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Cutaneous lye burns
INJURY : THE BRITISH JOURNAL OF ACCIDENT SURGERY
132
HICKS, J. H. (1959), ' Internal Fixation of Fractures ', in Modern Trends flz Accident Surgery and Medicine (ed. BADC3ER, F. G., CLARKE, R., and SEVIT'r, S.). London: Butterworths. - - - - (1961), ' Fractures of the Forearm Treated by Rigid Fixation ', J. Bone Jt Surg., 43B, 680. - - - - (1963), " Non-union of Fractures: Hypothesis ', Lancet, 1, 86. - - - - ( 1 9 6 4 ) , ' A m p u t a t i o n in Fractures of the Tibia ", J. Bone Jt Surg., 46B, 388. --(1965), ' T h e Treatment of Chronic Sepsis in Fractures ', Ibid., 47B, 584.
Injury Oct. 1971
HICKS, J. H. (1969), ' Rigidity in Fracture Fixation ', Injury, 1, 69. - - - - (1970), ' Sepsis in Fractures ', in Modern Trends in Accident Surgery and Medicine, 2 (ed. LONDON, P. S.). London: Butterworths. LAURENCE, M., FREEMAN, M. A. R., and SWANSON, S. A. V. (1969), 'Engineering Conditions in the Internal Fixation of Fractures of the Tibial Shaft ', J. Bone Jt Surg., 51B, 754. ROWUNG, D. E. (1959), ' A Positive Approach to Chronic Osteomyelitis ', Ibid., 41B, 681.
Requestsfor reprints shouMbe addressed to:--J. H. Hicks, Esq., M.Ch. (Orth.), F.R.C.S., Birmingham Accident Hospital, Bath Row, Birmingham BI5 INA.
ABSTRACTS BURNS
Early Excision and Grafting for Burned Hands
The r6gime described involves excision of fullthickness burns with split-skin grafting, to be completed before changes in the collagen of joint capsules produces permanent stiffness. This is done even at the expense of excising areas of a patchy burn that might have survived. The interesting phenomenon of collagen swelling due to bonding with water and protein, and not amenable to pressure or gravity, is put forward as the urgent reason for this early treatment. (Non-pitting oedema heralding joint stiffness is a widespread problem in trauma.) Some very gratifying results are illustrated. PEACOCK, E. E., MADDEN, J. W., and TRIER, W. C. (1970), ' Some Studies on the Treatment of Burned Hands ', Ann. Surg., 171, 903. Cutaneous L y e Burns
The authors state that most of the medical literature on lye injuries is concerned with the prevention and treatment of visual loss and oesophageal strictures, and that little has been written on the cutaneous wounds. They describe their experience in treating 42 patients (aged 10-72 years) admitted to the Johns Hopkins Hospital and the Baltimore City Hospitals with significant cutaneous lye burns involving from 5 to 60 per cent of the total body surface. Aetiology Nearly all lye injuries occur during a personal quarrel. Between 1952 and 1968, of 416 patients treated only 9 lye injuries followed an accident at work. Usually the concentrated lye solution is thrown at the victim. It may also be mixed with honey and sugar and poured over the victim while he is asleep. The stickiness of the mixture makes it difficult to remove quickly. Another method is to mix the alkali with a carbonated drink and then shake the container before squirting the liquid at the victim. Most victims, quite understandably, show marked psychological depression after lye burns of the face. The occasional victim who may be involved in sadomasochistic relationships with a lover or spouse may show an immediate revulsion against the partner,
but usually this disappears completely within a week or two. Effect of Lye on the Skin The skin is usually erythematous and blistered. The surface is soapy to the touch and is painful. The combination of lye with fat to form soaps is an exothermic reaction which damages the adjacent tissues, and in addition the hydroscopic nature of lye also produces cellular dehydration and death. These clinical processes continue until all the lye has been removed or sufficiently diluted by the body fluids. Thus long periods of contact with the lye, high concentrations, or long periods of delay in treatment will produce more thrombosis of the deeper capillary network, more ischaemic tissue necrosis, and a deeper burn wound. The lye burn also differs from the usual thermal burn in that there is usually full-thickness skin-loss, it being very unusual for the hair follicles and sweat-gland elements to escape destruction. For this reason skin-grafting is usually required to expedite healing. Special Complications Because lye is normally used in liquid form, the solution may flow into the external auditory meatus and produce parotid-cutaneous fistulae and perforation of the tympanic membrane. Keloid formation seems to be more prevalent after lye injuries and the authors report the development of Marjolin's ulceration in three patients, 3, 7, and 9 years respectively after the accident. This is a much shorter time interval than the average time lag previously reported for malignant degeneration in burn scars (i.e., normally 30-35 years). Treatment Thorough mechanical cleansing is essential and urgent. Continuous irrigation for 12-24 hours with water is the treatment of choice. To add hexachlorophene or saline soaks will only provoke an exothermic reaction and add to the damage. After the watershower treatment the burns are treated by exposure with topical application of mafenide (sulfamylon). Gentamicin is avoided as sulphate radicals also produce an exothermic reaction. Penicillin is given systemically as a prophylactic measure for 5 days. The separating eschar is removed surgically as early as possible to allow skin-grafting. WOLFORT, F. G., DEMEESTER, T., KNORR, N., and EDGERTON, M. T. (1970), 'Surgical Management of Cutaneous Lye Burns ', Surgery Gynec. Obstet., 131, 873.
132
HICKS, J. H. (1959), ' Internal Fixation of Fractures ', in Modern Trends flz Accident Surgery and Medicine (ed. BADC3ER, F. G., CLARKE, R., and SEVIT'r, S.). London: Butterworths. - - - - (1961), ' Fractures of the Forearm Treated by Rigid Fixation ', J. Bone Jt Surg., 43B, 680. - - - - (1963), " Non-union of Fractures: Hypothesis ', Lancet, 1, 86. - - - - ( 1 9 6 4 ) , ' A m p u t a t i o n in Fractures of the Tibia ", J. Bone Jt Surg., 46B, 388. --(1965), ' T h e Treatment of Chronic Sepsis in Fractures ', Ibid., 47B, 584.
Injury Oct. 1971
HICKS, J. H. (1969), ' Rigidity in Fracture Fixation ', Injury, 1, 69. - - - - (1970), ' Sepsis in Fractures ', in Modern Trends in Accident Surgery and Medicine, 2 (ed. LONDON, P. S.). London: Butterworths. LAURENCE, M., FREEMAN, M. A. R., and SWANSON, S. A. V. (1969), 'Engineering Conditions in the Internal Fixation of Fractures of the Tibial Shaft ', J. Bone Jt Surg., 51B, 754. ROWUNG, D. E. (1959), ' A Positive Approach to Chronic Osteomyelitis ', Ibid., 41B, 681.
Requestsfor reprints shouMbe addressed to:--J. H. Hicks, Esq., M.Ch. (Orth.), F.R.C.S., Birmingham Accident Hospital, Bath Row, Birmingham BI5 INA.
ABSTRACTS BURNS
Early Excision and Grafting for Burned Hands
The r6gime described involves excision of fullthickness burns with split-skin grafting, to be completed before changes in the collagen of joint capsules produces permanent stiffness. This is done even at the expense of excising areas of a patchy burn that might have survived. The interesting phenomenon of collagen swelling due to bonding with water and protein, and not amenable to pressure or gravity, is put forward as the urgent reason for this early treatment. (Non-pitting oedema heralding joint stiffness is a widespread problem in trauma.) Some very gratifying results are illustrated. PEACOCK, E. E., MADDEN, J. W., and TRIER, W. C. (1970), ' Some Studies on the Treatment of Burned Hands ', Ann. Surg., 171, 903. Cutaneous L y e Burns
The authors state that most of the medical literature on lye injuries is concerned with the prevention and treatment of visual loss and oesophageal strictures, and that little has been written on the cutaneous wounds. They describe their experience in treating 42 patients (aged 10-72 years) admitted to the Johns Hopkins Hospital and the Baltimore City Hospitals with significant cutaneous lye burns involving from 5 to 60 per cent of the total body surface. Aetiology Nearly all lye injuries occur during a personal quarrel. Between 1952 and 1968, of 416 patients treated only 9 lye injuries followed an accident at work. Usually the concentrated lye solution is thrown at the victim. It may also be mixed with honey and sugar and poured over the victim while he is asleep. The stickiness of the mixture makes it difficult to remove quickly. Another method is to mix the alkali with a carbonated drink and then shake the container before squirting the liquid at the victim. Most victims, quite understandably, show marked psychological depression after lye burns of the face. The occasional victim who may be involved in sadomasochistic relationships with a lover or spouse may show an immediate revulsion against the partner,
but usually this disappears completely within a week or two. Effect of Lye on the Skin The skin is usually erythematous and blistered. The surface is soapy to the touch and is painful. The combination of lye with fat to form soaps is an exothermic reaction which damages the adjacent tissues, and in addition the hydroscopic nature of lye also produces cellular dehydration and death. These clinical processes continue until all the lye has been removed or sufficiently diluted by the body fluids. Thus long periods of contact with the lye, high concentrations, or long periods of delay in treatment will produce more thrombosis of the deeper capillary network, more ischaemic tissue necrosis, and a deeper burn wound. The lye burn also differs from the usual thermal burn in that there is usually full-thickness skin-loss, it being very unusual for the hair follicles and sweat-gland elements to escape destruction. For this reason skin-grafting is usually required to expedite healing. Special Complications Because lye is normally used in liquid form, the solution may flow into the external auditory meatus and produce parotid-cutaneous fistulae and perforation of the tympanic membrane. Keloid formation seems to be more prevalent after lye injuries and the authors report the development of Marjolin's ulceration in three patients, 3, 7, and 9 years respectively after the accident. This is a much shorter time interval than the average time lag previously reported for malignant degeneration in burn scars (i.e., normally 30-35 years). Treatment Thorough mechanical cleansing is essential and urgent. Continuous irrigation for 12-24 hours with water is the treatment of choice. To add hexachlorophene or saline soaks will only provoke an exothermic reaction and add to the damage. After the watershower treatment the burns are treated by exposure with topical application of mafenide (sulfamylon). Gentamicin is avoided as sulphate radicals also produce an exothermic reaction. Penicillin is given systemically as a prophylactic measure for 5 days. The separating eschar is removed surgically as early as possible to allow skin-grafting. WOLFORT, F. G., DEMEESTER, T., KNORR, N., and EDGERTON, M. T. (1970), 'Surgical Management of Cutaneous Lye Burns ', Surgery Gynec. Obstet., 131, 873.