treatment, surgical wound management may be necessary. Dressing changes
are recommended at least daily, with increased
frequency to twice a day for higher-risk or infected
wounds, as well as those that saturate dressings
more frequently or require repeated debridement.
There are numerous dressings, applications, and
membranes available for burn wound management. The clear advantage of one over the rest has
not been demonstrated in the literature.
Simple wounds should be cleaned and covered with a nonadherent dressing with a more
absorbent layer on top. Antimicrobial preparations
applied to the skin during dressing changes can
help prevent infection and set up the optimal environment for skin healing. Although there are many
options available, silver-containing topical solutions
have been a gold standard. The broad-spectrum
antimicrobial properties of silver protect against a
wide range of microbes, including resistant strains,
such as MRSA and vancomycin-resistant enterococci, and many fungi.22 Silver sulfadiazine 1%
cream has variable gram-negative bacteria coverage, but good gram-positive bacteria and yeast
coverage. It does not cause significant discomfort
to the patient during or after application, nor does
it alter the appearance of the wound significantly,
like other applications that may discolor the skin.
However, it can form a thick exudate when mixing
with wound drainage, which can make it difficult to
clean off. Furthermore, it should not be used on
patients with a sulfa allergy or on women who are
pregnant or lactating. By its mechanism of action, it
halts epithelialization and should be stopped when
re-epithelialization is noted.
Other antimicrobial chemotherapeutic agents
may be used as alternatives to silver sulfadiazine.
Silver nitrate, which has good gram-negative bacteria, gram-positive bacteria, and yeast coverage
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can be substituted. As with silver sulfadiazine, it is
painless to apply, but it may discolor the wound,
which can make assessment challenging. Unlike
silver sulfadiazine and silver nitrate, mafenide acetate can penetrate eschars and can be used for
full-thickness burns. However, several disadvantages may limit its use. First, its lack of fungal coverage may necessitate concomitant use of topical
antifungal agents. Furthermore, it may precipitate
acidosis due to its anti-carbonic anhydrase activity, which may cause a hypersensitivity reaction.
Finally, it is often painful to apply to partialthickness wounds, and therefore some patients may
not tolerate it. Recently, triple antibiotic ointments
have gained favor in general and specialty practices
for outpatient management of minor burns.
As an alternative to antimicrobial application,
synthetic wound dressings may be applied to provide burn coverage. There are many alternatives,
but superiority of one over another has not been
demonstrated. Hydrocolloid dressings provide a
moist environment while limiting external contamination. These coverings, such as Comfeel (Coloplast), DuoDERM (ConvaTec), and Tegasorb (3M),
may be left on the wound and changed every few
days. Due to their absorbent property, ease of use,
and low cost of care, these dressings are a good
alternative for burn coverage.
Another frequently used synthetic product is
Biobrane (Smith & Nephew), which is a bilaminar membrane composed of a silicone film with
embedded nylon fabric into which fibrovascular
tissue can grow. Compared to silver sulfadiazine,
it has been shown to reduce pain medication requirements, decrease healing time, and decrease
length of hospital stay.23,24 TransCyte (Smith &
Nephew) is a similar product.
Other temporary and permanent skin substitutes currently available include human allograft
Orthopaedic Surgery Volume 8, Part 5 15
Thermal Injuries to the Extremities
(AlloDerm [LifeCell], NeoForm [Mentor Corporation]), epithelial sheets, amniotic membrane, xenograft (PriMatrix [TEI Bioscience], fetal bovine;
OASIS [Healthpoint Biotherapeutics], porcine; Unite
Biomatrix [Synovis Orthopedic and Wound Care],
equine), dermal regeneration templates, such as
the collagen-based INTEGRA (Integra LifeSciences) template, and cultured autologous grafts.
Surgical Indications and Debridement
Proper wound evaluation and mapping of burn
depth should be carefully documented. After debridement, the initial burn diagram should be revised. When treating complex burn wounds, it is
beneficial to have a wound care specialist evaluating and following the wound in conjunction with the
medical team. Evaluation under anesthesia may
further aid in the assessment of the tissues while
minimizing patient discomfort.
Superficial burns rarely require any surgical
intervention, except occasional blister management as discussed above. Partial-thickness burns
are difficult to manage, and much debate exists
regarding surgical versus conservative management. While superficial partial-thickness burns
usually heal adequately without intervention, deep
partial-thickness burns are often treated with excision and grafting due to the severe scar formation
that frequently occurs. Finally, it is universally accepted that full-thickness burns require operative
intervention.
Eschars that span the extremity and wrap circumferentially around a limb can cause vascular
insufficiency. Indications for escharotomy include
inadequate capillary refill, increasing pain in the
setting of a full-thickness burn that is out of proportion to exam, resistance to passive extension of the
fingers, and sensory changes such as numbness
or paraesthesias. In obtunded, sedated, or other16 Hospital Physician Board Review Manual
wise unresponsive patients, compartment pressure measurements (>30 mm Hg) may guide the
need of escharotomy. Elevated intracompartmental
pressures alone in alert patients, however, should
not be an indication for emergent escharotomy,
and should be used to aid in the decision process
when considering all other findings. Sheridan et
al25 described the principles of surgical management of eschars for diminished perfusion. Escharotomy may be performed at bedside or in the operating room. Using an electrocautery device, an
escharotomy is performed by creating medial and
lateral midaxial incisions through the eschar in the
extremities. This releases the pressure and helps
to decrease compartment tension in circumferential burns. Fasciotomy should be concomitantly
considered in involved areas, especially the hand,
to prevent ischemic contracture.26
In deep partial-thickness and full-thickness burns,
Janzekovic advocated early (post burn day 3 to
day 5) excision and grafting.27 Tangential excision
is performed to remove necrotic and devitalized
tissue. This approach preserves the deep dermal
layer and the underlying subcutaneous tissues.
Wounds are shaved down to viable vascularized
tissue where pinpoint bleeding can be noted. This
can be done with a scalpel, guarded dermatome,
or Goulian knife. It is wise to set realistic goals and
limits to the surgical excision as these procedures
carry significant risk of losing large volumes of
blood. Epinephrine may be used to help with hemostasis. When the tissues have been adequately
debrided, skin grafting should be performed. Superficial granulation and underlying tissue with
good vascularity provide a good foundation for skin
grafts (Figure 4).
Multiple graft options exist to cover tissue defects.
Full-thickness skin grafts (FTSG) may be used
when donor areas are readily available. However,
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Figure 4. Forearm after partial-thickness burn debridement and local wound treatments in preparation for skin grafting.
(Image courtesy of Professor Lajos Kemeny, MD, PhD, DSc.)
their use is limited by the need to close the donor
sites primarily. FTSGs are less likely to contract
since the entire dermis is transplanted and are
advantageous to use over areas of motion, such
as joints. When transplanted, FTSGs are durable,
preserve some sensibility, and maintain their texture and appearance. Therefore, they are used
preferentially on the face and palmar aspect of the
hand. Unlike FTSGs, split-thickness skin grafts
(STSG) do not involve the full layer of dermis. They
are frequently used when donor sites are scarce or
when large areas need to be covered. Compared
to FTSGs, STSGs undergo more contraction, are
less resilient, and offer poor tactile sensibility. These
grafts may be used for coverage of the dorsum of
the hand and for coverage of large defects. To inwww.turner-white.com
crease coverage area, these grafts are frequently
meshed in a 1.5:1 ratio.28 Overall, the usefulness
of skin grafts is limited in areas of exposed bones,
joints, tendons, or neurovascular structures, and in
these scenarios, muscle or fasciocutaneous flaps
offer additional protection and better outcomes.
Following grafting, the extremity should be immobilized in functional position to avoid development of contractures. Multiple visits to the operating room may be required to completely close
a wound. Additional devices, such as vacuumassisted therapy, may be utilized as well.
Orthopaedic Considerations
In orthopaedic practice, the skeletal effects
of burns may present challenging scenarios.
Orthopaedic Surgery Volume 8, Part 5 17
Thermal Injuries to the Extremities
Although the mechanism of bone metabolism is
incompletely understood, it is not surprising that
thermal injuries have effects on bone growth and
development. Rutan and Herndon29 have shown
that there is a linear growth retardation of children
following severe burns; however, with time, the
growth rate returns to normal, creating a fixed limb
length deformity. When burns involve skin over
joints, the scarring and contraction of the tissues
may progress to deformity and contractures. When
skin grafting is required, FTSGs should be used
for these areas to minimize the contracture that
occurs.
In patients with concomitant fractures and thermal injuries, careful consideration should be given
to the soft tissue status of the patient and treatment goals. Often, early skeletal stabilization outweighs the increased risk of infection in patients
with burns.30 In children, open reduction and internal fixation within 48 hours after thermal injury
has shown promising outcomes with high union
rates.31
Hand injuries present a unique challenge in orthopaedic practice. Given that we constantly use
our hands to interact with the external environment, burns often affect the upper extremity. Up
to 8% of upper extremity complaints that are seen
in the emergency room are due to thermal injury.32
Because of the high demands we place on our
hands and the intricate anatomy, even subtotal
burn injuries of the hand can lead to severe deformity and disability. Specifically, thermal damage
can lead to shortening of the collateral ligaments
and intrinsic tendons. At its worst, this will lead to
claw deformity. In order to prevent this deformity,
splinting and early rehabilitation should be instituted as soon as wounds allow. When a palmar hand
defect requires skin grafting, FTSGs provide less
risk of contracture formation and increased sen18 Hospital Physician Board Review Manual
sibility. STSGs provide the best option for dorsal
areas of the hand. As a substitute, skin alternatives
may be used. This is especially useful for patients
whose burns are extensive (>40% TBSA). When
bone or joint coverage is required, local flaps may
be beneficial if donor sites are available.
Other sequelae of thermal injuries are heterotopic ossification and periarticular contractures, which
frequently restrict motion of the affected joints. If
patient disability is significant and functional limitations exist, surgical release of contractures and
possible skin grafting or reconstruction may be
undertaken. Symptomatic heterotopic ossification,
although rare, may necessitate excision.
Rehabilitation
The goals of rehabilitation are to preserve motion
and to prevent contracture formation. These goals
are usually achieved via a multispecialty approach.
Initially, occupational and physical therapists will
focus on splinting and early motion protocols, but
various modalities can be used to supplement
rehabilitation. Specialized baths and hydrotherapy
can aid in wound care. Specific dressing and
splinting techniques can aid in edema control.
Desensitization is helpful in treating chronic pain.
Finally, psychological evaluation and treatment is
often necessary to counteract symptoms secondary to the disfiguring nature of serious thermal
injuries.33
Freezing Injuries
Frostbite injuries, which most commonly involve
acral structures, such as fingers, toes, ears, and
nose, classically result from prolonged exposure to
subfreezing temperatures. Freezing insults to the
extremities are common in cold climates and during winter recreational activities. However, tissue
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Thermal Injuries to the Extremities
damage may even ensue from seemingly benign
exposures, such as the use of cooling devices
or gel packs. With the wide acceptance of the
R.I.C.E. (rest, ice, compress, and elevate) protocol
for musculoskeletal injuries, iatrogenic frostbite has
been reported.34–37 Recently, a study determined
that frostbite injury may occur with finger contact of
highly conductive materials (conductivity close to
metals) in as quickly as 3 seconds at the temperatures of a conventional freezer (–15°C or 2°F).38
Pathophysiology
Thermal injuries due to cold exposure have long
been compared to burn injuries. In fact, the mechanism and the presentation of tissue injury is similar.
However, there are great differences due to the
temporal relationship and the anesthetic effects of
cold exposure. Unlike burns, cold injuries usually
require a prolonged exposure to the subfreezing
environment. This provides the exposed person a
chance to alter his or her contact with the environment by adding protective barriers or by escaping
the insult. Certain circumstances may prevent this
protective response, such as entrapment in a cold
environment due to concurrent injuries, intoxication, or psychiatric conditions. On the other hand,
the slow onset of frostbite may be ignored due to
analgesia of the involved areas, which disables
the conscious protective response to remove the
offending agent or escape the environment. It is
well documented that cooling therapy has analgesic effects locally and centrally, which increase
the pain threshold.39-41 Cryotherapy may create a
dangerous scenario where the analgesia locally
leads to the inability to feel the pain associated with
permanent nerve damage.
Cold temperatures lead to microscopic alterations of cell physiology that produce the clinical picture of frostbite. Decreasing temperatures
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cause vasoconstriction and increased blood viscosity, which in turn decreases tissue perfusion
and subsequent oxygenation. This procoagulable
environment can lead to the formation of thrombi in
small vessels. Furthermore, spreading inflammation, vascular stasis, and thromboses lead to local
ischemia on the cellular level.
Extracellular water plays a central role in this tissue destruction with the formation of ice crystals.
In addition to macroscopic mechanical destruction,
ice crystal formation leads to water shifts outside of
cells, which causes dehydration and cell death that
progresses to necrosis of the affected tissue bed.42
Understanding the microscopic pathology of freezing has helped guide the development of treatment
principles of these injuries.
Diagnosis
The proper evaluation of a cold-induced injury requires a detailed history and physical examination
with particular attention to the neurovascular status
of the affected extremities. Frequent reexamination is essential in following the evolving clinical
picture of these types of injuries. Evaluation of the
freezing wound is diagnostic and prognostic. It also
aids in guiding proper treatment. The system used
for classifying cold injuries according to severity is
similar to the system for burns. McAdams at al43
explored the commonly used 4-stage classification
in degrees and refined it in terms of depth of tissue
injury (Table 4).
First-degree and second-degree frostbite are
categorized as superficial insults (Figure 5). These
injuries demonstrate local effects that are limited
to the skin, with advanced forms causing blisters
that later desquamate and form an eschar. Thirddegree and fourth-degree frostbite involve the
subcutaneous tissues and other deep tissues,
respectively (Figure 5B). These stages present
Orthopaedic Surgery Volume 8, Part 5 19
Thermal Injuries to the Extremities
Table 4. Classification of Freezing Injury
Superficial
Deep
Classification
Depth
Characteristics
First degree
Superficial skin involvement
Edema, erythema
Second degree
Full-thickness skin involvement
Blistering, desquamation
Third degree
Involves subcutaneous tissue
Blue-gray discoloration, hemorrhagic blisters
Fourth degree
Deep tissue involvement
Deep necrosis to muscle, tendon, bone
with hemorrhagic blisters, necrosis and eventually,
mummified black tissues.
Advanced imaging techniques such as bone
scans (technetium-99m), magnetic resonance imaging, and laser Doppler flowmetry have been
used in clinical practice to further aid in the assessment, staging, and treatment of these injuries.
However, these methods have not been validated
to conclusively delineate the proper intervention.28
Management
Well-established guidelines have been developed for the treatment of these types of injuries.
The initial step is to remove the victim from the
cold exposure or the offending cold source. In
clinical practice, this step has usually already
been undertaken. Subsequently, the next step
in the management of freezing injuries is rewarming. The body’s core temperature has to
be elevated and the affected extremity warmed.
Rapid rewarming of the frostbitten region can
be achieved by using 40°C to 42°C water baths
for 15 to 30 minutes until the target temperature
is achieved. If vascular compromise is noted
without any structural constriction, sympathetic
blockade or antithrombotic therapy may be indicated. Bruen and colleagues demonstrated
that intra-arterial tissue plasminogen activator
(tPA) will decrease the rate of post-freezing
amputation when administered within 24 hours
20 Hospital Physician Board Review Manual
of exposure.44 However, this recommendation is
controversial, especially when wounds involve
localized areas in extremities that have otherwise intact vascular status.
The standard protocol for treating frostbite
injuries has been described by Su et al45 based
on McCauley’s initial guide of management. The
authors recommend careful monitoring if the
tissue involvement is superficial. However, according to their treatment algorithm, deep tissue
involvement warrants further investigation and
possible surgical intervention. They advocate
the use of a triple-phase bone scan at 48 hours
and at 5 days. The purpose is to delineate blood
flow and viable areas, which would aid in debridement efforts. Some debate has surrounded
the utility of bone scans, and their clinical use
has been questioned.46
The management of blisters has been a topic
of long-standing debate. It is thought that their
contents are similar in composition to those seen
in burns (high in prostaglandins and thromboxanes) and may predispose surrounding tissues
to ischemia and vasoconstrictive effects.47 Most
physicians believe that blisters should be left
alone unless they are ruptured, tight, or infected.48
However, others advocate opening clear vesicles
and draining hemorrhagic ones to eliminate the
potentially damaging effect of the fluid contents.46
When tense blisters compromise the vascular
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Thermal Injuries to the Extremities
status of the affected extremity, as in the case of
a constriction syndrome, urgent decompression
of the bullae is advocated. Topical antimicrobial
ointments and dressings may be applied according to burn wound management principles. Aloe
vera49 or silver sulfadiazine may be used for their
antimicrobial and antifungal properties as an adjunct. Early motion and physical therapy should
be started as soon as the wounds allow.
A
Complications and long-term disability
In children, long-term complications have been
reported due to the immature physiology of the
affected areas. When freezing injuries occur near
open growth plates, growth retardation and physeal arrest may occur, as described by Bigelow
and Ritchie.50 Frostbite has also been implicated
in early arthritis in children with a history of such
wounds.51
In the presence of circumferential confluent blisters, a constriction syndrome may ensue where
first vascular and then ischemic changes lead to
irreversible tissue damage. In these cases, the
external circumferential constraint functions like
a tourniquet, which may lead to insufficient blood
flow to the distal structures. This requires immediate surgical release in order to prevent necrosis
and neurological dysfunction. Although constriction
syndrome and compartment syndrome may cause
similar pathology and have similar mechanisms,
constriction syndrome implies an external agent
that impedes circulation to reach distal parts of the
extremity. With timely release of the constriction,
distal blood supply can be returned to the affected
areas without the need for fasciotomy.
Long-term disability from frostbite may include
cold intolerance and hyperhidrosis in the affected
extremity. Occasionally, frostbite-induced Raynaud’s
phenomenon may develop in these patients.
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B
Figure 5. Frostbite injuries. (A) Superficial frostbite with blister
formation (second degree). (B) Deep freezing injury. (Images
courtesy of Professor Lajos Kemeny, MD, PhD, DSc.)
Electrical Injury
In contrast to burns and freezing injuries, electrical injuries occur mostly in industrial settings.1
Although minor electrical contact does not create burns, high-energy exposure can cause fullthickness burns and major medical complications.
When evaluating these types of injuries, all areas
of contact have to be assessed. In addition to the
Orthopaedic Surgery Volume 8, Part 5 21
Thermal Injuries to the Extremities
A
entry wound, which is usually the contact point
between the electric source and the skin, the exit
wound has to be identified and examined. As may
be expected, the hand is affected in up to 90%
of all electrical injuries (Figure 6).52 However, it is
important to keep in mind that arcing may occur
and that the current may exit and reenter the body
(Figure 6B).
Pathophysiology
B
Figure 6. Electrical burn injuries. (A) High-voltage electric
injury. (B) Lightning injury. (Images courtesy of Professor
Lajos Kemeny, MD, PhD, DSc.)
22 Hospital Physician Board Review Manual
Current follows the path of least electrical resistance. As tissues have variable constituents, the
flow of charge will select a path through tissues
that is more accommodating to the passage of
electrons. Nerves and tissues with high water and
electrolyte content conduct electricity well. On the
other end of the spectrum, bones have high resistance and serve as relative insulators.
The flow of electrons creates current. The
magnitude of current determines the tissue damage (amount of heat that is generated given the
resistance of a particular tissue or material). Voltage is the potential difference and determines
if the current enters the body or not. Ohm’s law
relates the potential difference measured in volts
(V) to resistance (R, unit: Ω) and current (I, unit:
amp):
I = V
R
The severity of the burn relates to the magnitude
of the current, the type of current (direct or alternating), the duration of contact, and the path that the
electricity takes. Thermal injuries may be caused
by the electric current or the electric arc.
Alternating current is generally more dangerous with greater morbidity and mortality because
alternating current creates tonic muscle contractions, which often make it difficult for victims to let
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Thermal Injuries to the Extremities
go of the electric source and further propagates
the tissue damage.53 Current over 16 to 20 mA is
the threshold for tetany. Furthermore, alternating
current has the propensity to lead to cardiac arrhythmias and pulseless electrical activity, especially when the frequency is in the 40- to 60-Hz
range.54
Electrical injuries are categorized as high-voltage,
low-voltage, and lightning injuries. High-voltage is
defined as over 1000 V, while low-voltage is defined as under 1000 V. High-voltage may produce
a wide variety of systemic complications including
cardiovascular (eg, arrhythmias, asystole), pulmonary (eg, respiratory distress, diaphragm paralysis),
neurologic (eg, seizure, chronic pain), and renal (eg,
electrolyte imbalances, rhabdomyolysis, acute tubular necrosis) manifestations. From an orthopaedic
standpoint, tetany can cause fractures, dislocations,
tendon injuries, and muscle damage. Bone lesions
may be created by the current due to periosteal necrosis and melting of the calcium phosphate matrix
in high-energy insults.54 These lesions require a
long time to heal and occasionally may get infected
or create sinuses.
Management
Electrical burns that are seen in the emergency room need rapid evaluation and patienttailored treatment. After the patient is stabilized,
evaluation of electrolyte balance with lab work
and evaluation of cardiac function by electrocardiogram should be performed. When electricity
creates enough damage to cause a burn, 18%
of patients require wound debridement and 10%
need skin grafting.1 Due to the severity of the
thermal injury and the tissue damage associated
with electrical injuries, urgent escharotomies are
often required. Benign-appearing entry and exit
wounds may conceal full-thickness burns underwww.turner-white.com
neath that are more extensive than they appear
superficially. Therefore, any patient with a burn
from an electrical injury should be evaluated at
a burn center.
Immediate or early debridement should be
performed as soon as the patient can medically
tolerate it. A second debridement and evaluation should be undertaken 48 hours after the initial operation. This will help clarify the extent of
the injury and the viability of the tissues. Further
operations may be necessary until the wounds
are stable and the damage has evolved. At this
stage, flap coverage and tissue reconstruction
may begin. Wound care should follow general
burn principles as outlined in the above sections.
Chemical Burns
Chemical burns are less common than other
burn types, accounting for 3.4% of all burn injuries
(Figure 7).1 Chemical burns present a diagnostic
and management challenge. Often, the chemical
agent responsible for the injury and its specific
formulation is unknown. Even when the involved
agent is known, the clinical presentation may be
variable. Furthermore, since there is a vast number of agents that cause skin irritation and burns,
experienced clinicians may be misled by these
types of injuries.
Another characteristic of these insults that is
different from thermal injuries is the continuing
tissue damage until the chemical is removed from
the skin. If proper decontamination procedures
have not been initiated, this may be the case even
when the patient is in the health care setting. This
fact creates a risk for health care workers that
come in contact with the patient during the initial
encounter.
Orthopaedic Surgery Volume 8, Part 5 23
Thermal Injuries to the Extremities
Figure 7. Chemical burn of the forearm. (Image courtesy of Professor Lajos Kemeny, MD, PhD, DSc.)
Pathophysiology
Management
Chemicals that have a pH less than 7.0 are acidic.
Strong acids (pH <2.0), such as hydrochloric
acid, may damage the skin and other tissues. The
mechanism of the chemical reaction is release of
hydrogen ions, which causes molecular changes
leading to tissue damage by coagulation necrosis due to denaturation of proteins. This reaction
continues until the tissue neutralizes the acid or a
neutralizing agent is added.
Bases or alkaline solvents are chemicals that
have a pH greater than 7.0. Because of the body’s
limited capacity to buffer strong bases, these substances often cause serious tissue destruction,
forming fatty soaps by liquefaction necrosis. Some
substances (ie, cement or lime-alkaline solvent)
cause anesthesia of the skin, which delays treatment.
The first priority of chemical injury management
is decontamination. By removing the offending
agent from the skin, the chemical reaction is minimized. Dry chemicals and powders should first be
brushed off the skin with careful attention not to
spread the offending agent to uninvolved areas.
With a few exceptions, water dilution should start
immediately and continue for 20 to 30 minutes.
Alkali burns require prolonged dilution, often in
excess of 1 to 2 hours. Neutralizing agents should
generally be avoided as thermal damage from
neutralization as well as direct damage by the
treating agent may occur. Specific treatments of
commonly encountered chemical burns are listed
in Table 5.
When exposure is minor, topical antibiotics
may be applied and local wound care should be
24 Hospital Physician Board Review Manual
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Thermal Injuries to the Extremities
Table 5. Common Substances That Cause Chemical Burns and Treatment of the Burns Associated with Them
Agent
Common uses
Characteristics and Management
Hydrofluoric acid
Cleaning agent
Elemental sodium
Phenol
Metal processing,
chemical plants
Cleaning agent
Tar
Oil refining
White phosphorus
Fireworks, fertilizers
Formic acid
Nitric acid
Hydrochloric acid
Sulfuric acid
Agriculture
Fertilizers
Pool cleaner
Car batteries, chemical
manufacturing
Binds calcium
Causes bone and tendon erosion upon contact, resulting in chronic wounds
Treat with calcium gluconate systemically (2% intravenous or via Bier tourniquet),
subdermally (10%), or topically
Avoid water irrigation as this creates explosive combination
Brush off and wash with mineral oil
Remove from skin with glycerol or polyethylene glycol because it is not water
soluble (these chemicals may be irritating and should subsequently be removed
with copious water irrigation)
Hot tar will burn the skin
Cooling should start immediately
Delayed removal by petroleum-based ointment over days
May ignite spontaneously
Identify particles with copper sulfate
Remove by water irrigation or submersion
Irrigate with water
Irrigate with water
Irrigate with water
Produces severe deep tissue destruction and intense pain
Irrigate with water
started according to burn principles; however,
when exposure is major, wound debridement
should be done as soon as possible followed
by transfer to a burn center.55 After adequate
debridement, skin grafting may be necessary.
In general, after the offending agent is removed
or neutralized, general burn principles are followed to minimize tissue damage and optimize
healing.
Acknowledgment
The authors thank Professor Lajos Kemeny,
MD, PhD, DSc, Chairman and Professor of the
Department of Dermatology and Allergology,
University of Szeged, Hungary, for his expert
guidance, invaluable advice, and clinical photographs to illustrate the intricacies of the burned
extremity.
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