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Burned feet in children
Burned Feet in Children Acute and Reconstructive Care
Richard A. Heimburger, MD, Galveston, Ernest0 Marten, MD, Galveston, Duane L. Larson, MD, Galveston, Sally Abston, MD, Galveston,
Texas
Texas Texas
Texas
Stephen I?. Lewis, MD, Galveston,
Texas
Scarring and contracture of the foot can be very disabling sequelae of burn injury, leading to gait disturbances, chronic problems in wearing shoes, and recurrent ulcerations. The experience at the Shriners Burns Institute in Galveston indicates that split thickness skin grafts provide satisfactory surfacing for deep burns of the feet in children, even on the weight-bearing portions of the foot. A strict regimen of firm elastic support is required after grafting until orthopedic shoes can be fitted. Deep burns of the feet are infrequent because of the thickness of the callus on the weight-bearing portion of the foot and the protection afforded by shoes. The majority of our patients with burned feet have other extensive severe burns. Material and Methods Between April 1966 and December 1971, sixty-six patients with third degree burns involving a total of 110 feet were treated at the Shriners Burns Institute. This represents 5.6 per cent of 1,181 burned children sixteen years old or younger who received acute and reconstructive care
From the University of Texas Medical Branch, Shriners Burns Institute. Galveston, Texas. Presented at the Plastic Surgery Residents’ Conference, Toledo, Ohio, March 6, 1972. Reprint,requests should be addressed to Dr Larson, Shriners Burns Institute, 610 Texas Avenue, Galveston. Texas 77550.
Volume 125. May 1973
in our institution.
Included in this series are all those who required skin grafting in the acute phase or those who were later admitted for reconstructive surgery of the feet. This excludes a large group with second degree burns of the feet that healed spontaneously with no later difficulty. The burns were caused by gasoline explosion in twentyseven patients, scalding in seventeen, flames in twelve, electricity in five, contact in four, and a firecracker in one. Of the sixty-six patients in our study, forty-six were treated in the acute period at the Shriners Burns Institute. (Table I.) Ten of these forty-six required later reconstructive surgery at our hospital. We have reconstructed the feet of twenty other burn patients who received acute care elsewhere. During the acute phase the burn wounds were treated with topical antibacterial cream and daily Hubbard tank baths and dressing changes. Conservative surgical debridement was used when the eschar became demarcated. Pig skin xenografts were frequently used on extensive burn wounds as a temporary biologic dressing. Split thickness skin grafts in large sheets were laid in place in a circular manner without sutures and dressing. Threaded Steinmann pins were placed through the calcaneus and tibia at the time of skin grafting. (Figure 1.) The extremities were kept continuously elevated in balanced traction two to three weeks until the epithelium had healed sufficiently to withstand elastic bandage support. The pin sites were cleaned regularly to prevent crusting and the accumulation of any suppuration. Whirlpool baths were resumed while the pins were still in place. After approximately two weeks the pins were removed and elastic
575
Heimburger
et al
Figure 1. Skeletal suspension through tibia and calcaneus for grafting acute of burn.
Figure 2. Orthopedic shoes worn six to twelve months after skin grafting. Figure 3. Patient two years later.
bandages applied. By three weeks postoperatively the graft take was usually firm enough to allow dependent positioning and ambulation with firm elastic support, and orthopedic shoes were individually fitted. The shoes had high tops, padded tongues, a metatarsal bar or pad, and laces; they were worn day and night for six to nine months. (Figures 2 and 3.) Two layers of socks, one thin and one thick, were worn beneath the shoes to diminish friction. When contracture has occurred, release and split thickness skin grafting has been the usual procedure. It has been facilitated by skeletal traction through the distal phalanx of each digit. (Figures 4 to 8.) Moderately thick (10 to 12/1000ths of an inch) split thickness grafts were used. Amputation of a foot or toe was rarely needed, and tenotomy of the dorsal extensor tendons proved unnecessary. Release was carried widely across the contracture into normal skin; darts were made to prevent new contracture bands, the foot was placed in the skeletal traction device, and the graft was simply laid on without stitches or dressing. (Figures 6 to 9.) The grafts were rolled with cotton application sticks every two hours until adherent. The pins were removed in ten to fourteen days. Tenotomy was performed in only eight instances. All tenotomies were carried out early in the series and we have now discontinued this procedure because we find it TABLE I
Operative
Procedure
on Severely
unnecessary. A prolonged regimen of firm padded shoe support was instituted postoperatively, as after grafting in acute burns. Several small contractures responded to Z-plasty or a small rotation flap, one of which was combined with a split thickness skin graft. Only one cross-leg flap has been applied to the foot, this to a heel. (Figure 9.) An additional one was applied above the ankle to the pretibial area. Both of these were applied to unstable scars in old wounds
from electrical burns. The rules we now find important II. Results
Split thickness skin grafts have proved satisfactory even on the weight-bearing portions of the foot. Healing was a problem in only three instances, two in the Achilles tendon area and the third in the lateral metatarsal area in a patient who lost all the toes on the foot. All of these wounds healed after repeated grafting. Only one patient treated with orthopedic shoes after healing required later release and grafting.
Amputation
Acute and reconstructive care at Shriners Burns Institute Acute care elsewhere
576
in Table
Burned Feet
Number of Number of Patients Feet Acute patients No reconstruction Later reconstruction Reconstructive care
are outlined
46 38 10 30
73 53 27 43
10 20
15 28
Toe
Leg
4
1
1 4
Split Thickness Skin Grafting
Skeletal Traction
Tendon Release
Z-plasty or Rotation Flap
73 49 22 32
58 39 20 31
8
11
11 21
8 23
3 5
5 7
The American Journal of Surgery
Burned Feet
Figure 4. Eversion contracture foot. of Figure 5. Dorsal contracture of foot.
Over half of the patients with scald burns (ten of seventeen) required later reconstructive surgery. The only reconstructive procedure performed for electrical burns was a cross-leg flap in two cases. Presumably the deepest burns are the ones requiring reconstructive surgery. Comments
Pap [I] noted that “a. burn of the foot results in high morbidity, extended absence from work, and a [2] in 1944 long convalescence.” Brown and Cannon advocated obtaining primary healing with split thickness skin grafts for burns of the feet, but suggested that if this method was not satisfactory, the pedicle flap could be substituted. Brown and McDowell [3] noted that the flap never forms a normal sole and that a soft rubber pad in the shoe should be used continually. They stated that, “One vigorous active boy has had the entire sole of his foot covered with split grafts for six years and has carried out all normal activities, including participation in baseball and other games.” Although Avellan [4] suggested using full thickness skin grafts for the
weight-bearing surface, his series included only one burn patient, and we have not found this necessary. London [5], in the only other large series of burns of the foot, also had satisfactory results with split thickness skin grafts; he advocated early excision and grafting. Of the feet grafted, sixty-one were grafted on the day of burn, twenty-seven within the first week, and ninety-nine later. Although healing averaged one week longer after early excision and grafting, he found hospital time to be decreased. In addition, he closed two wounds by suture and performed primary rotation flap on one. Two of London’s patients required subsequent contracture release for dorsal subluxation with concurrent tenotomy. In contrast to London’s study, we have not had satisfactory results with early grafting because of the difficulty in determining the depth of injury. In addition, we have not used primary suture, and we reserve rotation flaps for reconstructive procedures after healing has been achieved. In 1965 Larson [6], following the teaching of Truman Blocker, emphasized a conservative approach to
Figure 6. Digital skeletal traction for release and graft of foot. Figure 7. Early device using plaster of Paris and coat hanger for digital traction.
Volume 125. Mav 1973
577
Heimburger
et al
Figure 8. Immobilization of foot for release and split thickness skin grafting utilizing digital traction and Orthoplast Isoprene@ (Johnson &Johnson) splint.
care and an aggressive approach to grafting in closure of the burn wound. We continue the same regimen of debriding the eschar as it becomes separated by bacterial autolysis. Previously we changed the dressing and applied Furacin@ or Vaseline@ gauze in the operating room every three days with the patient under anesthesia; surgical technicians and nurses now change the dressings and apply silver sulfadiazine dressings daily during and after soaking in the Hubbard tank without using anesthesia. We continue to recommend the large sheet skin graft because it produces less scarring than does the “postage stamp graft.” Skeletal traction is uniquely useful in the surgical treatment of burn scars in extremities because of the force of the contracting scar and the fragility of the surrounding skin [ 7j. Skeletal fixation in the acutely burned and grafted extremity has been used in Galveston for years and previously reported by Larson [7,8], Evans [9,10], Adams [II], and their coworkers. Preferred areas of pin fixation of the lower extremity have been the calcaneus and tibia. The position can be varied when used in cross-leg flaps [II]. Feet should be supported so that the ankles are at a 90 degree angle, a neutral and functional position. Traction on the tubercle or body of the calcaneus assists in dorsiflexion of the ankle. The pins may be piaced through acutely burned or granulating areas but the pin sites must be kept open and scrupulously clean to prevent suppuration. The pin acts as its own drain whenever there is any infection, and we have not had any wound
578
Figure 9. Skeletal traction used for cross-leg flap.
problems with osteomyelitis persisting after removal of the pins. Digital pins are placed through the distal phalanx of each toe at the time of contracture release and grafting in a manner similar to the method previously described for the hand [ 7,8]. When joints are exposed by a burn, infection is inevitable and ankylosis usually occurs [12]. This is managed by keeping the joint moist and clean, maintaining a functional position, and obtaining skin coverage as quickly as possible. We have used Steinmann pin fixation for reconstruction in two patients with cross-leg flaps after electrical burns of the lower extremities [II]. One of these wounds was on the heel and the other was above the ankle on the pretibial surface. TABLE II
Points of Emphasis in Burned
Foot Care
A. Acute care: 1. Early excision of the eschar and immediate skin grafting are not advocated. 2. Split thickness skin grafts give satisfactory cover in almost all burns of the feet. 3. Steinmann pin skeletal fixation is helpful during grafting. 4. Firm support is necessary over the burned and grafted areas before ambulation. 5. Amputation of a toe is infrequently required. 6. Reconstructive care: 1. Release and graft are required for dorsal subluxation. 2. Tendon division is not necessary. 3. Digital skeletal traction is helpful in releasing contractures. 4. Occasionally a simple Z-plasty or small rotation flap will correct small contracture. 5. Cross-leg flaps are rarely needed, usually only in deep electrical burns. 6. Full thickness skin grafts are not needed.
The American Journal of Surgery
Burned Feet
Scars from third degree burns can produce abnormalities in bone growth when intraosseous pins are not used 1131. We have noted no discrepancies in bone growth due to the pins themselves. Follow-up study at the Shriners Burns Institute is curtailed when the patient reaches age sixteen, and the Galveston Unit has been open only since 1966. This is too short a period in which to evaluate longterm results in patients with chronic foot problems. Our experi.ence at the main teaching hospital of the University of Texas Medical Branch indicates that some patients will have ulcerations and may eventually require pedicle flap coverage. Firm shoe support and careful foot care are important in preventing future scar problems.
Acknowledgment: We wish to thank Miss Barbara Willis for her expert assistance with the Isoprene splints and Mrs Joanne Shandley for her help with the statistical data. References 1. Pap AS: Hot metal
2. 3. 4. 5. 6.
Summary Scarring and contractures of the foot can be very disabling ;sequelae of burn injury, leading to recurrent ulcerations and chronic problems in wearing shoes. Proper management during the acute phase and reconstruction can prevent most of these disabilities. At t.he Galveston Unit of the Shriners Burns Institute, split thickness skin grafts and local flaps have proved satisfactory for reconstructing almost all burn scars of the foot in children. We use skeletal traction immobilization for skin grafting, and firm elastic and orthopedic shoe support after healing, We have reviewed our experience in the acute and reconstructive surgical care of sixty-six patients with third degree burns of the feet including grafting, skeletal traction, %-plasty, and local and cross-leg flaps. Am-
Volume 125,
putation of a toe or extremity has rarely been needed nor has tendon lengthening been required.
May
1973
7.
a.
9.
10.
11.
12. 13.
burns of the feet in foundry workers. J Occup Med 8: 537.1966. Brown JB, Cannon B: The repair of surface defects of the foot. Ann Surg 120: 417, 1944. Brown JB, McDowell F: Skin Grafting of Burns. London, Lippincott, 1943. Avellan L: Reconstruction of defects in the weight-bearing surfaces of the foot. Acta Orthop Stand 36: 340, 1965. London PS: The burned foot. 6ritJ Surg 40: 293, 1953. Larson DL: Closure of the burn wound. J Trauma 5: 254, 1965. Larson DL, Abston S, Evans EE3, Dobrkovsky M, Linares HA: Techniques for decreasing scar formation and contractures in the burn patient. J Trauma 11: 807, 1971. Larson DL. Evans EB, Abston S, Lewis SR: Skeletal suspension and traction in the treatment of burns. Ann Surg 166: 9ai,l968. Evans EB, Larson DL. Yates S: Preservation and restoration of joint function in patients with severe burns. JAMA 204: 843,196a. Evans EB, Larson DL, Abston S, Willis B: Prevention and correction of deformity after severe burns. Surg C/in N Amer50: 1361,197O. Adams WM Jr, Wisner HK, Larson DL, Lynch JB, Lewis SR: Steinmann pin fixation of extremities for cross-leg flaps. Plasf Reconsfr Surg 44: 364, 1969. Evans EB, Smith JR: Bone and joint changes following burns. J Bone Joint Surg 41: 785. 1959. Frantz CH, Delgado S: Limb-length discrepancy after thirddegree burns about the foot and ankle. Report of four cases. J Bone Joint Surg 46: 443, 1966.
579
Richard A. Heimburger, MD, Galveston, Ernest0 Marten, MD, Galveston, Duane L. Larson, MD, Galveston, Sally Abston, MD, Galveston,
Texas
Texas Texas
Texas
Stephen I?. Lewis, MD, Galveston,
Texas
Scarring and contracture of the foot can be very disabling sequelae of burn injury, leading to gait disturbances, chronic problems in wearing shoes, and recurrent ulcerations. The experience at the Shriners Burns Institute in Galveston indicates that split thickness skin grafts provide satisfactory surfacing for deep burns of the feet in children, even on the weight-bearing portions of the foot. A strict regimen of firm elastic support is required after grafting until orthopedic shoes can be fitted. Deep burns of the feet are infrequent because of the thickness of the callus on the weight-bearing portion of the foot and the protection afforded by shoes. The majority of our patients with burned feet have other extensive severe burns. Material and Methods Between April 1966 and December 1971, sixty-six patients with third degree burns involving a total of 110 feet were treated at the Shriners Burns Institute. This represents 5.6 per cent of 1,181 burned children sixteen years old or younger who received acute and reconstructive care
From the University of Texas Medical Branch, Shriners Burns Institute. Galveston, Texas. Presented at the Plastic Surgery Residents’ Conference, Toledo, Ohio, March 6, 1972. Reprint,requests should be addressed to Dr Larson, Shriners Burns Institute, 610 Texas Avenue, Galveston. Texas 77550.
Volume 125. May 1973
in our institution.
Included in this series are all those who required skin grafting in the acute phase or those who were later admitted for reconstructive surgery of the feet. This excludes a large group with second degree burns of the feet that healed spontaneously with no later difficulty. The burns were caused by gasoline explosion in twentyseven patients, scalding in seventeen, flames in twelve, electricity in five, contact in four, and a firecracker in one. Of the sixty-six patients in our study, forty-six were treated in the acute period at the Shriners Burns Institute. (Table I.) Ten of these forty-six required later reconstructive surgery at our hospital. We have reconstructed the feet of twenty other burn patients who received acute care elsewhere. During the acute phase the burn wounds were treated with topical antibacterial cream and daily Hubbard tank baths and dressing changes. Conservative surgical debridement was used when the eschar became demarcated. Pig skin xenografts were frequently used on extensive burn wounds as a temporary biologic dressing. Split thickness skin grafts in large sheets were laid in place in a circular manner without sutures and dressing. Threaded Steinmann pins were placed through the calcaneus and tibia at the time of skin grafting. (Figure 1.) The extremities were kept continuously elevated in balanced traction two to three weeks until the epithelium had healed sufficiently to withstand elastic bandage support. The pin sites were cleaned regularly to prevent crusting and the accumulation of any suppuration. Whirlpool baths were resumed while the pins were still in place. After approximately two weeks the pins were removed and elastic
575
Heimburger
et al
Figure 1. Skeletal suspension through tibia and calcaneus for grafting acute of burn.
Figure 2. Orthopedic shoes worn six to twelve months after skin grafting. Figure 3. Patient two years later.
bandages applied. By three weeks postoperatively the graft take was usually firm enough to allow dependent positioning and ambulation with firm elastic support, and orthopedic shoes were individually fitted. The shoes had high tops, padded tongues, a metatarsal bar or pad, and laces; they were worn day and night for six to nine months. (Figures 2 and 3.) Two layers of socks, one thin and one thick, were worn beneath the shoes to diminish friction. When contracture has occurred, release and split thickness skin grafting has been the usual procedure. It has been facilitated by skeletal traction through the distal phalanx of each digit. (Figures 4 to 8.) Moderately thick (10 to 12/1000ths of an inch) split thickness grafts were used. Amputation of a foot or toe was rarely needed, and tenotomy of the dorsal extensor tendons proved unnecessary. Release was carried widely across the contracture into normal skin; darts were made to prevent new contracture bands, the foot was placed in the skeletal traction device, and the graft was simply laid on without stitches or dressing. (Figures 6 to 9.) The grafts were rolled with cotton application sticks every two hours until adherent. The pins were removed in ten to fourteen days. Tenotomy was performed in only eight instances. All tenotomies were carried out early in the series and we have now discontinued this procedure because we find it TABLE I
Operative
Procedure
on Severely
unnecessary. A prolonged regimen of firm padded shoe support was instituted postoperatively, as after grafting in acute burns. Several small contractures responded to Z-plasty or a small rotation flap, one of which was combined with a split thickness skin graft. Only one cross-leg flap has been applied to the foot, this to a heel. (Figure 9.) An additional one was applied above the ankle to the pretibial area. Both of these were applied to unstable scars in old wounds
from electrical burns. The rules we now find important II. Results
Split thickness skin grafts have proved satisfactory even on the weight-bearing portions of the foot. Healing was a problem in only three instances, two in the Achilles tendon area and the third in the lateral metatarsal area in a patient who lost all the toes on the foot. All of these wounds healed after repeated grafting. Only one patient treated with orthopedic shoes after healing required later release and grafting.
Amputation
Acute and reconstructive care at Shriners Burns Institute Acute care elsewhere
576
in Table
Burned Feet
Number of Number of Patients Feet Acute patients No reconstruction Later reconstruction Reconstructive care
are outlined
46 38 10 30
73 53 27 43
10 20
15 28
Toe
Leg
4
1
1 4
Split Thickness Skin Grafting
Skeletal Traction
Tendon Release
Z-plasty or Rotation Flap
73 49 22 32
58 39 20 31
8
11
11 21
8 23
3 5
5 7
The American Journal of Surgery
Burned Feet
Figure 4. Eversion contracture foot. of Figure 5. Dorsal contracture of foot.
Over half of the patients with scald burns (ten of seventeen) required later reconstructive surgery. The only reconstructive procedure performed for electrical burns was a cross-leg flap in two cases. Presumably the deepest burns are the ones requiring reconstructive surgery. Comments
Pap [I] noted that “a. burn of the foot results in high morbidity, extended absence from work, and a [2] in 1944 long convalescence.” Brown and Cannon advocated obtaining primary healing with split thickness skin grafts for burns of the feet, but suggested that if this method was not satisfactory, the pedicle flap could be substituted. Brown and McDowell [3] noted that the flap never forms a normal sole and that a soft rubber pad in the shoe should be used continually. They stated that, “One vigorous active boy has had the entire sole of his foot covered with split grafts for six years and has carried out all normal activities, including participation in baseball and other games.” Although Avellan [4] suggested using full thickness skin grafts for the
weight-bearing surface, his series included only one burn patient, and we have not found this necessary. London [5], in the only other large series of burns of the foot, also had satisfactory results with split thickness skin grafts; he advocated early excision and grafting. Of the feet grafted, sixty-one were grafted on the day of burn, twenty-seven within the first week, and ninety-nine later. Although healing averaged one week longer after early excision and grafting, he found hospital time to be decreased. In addition, he closed two wounds by suture and performed primary rotation flap on one. Two of London’s patients required subsequent contracture release for dorsal subluxation with concurrent tenotomy. In contrast to London’s study, we have not had satisfactory results with early grafting because of the difficulty in determining the depth of injury. In addition, we have not used primary suture, and we reserve rotation flaps for reconstructive procedures after healing has been achieved. In 1965 Larson [6], following the teaching of Truman Blocker, emphasized a conservative approach to
Figure 6. Digital skeletal traction for release and graft of foot. Figure 7. Early device using plaster of Paris and coat hanger for digital traction.
Volume 125. Mav 1973
577
Heimburger
et al
Figure 8. Immobilization of foot for release and split thickness skin grafting utilizing digital traction and Orthoplast Isoprene@ (Johnson &Johnson) splint.
care and an aggressive approach to grafting in closure of the burn wound. We continue the same regimen of debriding the eschar as it becomes separated by bacterial autolysis. Previously we changed the dressing and applied Furacin@ or Vaseline@ gauze in the operating room every three days with the patient under anesthesia; surgical technicians and nurses now change the dressings and apply silver sulfadiazine dressings daily during and after soaking in the Hubbard tank without using anesthesia. We continue to recommend the large sheet skin graft because it produces less scarring than does the “postage stamp graft.” Skeletal traction is uniquely useful in the surgical treatment of burn scars in extremities because of the force of the contracting scar and the fragility of the surrounding skin [ 7j. Skeletal fixation in the acutely burned and grafted extremity has been used in Galveston for years and previously reported by Larson [7,8], Evans [9,10], Adams [II], and their coworkers. Preferred areas of pin fixation of the lower extremity have been the calcaneus and tibia. The position can be varied when used in cross-leg flaps [II]. Feet should be supported so that the ankles are at a 90 degree angle, a neutral and functional position. Traction on the tubercle or body of the calcaneus assists in dorsiflexion of the ankle. The pins may be piaced through acutely burned or granulating areas but the pin sites must be kept open and scrupulously clean to prevent suppuration. The pin acts as its own drain whenever there is any infection, and we have not had any wound
578
Figure 9. Skeletal traction used for cross-leg flap.
problems with osteomyelitis persisting after removal of the pins. Digital pins are placed through the distal phalanx of each toe at the time of contracture release and grafting in a manner similar to the method previously described for the hand [ 7,8]. When joints are exposed by a burn, infection is inevitable and ankylosis usually occurs [12]. This is managed by keeping the joint moist and clean, maintaining a functional position, and obtaining skin coverage as quickly as possible. We have used Steinmann pin fixation for reconstruction in two patients with cross-leg flaps after electrical burns of the lower extremities [II]. One of these wounds was on the heel and the other was above the ankle on the pretibial surface. TABLE II
Points of Emphasis in Burned
Foot Care
A. Acute care: 1. Early excision of the eschar and immediate skin grafting are not advocated. 2. Split thickness skin grafts give satisfactory cover in almost all burns of the feet. 3. Steinmann pin skeletal fixation is helpful during grafting. 4. Firm support is necessary over the burned and grafted areas before ambulation. 5. Amputation of a toe is infrequently required. 6. Reconstructive care: 1. Release and graft are required for dorsal subluxation. 2. Tendon division is not necessary. 3. Digital skeletal traction is helpful in releasing contractures. 4. Occasionally a simple Z-plasty or small rotation flap will correct small contracture. 5. Cross-leg flaps are rarely needed, usually only in deep electrical burns. 6. Full thickness skin grafts are not needed.
The American Journal of Surgery
Burned Feet
Scars from third degree burns can produce abnormalities in bone growth when intraosseous pins are not used 1131. We have noted no discrepancies in bone growth due to the pins themselves. Follow-up study at the Shriners Burns Institute is curtailed when the patient reaches age sixteen, and the Galveston Unit has been open only since 1966. This is too short a period in which to evaluate longterm results in patients with chronic foot problems. Our experi.ence at the main teaching hospital of the University of Texas Medical Branch indicates that some patients will have ulcerations and may eventually require pedicle flap coverage. Firm shoe support and careful foot care are important in preventing future scar problems.
Acknowledgment: We wish to thank Miss Barbara Willis for her expert assistance with the Isoprene splints and Mrs Joanne Shandley for her help with the statistical data. References 1. Pap AS: Hot metal
2. 3. 4. 5. 6.
Summary Scarring and contractures of the foot can be very disabling ;sequelae of burn injury, leading to recurrent ulcerations and chronic problems in wearing shoes. Proper management during the acute phase and reconstruction can prevent most of these disabilities. At t.he Galveston Unit of the Shriners Burns Institute, split thickness skin grafts and local flaps have proved satisfactory for reconstructing almost all burn scars of the foot in children. We use skeletal traction immobilization for skin grafting, and firm elastic and orthopedic shoe support after healing, We have reviewed our experience in the acute and reconstructive surgical care of sixty-six patients with third degree burns of the feet including grafting, skeletal traction, %-plasty, and local and cross-leg flaps. Am-
Volume 125,
putation of a toe or extremity has rarely been needed nor has tendon lengthening been required.
May
1973
7.
a.
9.
10.
11.
12. 13.
burns of the feet in foundry workers. J Occup Med 8: 537.1966. Brown JB, Cannon B: The repair of surface defects of the foot. Ann Surg 120: 417, 1944. Brown JB, McDowell F: Skin Grafting of Burns. London, Lippincott, 1943. Avellan L: Reconstruction of defects in the weight-bearing surfaces of the foot. Acta Orthop Stand 36: 340, 1965. London PS: The burned foot. 6ritJ Surg 40: 293, 1953. Larson DL: Closure of the burn wound. J Trauma 5: 254, 1965. Larson DL, Abston S, Evans EE3, Dobrkovsky M, Linares HA: Techniques for decreasing scar formation and contractures in the burn patient. J Trauma 11: 807, 1971. Larson DL. Evans EB, Abston S, Lewis SR: Skeletal suspension and traction in the treatment of burns. Ann Surg 166: 9ai,l968. Evans EB, Larson DL. Yates S: Preservation and restoration of joint function in patients with severe burns. JAMA 204: 843,196a. Evans EB, Larson DL, Abston S, Willis B: Prevention and correction of deformity after severe burns. Surg C/in N Amer50: 1361,197O. Adams WM Jr, Wisner HK, Larson DL, Lynch JB, Lewis SR: Steinmann pin fixation of extremities for cross-leg flaps. Plasf Reconsfr Surg 44: 364, 1969. Evans EB, Smith JR: Bone and joint changes following burns. J Bone Joint Surg 41: 785. 1959. Frantz CH, Delgado S: Limb-length discrepancy after thirddegree burns about the foot and ankle. Report of four cases. J Bone Joint Surg 46: 443, 1966.
579