Managing Burns and Limb Trauma
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Top Contributors - Wanda van Niekerk, Jess Bell and Tarina van der Stockt
Introduction[edit | edit source]
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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
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