Managing Burns and Limb Trauma

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Top Contributors - Wanda van Niekerk, Jess Bell and Tarina van der Stockt  

Considerations with Amputations

• Zone of Injury
  • The zone of injury is defined as: The area surrounding a wound that is traumatised but may not appear so.  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:
    • zone of coagulation
    • zone of stasis
    • zone of hyperaemia
    • Read more about the local response to burn wounds here.

• The multidisciplinary team approach is necessary to provide person-centered care that will facilitate positive outcomes and optimise quality of life. In cases where emergent amputation (in situations such as severe sepsis or life-threatening trauma) is needed it is not always possible to get input from the full multidisciplinary team, but this should be incorporated as soon as the person is medically stable and allow for the team to formulate the treatment plan.

• 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:
        • provides distal coverage
        • improves vascularisation
        • may improve wound healing outcomes
        • suture line is away from end weight-bearing surface
    • Other flap techniques:
      • 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.
  • 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.

• Energy requirements (indicated as percentage increased energy expenditure above normal) for different levels of amputation:
  • Transtibial amputation - 20 to 25%
  • Bilateral transtibial amputation - 25%
  • Transfemoral amputation - 60 to 70%
  • Transtibial/transfemoral - 118%
  • Bilateral transfemoral - > 200%

• Amputation levels
  • Read more about the levels of lower limb amputation and how this affect weight-bearing, gait and balance: Levels of lower limb amputations

• Surgical Techniques
  • The goals of amputation surgery include:
    • consideration of analgesia - early and continued stages
    • optimise the length of the residual limb
    • wound healing that allows for prosthesis fitting is essential
    • avoid painful neuromas
    • keep other joints supple
    • avoid contractures
    • early involvement of multidisciplinary team
  • 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-bearing areas or bony prominences
  • Neuroma is a dissected nerve buried in muscle. These neuromas can cause pain, but 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 are:
    • 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: Evolution of amputee care

• 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 formation however, often these treatments are contraindicated in an complex trauma patient.
  • For symptomatic HO, initial management includes:
    • pain management
    • physiotherapy
    • socket modifications
  • If surgical excision is needed the following should be considered:
    • surgery is 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 excision, but relieve of symptoms and patient satisfaction is typically achieved

Wound Healing

Key considerations for burn healing:

• Nutritional intake is essential to the recovery and health of people with burn injuries and medical nutritional therapy is necessary to improve clinical outcomes. Fluid shifts after injury, increased risk for loss of lean body mass and the production of potentially damaging free radicals are all key aspects that need to be addressed with targeted nutritional therapy following major burns.
  • Increased caloric intake:
    • Protein
      • 100 extra calories per each 1% of body surface area burned
      • While healing: 1.5 grams of protein per 1 pound (lb) of body weight
      • Healed: 0.5 grams of protein per 1 pound (lb) of body weight to maintain healed skin
      • Protein dosage: 20 - 30 grams, throughout the day

• Sleep
  • minimum of 5 hours of consistent sleep to assist with wound healing
  • hours 0 -5 = rest
  • hours 5 -8 = healing

Contractures

• High risk for contractures in people with burn injuries
• In persons with amputation contractures may require prosthetic alignment compensations
• Contractures increases energy requirements with ambulation
• Contractures may increase the risk of injury with asymmetrical ambulation patterns
• Typical contracture patterns in the lower limb:
  • Hip flexion
  • Hip abduction
  • Hip external rotation
  • Knee flexion

• Prevention and early treatment of contractures is important. Useful techniques to preserve range of motion or to correct contractures include:
  • scar management
  • stretching
  • prolonged positioning
    • to minimise the risk of contractures post-amputation positioning can be used. Consider the person's overall health, the level and type of amputation and recommendations from other members of the multidisciplinary team. Some examples to consider:
      • Trans-tibial/ below knee amputation - avoid shortening of the hip and knee flexors
      • Trans-femoral/ above knee amputation - avoid shortening of the hip abductors and external rotators
  • adaptive equipment
  • splinting
    • read more: Splinting for burns
  • serial casting
  • surgery

Prevention is more manageable than correction! Work smarter, not harder!

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