Managing Burns and Limb Trauma

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Surgical Considerations

Zone of injury

Definition: The area surrounding a wound that is traumatised but may not appear so. Loos MS, Freeman BG, Lorenzetti A. Zone of injury: a critical review of the literature. Annals of plastic surgery. 2010 Dec 1;65(6):573-7.  It may be difficult to define the response of soft tissue and bone to traumatic injury. Thorough assessment and careful consideration of the zone of injury are needed when deciding the level of amputation.

Burn injuries produce a definable zone of injury. The Jackson’s Burn Model divides the wound into these zones: Whitaker I, Shokrollahi K, Dickson W. Burns. OUP Oxford, 2019.

Zone of coagulation

Zone of stasis

Zone of hyperaemia

Read more about the local response to burn wounds here: https://www.physio-pedia.com/Assessment_of_Infection_in_Burn_Injuries#Physiological_Response_to_Burn_Injuries

Consideration of zone of injury in amputation

How is MDT involved in discussion around zone of injury and amputation decisionsKeszler MS, Wright KS, Miranda A, Hopkins MS. Multidisciplinary amputation team management of individuals with limb loss. Current Physical Medicine and Rehabilitation Reports. 2020 Sep;8:118-26.

Flap techniques

Different flap techniques may be used to close the wound and create a functional stump. Techniques include:

Long posterior flap – this is the most commonly used technique

Benefits of posterior flaps: Dewi M, Gwilym BL, Coxon AH, Carradice D, Bosanquet DC. Surgical techniques for performing a through knee amputation: a systematic review and development of an operative descriptive system. Annals of Vascular Surgery. 2023 Jan 26.

Provides distal coverage

Improves vascularisation

May improve wound healing outcomes

Suture line is away from end weight-bearing surface

Skew flap

Sagittal flap

Medial flap

Amputation level and energy expenditure

Energy expenditure and mechanical efficiency are influenced by the length of the residual limb. With more proximal amputations the metabolic cost of walking is significantly increased – the higher the level of amputation the more energy is needed for ambulation. For example, walking with a trans-femoral prosthesis takes much more effort than a trans-tibial prosthesis. Penn-Barwell JG, Bennett PM. Amputations and rehabilitation. Surgery (Oxford). 2023 Mar 22. The highest energy requirement is seen in persons with bilateral amputations. Aetiology may also influence energy expenditure in persons with amputation. Traumatic amputations often occur in younger, healthier individuals with higher baseline activity levels. These individuals can often compensate better, and the energy required for prosthetic gait may be less. In individuals with vascular disease who require an amputation, their baseline activity levels are usually lower and thus energy expenditure is higher as these patients do not compensate that easily with regards to endurance and cardiovascular capacities. Meier RH, Melton D. Ideal functional outcomes for amputation levels. Physical Medicine and Rehabilitation Clinics. 2014 Feb 1;25(1):199-212.

Tabel

Level of amputation (add refs)                  Increased energy expenditure above normal (%)

Transtibial                                                      20 – 25

Traumatic transtibial                                   25

Vascular transtibial                                      40

Bilateral transtibial                                      41

Transfemoral                                                 60 – 70

Traumatic                                                      68

Vascular                                                         100

Transtibial/Transfemoral                             118

Bilateral transfemoral                                 > 200

Amputation levels

Read more about Levels of lower limb amputation and this affects weight-bearing, gait and balance:

https://www.physio-pedia.com/Principles_of_Amputation#Levels_of_Lower_Limb_Amputations

Surgical Techniques

Goals of amputation surgery Penn-Barwell JG, Bennett PM. Amputations and rehabilitation. Surgery (Oxford). 2023 Mar 22.:

Consideration of analgesia

Optimal length of residual limb

Wound healing that allows for prosthesis fitting,

Avoid painful neuromas

Keep other joints supple

Avoid contractures

Early involvement of multidisciplinary team - prosthetist and rehabilitation professionals such as pt and ot

Bevelled or contoured bone ends can reduce discomfort caused by bone edges and prominences.

For wound and scar management, soft tissue flaps should be planned in such a way that the incision and scar is not over weight-bearinf areas or bony prominences

Neuromas - dissected nerve buried in muscle

There have been advancements in physiologic nerve stabilisation, which is a good way to prevent or reduce post-amputation pain. Most common techniques for physiologic nerve stabilisation is:

Targeted muscle reinnervation = " a nerve transfer of a proximal nerve, either mixed or sensory, into a distal motor nerve"

Regenerative peripheral nerve interface = an autologous free muscle graft that is wrapped around the end of a transected peripheral nerve"

Read more here:

https://www.sciencedirect.com/science/article/pii/S2666769X23000064

Heterotropic Ossificans (HO)

Heterotropic ossification is defined as "the formation of bone at extraskeletal sites"It is more common in persons undergoing amputation for trauma. The incidence of HO in military people with amputations has been reported to be as high as 65%.

Non-steroidal anti-inflammatories and local radiotherapy may prevent HO formationref 24 however, often these treatments are contraindicated in an complex trauma patient

For symptomatic HO management:

pain management

physiotherapy

socket modifications

Surgical excision:

usually delayed until local inflammation has decreased

best results are achieved with complete excision of lesions performed at least 6 months from injury

wound complications are a risk after exision, but relieve of symptons and patient satisfaction is typically achieved

Edwards DS, Kuhn KM, Potter BK, Forsberg JA. Heterotopic ossification: a review of current understanding, treatment, and future. Journal of orthopaedic trauma. 2016 Oct 1;30:S27-30.

Read more: https://journals.lww.com/jorthotrauma/fulltext/2016/10001/heterotopic_ossification__a_review_of_current.7.aspx

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