Abstract
The initial care of burn patients follows principles from the Advanced Trauma Life Support (ATLS) protocol with an emphasis on the ABCs (airway, breathing, and circulation) and adequate fluid resuscitation and with special attention to signs of smoke inhalation and carbon monoxide poisoning. The burn itself should be evaluated for extent (percent of total body surface area) and depth (grade) and should not distract from implementing an adequate ATLS protocol.
Electrical, circumferential, and full-thickness burns all are associated with an elevated risk of compartment syndrome. Prompt escharotomy or fasciotomy should be performed if patients exhibit increasing analgesic requirements or have elevated compartment pressures.
The historical standard of care for the treatment of fractures in association with burns has been external fixation. More recent data suggest that if patients are adequately resuscitated and stable, internal fixation of orthopaedic injuries within the first forty-eight hours after injury is associated with improved healing rates and a lower incidence of infection. Surgical incisions can be safely extended into burnt tissue to provide adequate operative exposure and fracture reduction.
Joint contracture is often a complication associated with burns, and patients with joint contracture as a consequence of being burned will often present to an orthopaedist for treatment. The optimal method to treat joint contractures in burn patients is to take a preventative approach that includes the provision of adequate analgesia, early active range-of-motion exercises, and timely plastic surgery consultation with regard to the excision of scar tissue.
Heterotopic ossification occurs in as much as 3% of burn patients and is not dependent on the location of the burn. Patients with heterotopic ossification are often referred to orthopaedists for treatment. Early active range-of-motion exercises, manipulation while the patient is under anesthesia, and delayed surgical resection are treatment options, but the overall risk for recurrence is high. In general, surgical excision of heterotopic bone is effective, but, to minimize the rate of recurrence, excision should be delayed until twelve months or more after injury, when maturation is complete. Neurovascular integration within the heterotopic bone is common; therefore, preoperative computed tomography (CT) or magnetic resonance imaging (MRI) is indicated to plan safe excision of mature heterotopic bone.