Atlas Lâm Sàng Về Quản Lý Và Điều Trị Bỏng (Clinical Atlas of Burn Management)

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Fig. 6.28A: Low voltage electrical injury involving extensor
surface of the hand (Courtesy: Dr SP Bajaj, Jaipur Golden
Hospital, New Delhi, India)
Fig. 6.28B: Early debridement of the charred skin
showing thrombosed veins and dead underlying soft tissue
Fig. 6.28C: Dead extensor tendons in the affected area
also have to be debrided
Fig. 6.28D: Primary tendon grafting done with tensor
fascia lata graft

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Fig. 6.28E: Cover by pedicled groin flap preferred over a
free flap in view of the thrombosed veins. A water tight
insetting could be easily achieved with the groin flap
Fig. 6.29A: Case of faecal fistula following electrical contact
injury on abdomen. Patient taken up for laparotomy: Bowel
delivered from laparotomy wound (Courtesy: Dr SP Bajaj,
Jaipur Golden Hospital, New Delhi, India)
Fig. 6.29B: Resection anastomosis of diseased
bowel done
Fig. 6.29C: Extended tensor fascia lata flap raised to cover
exposed bowel site but was insufficient hence groin flap was
also dissected

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Fig. 6.29D: Laparotomy wound closed and defect
covered by TFL and groin flap
Fig. 6.30: Electric burn on left thigh in an electrician,
sustained while working on an electric pole with extensive
muscle damage exposing the hip joint
Fig. 6.31A: Bilateral gangrene till elbow in a young boy
carrying an iron pole which accidentally touched a high
tension wire running overhead. Another area of contact is in
the left thigh showing extensive necrosis of muscles of the
anterior compartment
Fig. 6.31B: Bilateral above elbow amputation was done
for the same patient but the thigh was managed conservatively
till the dead tissue sloughed out exposing femoral vessels
and small part of femur

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Fig. 6.31C: Gracilis myocutaneous flap dissected and
transposed to cover the femoral vessels in femoral triangle
Fig. 6.31D: Following grafting of the rest of the area
Fig. 6.32A: Electric burn exposing neurovascular structures
in the elbow and forearm requiring an early flap cover for
salvaging the arm. Latissimus dorsi pedicled flap was raised
and used for cover
Fig. 6.32B: Posterior aspect of upper arm showing how
the LD flap was tunneled till the elbow

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Fig. 6.32C: After skin graft application over the LD muscle.
The arm and its full function could be saved by timely
intervention and flap cover
Fig. 6.33A: Electric contact burn over upper arm in a
2-year-old child who presented with exposed humerus in the
upper half of arm and lower end at the elbow joint
Fig. 6.33B: Latissimus dorsi flap being dissected
Fig. 6.33C: Vascular pedicle of LD flap was skeletonized
and muscle transferred anteriorly into the upper arm and
pulled distally till beyond the elbow joint to provide cover to
the exposed bone

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Fig. 6.33D: Donor area closed primarily
Fig. 6.33E: Skin graft applied over the LD muscle
Fig. 6.33F: One month postoperative picture showing
successful cover achieved and exposed bone and joint saved
by the vascular cover
Fig. 6.34: High tension electrical burn of abdominal wall
when patient climbed on roof top of an electrified train.
Because of severe necrosis of the abdominal wall, the
intestines got exposed and were found lying outside the
abdomen. There was total loss of external genitalia and
exposed urinary bladder also. These burns carry a high
mortality. In this case, patient died after 2 hours of admission
because of associated head injury

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Fig. 6.35: One week old electric contact burn over abdomen.
On admission, bowel and omentum were prolapsing out of
the defect on the anterior abdominal wall and a drain which
had been placed in the peritoneal cavity was draining faeculent
material indicating ileal perforation. These cases are very
challenging because a large flap cover is needed following
debridement and resection anastomosis of perforated bowel
Fig. 6.36A: Late presentation of fourth degree burn following
contact with high power wire involving skin, muscles and
outer table of skull but sparing the eye. However, the passage
of current so close to the eye has lead to cataract formation
in the eye on the affected side
Fig. 6.36B: Another patient with a similar injury to right
side of face and scalp who was operated primarily by
transposing scalp flap for covering brain exposed following
removal of dead skull bone. These patients have a high
mortality if not treated early. The defect in the right side of
cheek and lip has to reconstructed in a second stage as there
is no mouth seal and drooling of saliva and liquids making
the patient’s life miserable
Fig. 6.37: Cataract development in a young girl 1 year
following electric contact injury to skull even after healing of
all wounds

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Fig. 6.38A: Postdebridement defect in scalp following
electric contact burn in scalp. The inner cortex was intact
Fig. 6.38B: Flap transposed from adjacent scalp to cover
exposed bone completely
Fig. 6.39A: A young boy after contact with high tension
wire on his legs and back of trunk showed paraplegia with
full thickness burns over the back of his legs. After
debridement of dead tissue over the left leg, the popliteal
vessels were exposed in the popliteal fossa. Gastrocnemius
muscle was divided distally, mobilized and transposed
superiorly based on its vascular pedicle to cover the exposed
vessels
Fig. 6.39B: Graft was applied over the muscle and rest of
the raw areas of the leg: Two weeks postoperative picture

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Fig. 6.39C: One year postoperatively the boy could stand
without support, all his areas healed completely
Fig. 6.39D: He gradually learnt to walk with a caliper
gradually till he regained full power. The paresis following
passage of electrical current through the spinal cord and
nerves is found to recover spontaneously without any
operative intervention
Fig. 6.40A: Twenty-five percent electric flash burns with
majority of the burns being superficial dermal and few
scattered areas being deep (Courtesy: Dr N Jithendran, Global
Hospital, Hyderabad, Andhra Pradesh, India)
Fig. 6.40B: Dead skin debrided in operation theater

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Fig. 6.40C: Wet collagen applied over the debrided areas
Fig. 6.40D: All the superficial areas healed in 10 days
except for the deep areas
Fig. 6.40E: Deeper areas grafted once the granulation
tissue was healthy leading to complete healing
Fig. 6.41: Electric contact burn over the face leading to
loss of left eye, cheek and half of upperlip. Will require
reconstruction of the cheek as well as the upper lip

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Fig. 6.42: Seven days after contact injury in hand with
primary gangrene of the hand. Despite fasciotomy incision
in arm, it could not be salvaged as the damage is usually
progressive in electric burn and the whole muscle mass till
the shoulder joint was damaged. This patient requires a
shoulder amputation with higher ligation of subclavian vessels
Fig. 6.43: Extensive raw areas following separation of eschar
following electric burn over back of chest, trunk and scalp
Fig. 6.44: Deep contact wound due to entry of current in
thigh. The damage is usually much deeper than visible as
the underlying muscle mass is also dead. If damage extends
to the femoral triangle then the chances of femoral vessels
getting exposed are high and these cases then require early
debridement and flap cover. The best flap for this area will
be tensor fascia lata from lateral side or gracilis muscle from
medial side
Fig. 6.45: Electric contact in bilateral groin and perineum
with loss of the external genitalia and exposed femoral vessels.
Early debridement and flap cover is mandatory in this case

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Fig. 6.46A: Electric contact burn over scalp with exposed
skull. Outer dead cortex being chiseled out
Fig. 6.46B: Scalp flap transposed anteriorly and donor
area grafted
Fig. 6.46C: Two months postoperative picture

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Fig. 6.47A: Postelectric contact burn raw area over wrist
exposing the flexor tendons and nerves
Fig. 6.47B: Marking for posterior interrosseous artery flap
from the same forearm after confirming the patency of the
vessels of forearm as in electric burn there might be thrombosis
of other vessels
Fig. 6.47C: Raised flap. The advantage of this flap over
groin flap for small defects such as these, is the ease of
transfer of this flap into the defect as it is a regional flap and
unlike groin flap no second surgery is needed for dividing the
pedicle
Fig. 6.47D: Seven days postoperative picture of
the inset flap

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Fig. 6.47E: Two months postoperative picture
Fig. 6.47F: Grafted donor area
Fig. 6.48A: Extensive raw areas following electric burn were
grafted except for an exposed lower half of radius. The
exposed bone appeared to be dead and required debridement
and flap cover. Primary flap cover could not be given because
of unstable general condition of the patient due to extensive
raw areas which was stabilized first by covering the raw areas
Fig. 6.48B: Superiorly based abdominal flap cover was
planned for the same despite a full thickness post-burn wound
which had been grafted earlier

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Fig. 6.48C: Abdominal flap raised
Fig. 6.49A: Postelectric burn raw area anterior thigh with
exposed femoral vessels
Fig. 6.48D: Inset abdominal flap after excision of the graft
and debridement of dead bone and it could cover the entire
forearm. The donor area was grafted
Fig. 6.49B: Tensor fascia lata flap raised to cover the
exposed vessels in order to avoid a blowout

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Fig. 6.49C: Inset TFL flap with graft applied
on donor area
Fig. 6.49E: Radial recurrent artery flap marked for cover
over the brachial vessels
Fig. 6.49D: Below elbow amputated stump of same
patient with exposed brachial vessels
Fig. 6.49F: Raised flap transposed over the defect after
debridement of dead tissue

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Fig. 6.49G: One week postoperative picture with healty
flap which prevented blow out from brachial vessels
Fig. 6.50A: 45 percent electric flash burns (Courtsey:
Dr N Jithendran, Global Hospital, Hyderabad, Andhra
Pradesh, India)
Fig. 6.50B: Same patient with contact injury through the
feet showing areas of deep circumferential electric arc burns
inovlving bilateral ankle and leg
Fig. 6.50C: Initial period of good response for few days
after collagen sheet application

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Fig. 6.50D: Development of septicemia due to lung infection
with multidrug resistant virulent strain of acinetobacter
boumani, patient developed bilateral massive pleural effusion
requiring bilateral ICD placement. After some temporary
improvement, the patient developed ARDS and had to be
put on venitlator and inotropic support
Fig. 6.50E: Development of bilateral foot and ankle
gangarene in lower limbs which were thought to be a visible
source of infection
Fig. 6.50F: Emergency bilateral guillotine below knee
amputation done
Fig. 6.50G: Tracheostomy was done. Bilateral ICD’s in
place, all external burn wounds had healed by now and
patient became conscious and had started responding to
treatment

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Fig. 6.50H: Picture after all burn wounds have healed
Fig. 6.50I: Patient awaiting B/L below knee
prosthetic rehabilitation
Fig. 6.51: Electric contact burn in the tongue and bilateral commissure, urine showing myoglobinurea. Patient required
tracheostomy due to gross edema of intraoral structures following burns

Chemical Burns 7

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Fig. 7.1: Accidental acid burn in a child due to falling of
bottle containing toilet cleaner kept in the bathroom. The toilet
cleaner usually used in remote areas contains dilute
hydrochloric acid. Even though the burns appear superficial
it is sometimes difficult to assess depth of damage in a child
because of the thin skin
Fig. 7.2A: Homicidal acid burns of face in an adult with
involvement of both eyes. There is bilateral sclera congestion
and edema with corneal opacification on right side. Patient
complains of pain and photophobia, irritation and foreign
body sensation, excessive lacrimation, blurred vision. In first
aid, it is essential to wash the eyes thoroughly with cool tap
water for atleast 10 minutes or till litmus test is negative
Fig. 7.2B: The burns were superficial and healed within 10
days with only application of topical antibiotic ointment. The
vision in both eyes was eventually regained
Fig. 7.3A: Homicidal acid burns with sulfuric acid with typical
brown discoloration of skin on face and chest sparing the eyes.
The areas were left exposed

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Fig. 7.3B: Wounds started healing from below the superficial
eschar and complete healing was achieved in 10 to 15 days.
The depth of damage depends mainly on the concentration
of the acid
Fig. 7.3C: One month after complete healing showing
hyperpigmented scars on face and some hypertrophic scarring
in presternal area of chest
Fig. 7.4: Brownish black eschar typical of sulfuric acid burns
because it reacts with glucose in the tissues to release carbon.
Majority of the areas are deep burns probably because
concentrated acid was used. Corneal burns in the left eye can
also be appreciated as being very severe (about to perforate)
because of the concentrated acid
Fig. 7.5: Full thickness black eschar due to sulfuric
acid assault

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Fig. 7.6A: Patient with sulfuric acid assault causing
intermediate thickness burns on the face
Fig. 7.6B: Two months posthealing showing severe
hypertrophy of all facial scars causing microstomia and stenosis
of both nostrils
Fig. 7.7A: Alkali burns of face with involvement of both eyes.
Alkali burns are always deeper because of liquifactive necrosis
of tissue. The involved area is seen as a dry, white eschar
Fig. 7.7B: Litmus paper test to identify the chemical (red
paper turning blue indicating alkali) showing that the alkali is
still present on the surface and initial decontamination attempt
by washing was inadequate

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Fig. 7.7C: Ocular involvement indicated by edema and
congestion of bulbar conjunctiva and corneal opacification
Fig. 7.8: Yellowish brown discoloration of burnt skin indicating
hydrochloric acid burns. Deep burns over tip of nose and ala
can be appreciated
Fig. 7.9: Palmar aspect of hand showing accidental alkali
burns sustained in a laboratory while working with the alkali
Fig. 7.10: Patient with alkali burns due to Drainex (NaOH).
Alkali burns are usually more severe than acid burns because
of greater depth of damage produced by alkalis, since they
dissolve and unite with proteins of the tissues to form alkaline
proteinates which are soluble and contain hydroxyl ions which
cause further chemical reactions

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Fig. 7.11: Deep sulphuric acid burn over face indicated by
blue litmus paper turning red
Fig. 7.12: Superficial burns in a female caused by
concentrated savlon used for cleaning during dilatation and
curettage procedure. These heal without any scarring
Fig. 7.13A: Superficial perineal burns due to concentrated
potassium permanganate used for sitz bath
Fig. 7.13B: Same patient after complete healing of
wounds in 2 weeks

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Fig. 7.14: A case of homicidal acid burns when it was thrown
onto the patients face causing ingestion of acid and inhalation
of its fumes also. Because of the severe reaction to inhaled
and ingested chemical causing laryngopharyngeal edema,
emergency tracheostomy was required for proper ventilation
even though the burns were not extensive
Fig. 7.15: Badly deformed face with symblepharosis in right
eye. In left eye due to total loss of both lids, the upper and
lower conjunctiva was mobilized and sutured over the cornea
and skin graft applied over it. Right nostril completely stenosed
due to hypertrophic scarring
Fig. 7.16: Post acid burn deformity of face. Left upper and
lower lid ectropion released and grafted, right eyelids
approximated by tarsorrhaphy although cornea is partly
opacified. Usually immediately after burns the lid edema is so
severe that tarsorrhaphy gives way
Fig. 7.17: 2-month-old acid burn where the wounds have
healed with severe scarring leading to ectropion of both lids
in right eye. The upper lid palpebral conjunctiva can be seen
totally everted. Urgent release of upper lid is required to save
the cornea from drying

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Fig. 7.18A: One and a half months old dry gangrene of distal
phalanges of all fingers of hand due to frostbite: palmar aspect.
The line of demarcation had already formed
Fig. 7.18B: Dorsal aspect of same hand
Fig. 7.18C: Following amputation of gangrenous tips and
primary closure of the defect
Fig. 7.18D: Dorsal view of same hand

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Fig. 7.19A: Coal tar or bitumen burns in palmar aspect of
hands of a laborer while constructing road. When skin comes
in contact with bitumen it rapidly cools down and adheres
tightly to the skin and heat contained within this layer of tar
can continue to damage the underlying skin. So, it is advisable
to cool the skin with water for 30 minutes as a first aid measure
to limit the damage
Fig. 7.19B: Dorsal aspect of same hand
Fig. 7.20: Coal tar or bitumen burns in foot of another patient.
Swabs soaked in paraffin oil being used to remove the coal
tar from the skin (Butter, fat or cooking oil can also be used.
Though kerosene oil can also be used, it can irritate the skin
and superficial burns may become deep). Underlying skin
shows superficial burns. It may not be possible to remove the
entire material, which can be trimmed away as it separates
spontaneously over 3 weeks as the skin heals
Fig. 7.21: Burns of face due to blast from a mixture of sodium
and potassium that the patient was grinding. Water should
not be used for removal of these particles as the particles ignite
on contact with water. The area should be covered with some
oil and then particles should be removed manually

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Fig. 7.22: Phosphorus burns of face due to accidental bursting
of fire crackers. During transport, the areas are covered with a
moist cloth and on reaching the hospital, the area can be
washed with 1 percent copper sulfate solution which combines
with phosphorus to form copper phosphate which can be
identified as black particles which can then be removed. The
area is then washed copiously with water to remove copper
salts
Fig. 7.23: Yellowish discoloration of skin and eschar
indicating deep hydrochloric acid burns
Fig. 7.24: Superficial burns of face due to dilute sulphuric
acid leading to a light brown eschar. Sulphuric acid is a part
of ‘Aqua Razia’ which is used by goldsmith for cleaning
jewellery. Therefore, it is stored in their houses and is the cause
of accidental domestic chemical burns also
Fig. 7.25: Post-acid burn deformity of face seen as ectropion
of both lower lids, loss of vision in both eyes, linear
hypertrophic scarring indicative of the trickling of the acid
down the face forming acid flow tracks. There is loss of normal
anatomy of nose and upper lip because of the severe scar
contracture

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Fig. 7.26A: Hot liquid plastic splashing on thighs due to water
being poured on molten plastic leading to burns. The
temperature of the molten plastic is as high as 1000°C,
therefore, the burns are usually deep dermal or full thickness.
As the plastic comes in contact with the skin and cools, it
solidifies and it is difficult to ascertain the depth of the burns.
No attempt should be made to remove the adhered plastic as
it can cause further damage to the deeper tissue as it firmly
adheres to the skin
Fig. 7.26B: Same patient’s face with plastic sticking to the
face firmly. Patient is unable to open his eyes
Fig. 7.26C: Seven days following burns showing spontaneous
separation of the plastic as the underlying surface epithelializes
Fig. 7.26D: Ten days post-burn showing superficial burns
healed completely and deeper areas still showing
encrustations. In the bearded area of face even the deeper
burns heal spontaneously because of the epithelialization from
the abundant epithelial appendages

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Fig. 7.26E: Fourteen days post-burn with almost completely
healed face. Since the skin of the lid is thin, the same depth of
burn does not heal spontaneously and may leave a raw area
which ultimately heals by contraction leading to ectropion
Fig. 7.26F: Same patient’s thigh wounds have healed with
conservative management wherever the burns were superficial.
Granulating wounds are left wherever the burns were deep
which will require grafting
Fig. 7.27: Linear hypertrophic scarring over the chest
indicating typical “Acid trickle marks”

Burns of Special Areas 8

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Fig. 8.1A: Thermal burns of the face—healing is very quick
in face because of good blood supply and management is
therefore by exposure treatment only
Fig. 8.1B: Seven days post-burn the face has completely
healed and scarring will be negligible. But skin has to be
protected from sun in order to avoid hyperpigmentation
Fig. 8.2: Deep burns of face after eschar separation leaves
raw areas which will require skin grafting. Unfortunately, there
is no objective measurement which can predict whether a
facial burn will heal of its own or will require surgical
intervention as the burn wound changes its appearance with
time and after application of antibiotic ointments. A given
anatomical depth may not heal in a non-hair bearing area
whereas the same depth of burn may heal well in a hair
bearing areas as in bearded portion of male face
Fig. 8.3A: Deep burns of face in a 2-year-old child. Even
though facial skin has a high potential for spontaneous
epithelialization it is better to graft some deep burns in order
to get better scars

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Fig. 8.3B: Facial burns are best left exposed by applying
antimicrobial ointment over vaseline gauze. This keeps the
wounds lubricated, prevents its drying and vaseline gauze
when changed does not peel off the epithelializing surface
Fig. 8.3C: Same patient’s face wounds were grafted as
soon as the eschar separated. In case the areas are left for
delayed spontaneous healing they tend to produce
hypertrophic scars which causes contractures in different
areas leading to deformities
Fig. 8.4A: Superficial dermal burns in ear seen as blistering.
The ear cartilage gets its blood supply from the tightly
adherent overlying skin. Therefore, the edema following burns
on both surfaces of ear may compromise the blood supply
of the ear cartilage. Slightest infection in an avascular
cartilage can lead to chondritis, therefore a closed dressing
of ear can help in avoiding this
Fig. 8.4B: Superficial dermal burns in a child.The superficial
burnt epithelium has been debrided for dressing. A donut is
placed below the occiput to avoid friction and pressure on
the burnt ear

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Fig. 8.5: Similarly burnt ear in another patient shows
healing after 1 week
Fig. 8.6: Full thickness burns of the skin of the ear as
evidenced by the black dry eschar and thrombosed vessels.
In this case, it is not possible to save the cartilage by dressing
alone. Immediate debridement of dead skin and vascular
cover over the cartilage framework by a temporoparietal flap
over which a skin graft can be applied can only save the ear
framework
Fig. 8.7A: Chondral abscess in upper part of ear, 3 weeks
after healing of the burns. The ear probably was not dressed
following burns and the cartilage got infected and necrosed
leading to abscess formation. Abscess has to be drained
and ear dressed to prevent further damage. Ear cartilage
being a single cartilage usually gets involved into and leads
to crumpled ear deformity, if not treated timely
Fig. 8.7B: Typical crumpled ear deformity following
neglected chondritis

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Fig. 8.8A: Case of chondritis in right ear following ear burns
characterized by pain, tenderness and erythematous swelling
of ear. The throbbing pain in ear is not relieved by analgesics.
The increase in cephaloconchal angle on right side is usually
the first sign of chondritis
Fig. 8.8B: Chondral abscess developed following
neglected chondritis
Fig. 8.8C: Bivalving type incision given at helical rim and
drainage of abscess along with excision of all infected necrotic
cartilage till bleeding healthy cartilage is the key to maintaining
the normal anatomical contours of the ear and preventing a
crumpled ear deformity which is very difficult to correct later
on
Fig. 8.8D: Contoured dressing over treated ear

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Fig. 8.8E: Two weeks after healing of the ear
Fig. 8.9A: Five weeks after burns, chondritis developing
into abscess which is pointing at the superior crub of the
helix
Fig. 8.9B: After incision and drainage of pus and removal
of dead cartilage the ear is packed with antibiotic impregnated
gauze
Fig. 8.9C: 1 month after complete healing of ear showing
well-maintained contours and minimal deformity

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Fig. 8.10: A case of suppurative chondritis. Redness, swelling
and severe pain in the ear—3 weeks after superficial burns.
Topical mafenide acetate cream dressing can prevent further
complications as it has good penetration
Fig. 8.11A: Post-burn keloid of helical rim. Treatment is
repeated injections of steroid (Kanacort) into the keloid to
soften it
Fig. 8.11B: After softening of the keloid, the extra skin and
keloid tissue can be excised to get a good contour. Immediate
postoperative picture after excision

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Fig. 8.11C: One year postoperatively showing a smooth
contour with no recurrence
Fig. 8.11D: Other ear also presenting with similar keloid
post-burn
Fig. 8.11E: Immediate postoperative picture
Fig. 8.11F: After excision of the keloid, the contour of the
helical rim is well-maintained even 1 year later

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Fig. 8.12A: Badly scarred face (post-burn) with severe
ectropion of all four lids and lips
Fig. 8.12B: Postoperative picture following release of all
four lids and upper lip
Fig. 8.13A: Post-burn loss of both eyebrows (Courtesy:
Dr PS Bhandari, LNJP Hospital, New Delhi, India)
Fig. 8.13B: Hair bearing island flap-based on temporal
branch of superficial temporal artery

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Fig. 8.13C: Postoperative result after reconstruction of
both eyebrows by superficial temporal artery flap
Fig. 8.14A: Post-burn loss of eyebrows bilaterally
Fig. 8.14B: Composite graft taken from scalp being
sutured in defect created in the line of eyebrow
Fig. 8.14C: After take of graft

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Fig. 8.15: Postchemical burn deformity of eye presenting
with loss of both eyelids, corneal opacification. Lid
reconstruction with forehead flap followed by corneal
transplant can restore some vision in this eye
Fig. 8.16: Deep burns of entire face leading to exposure
keratitis in both eyes was managed by release of both eyelid
ectropion and tarsorraphy between the lids. The raw area
over the lids requires skin grafting
Fig. 8.17A: Deep burns over tendoachilles exposing the
same, in both legs following heat therapy for rigors, by putting
hot water bottle beneath the legs in immediate postoperative
period following spinal anesthesia. Patient sustained full
thickness burns as his legs were anesthetic and hot water
bottle was left for a very long time
Fig. 8.17B: Since the tendoachilles and underlying bone
were exposed skin grafting could not be done and bilateral
reverse sural flaps were planned as shown in the marking

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Fig. 8.17C: Flaps raised bilaterally
Fig. 8.17D: Bilaterally inset flaps
Fig. 8.17E: Late postoperative picture of the same
patient walking
Fig. 8.18: Deep frictional burns following run over by truck
tyre with loss of skin at places.The chances of blunt
abdominal injury are high and have to be ruled out before
taking up the patient for debridement and grafting

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Fig. 8.19: Usually burns over the palmar aspect of hand
heal spontaneously because of the thick epidermis but in
rare cases such as this young boy who was taking an oath
for swearing loyalty and allegiance to his organization by
putting his hand over a burning candle while taking oath.
There is full thickness burns of palmar skin and following
removal of eschar shows a granulating bed which can be
grafted
Fig. 8.22: Typical post-burn hand deformity with wrist in
extension due to spontaneous healing of deep burns on
dorsum of hand and forearm by contraction, Hyperextension
at MCP joints and flexion at IP joints.There is extensive
hypertrophic scarring over the forearm circumferentially
Fig. 8.20: If a burnt hand is not splinted it naturally assumes
the position of rest—flexion at wrist, which should be avoided
in order to prevent MCP joints from going into hyperextension
which will lead to claw deformity of hand
Fig. 8.21: Dressing during acute burns keeping wrist in
extension and MCP and IP joints in flexion—Cock up position
which is the functional position to avoid deformities

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Fig. 8.23: 10-year-old child with superficial dermal burns
with blistering in perineal region. These cases need to be
admitted and catheterized. The area is treated by exposure
method with application of some antimicrobial agent only
Fig. 8.24: 8-year-old child who came in contact with high
tension wire over the genitals and groin with total loss of
penis. Suprapubic cystostomy is needed for urinary diversion
till all wounds heal. Secondary penile reconstruction can be
attempted later on
Figs 8.25A and B: Picture of hand burns due to hot oil.
The burns appear to be superficial dermal
Fig. 8.25A
Fig. 8.25B

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Fig. 8.26A
Fig. 8.27A
Figs 8.26A and B: The burns over some areas are actually
deep dermal as seen after eschar separation just before skin
grafting at day 16
Figs 8.27A and B: Immediate picture after skin grafting
Fig. 8.26B
Fig. 8.27B

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Fig. 8.28: Five days postoperative picture of same patient after skin grafting
Figs 8.29A to D: Healed burn wounds after single sitting of skin grafting
A
B
C
D

Postourn Sequelae 9

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194
Fig. 9.1: Immature postburn scar in healed deep dermal
burns on chest and lower neck. Burns which require more
than 3 weeks to heal are likely to develop hypertrophy. The
scar is raised, hyperemic, itchy and blanches on pressure.
They mature with massage, pressure garments and passage
of time
Fig. 9.3: Mature postburn hypertrophic scarring following
spontaneous healing of deep burns by contracture formation
at neck, axilla and elbow. Excision and release of the scar
once it is mature, can only give best results both functionally
and esthetically
Fig. 9.2: Irregular hyperpigmented, hypertrophic scar
following deep burns produced during removal of a tattoo
by using acid. Since the pigment in the tattoo extends till the
deep dermis their removal by any procedure leads to
hypertrophic scarring