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Deep burn due to an unusual cause—boiling blood!
Burns 29 (2003) 287–290
Case report
Deep burn due to an unusual cause—boiling blood! Emma Igras a , Dilip Gahankari b,∗ , Carlo Yuen c , Michael Fish d , Stuart Pegg e,1 b
a Royal Brisbane Hospital, Queensland, Brisbane, Australia Royal Brisbane Hospital, Brisbane, 44/89 Scott Road, Queensland, Herston 4006, Australia c Nambour General Hospital, Queensland, Nambour, Australia d Townsville General Hospital, Townsville, Queensland, Australia e Burns Unit, Royal Brisbane Hospital, Brisbane, Australia
Accepted 19 November 2002
1. Case report G.B., a 27 years old, previously well, Caucasian male was admitted to our burns unit, transferred from one of the peripheral hospitals with 4% TBSA burns to the left foot and distal left leg approximately 6 h after accident due to boiling blood. The patient was employed in a small town abattoir where he oversees the drying of pigs’ blood for reuse as pig feed in the meat-works. This process involves distilling of blood in a vat heated by steam elements at its base. When the blood has had sufficient fluid distilled off, it is manually transferred into an auger to be further dried into a powder form for use as fodder. The blood sludge from the vat is removed via a release valve on its side. The patient sustained his burns when he attempted to open the faulty valve and spilt boiling blood into his left knee-high boot that had not been protected by a boot guard. Immediately after the incident, both boots were removed and his left lower limb was immersed in cool tap water for 30 min before presenting to the referring hospital. On examination, the patient was found to have full thickness burns of approximately 4% TBSA to his (L) foot and circumferentially around his ankle and distal leg (Figs. 1 and 2). The worst affected area was the dorsal aspect of his foot and around the ankle region including skin on the Achilles tendon. The plantar aspect had relatively superficial dermal burns. The patient underwent tangential excision and split skin grafting on the 3rd post-burn day to his left distal leg and the dorsum of his left foot. Surgery was performed using a proximal tourniquet. Most of the burn wound was found ∗ Corresponding author. Present address: University of Queensland, Queensland, Brisbane, Australia. 1 University of Queensland, Queensland, Australia.
to be deep partial or full thickness. Debridement of full thickness burn over the Achilles tendon left the lower 3 cm of tendon exposed. Two longitudinally oriented bipedicled adipo-fascial flaps each about 8 cm long and 2.5 cm wide, were planned on both sides. These flaps were based on distal perforating vessels from the posterior tibial and peroneal systems. The flaps were raised using loupe magnification. The perforating vessels were carefully dissected and lengthened by gentle teasing until the flaps were able to approximate to each other without tension, covering the entire exposed tendon. This involved side-ways movement of approximately 1.5 cm for each flap. The flaps were sutured to each other with interrupted 4-0 polyglactin sutures. Fig. 3 shows the schematic illustration of the design of these flaps. These flaps as well as the lateral and medial raw areas at their donor sites were then covered with skin grafts meshed 1:1.5. The wound was dressed with Bactigras (Smith and Nephew, Australia), gauze and bandages as usual. Two days later, the SSG on the flaps was found to be well adherent indicating survival of the adipo-fascial flaps beneath the SSG. However, some patchy areas approximating 1% TBSA over the distal leg and foot were noticed to have be inadequately debrided, with loss of overlying SSG. These were addressed on day 12 of burn with repeat debridement and further SSG. Routine regimen of bed rest, elevation, compression bandaging and splinting was advocated for the entire duration of this surgical management. Regrafted areas had good graft take and the patient went on to make a good functional recovery of Achilles function with adequate cosmetic result and complete coverage of the Achilles tendon. He was subsequently provided with a compression garment for long-term use. Follow up at 6 months (Figs. 4 and 5) showed stable skin graft over entire area including that on the Achilles tendon. He has full range of ankle movement and he is back to his old job without any restriction of activities.
0305-4179/03/$30.00 © 2003 Elsevier Science Ltd and ISBI. All rights reserved. doi:10.1016/S0305-4179(02)00308-X
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E. Igras et al. / Burns 29 (2003) 287–290
Fig. 1. Burnt (L) lower leg and foot 6 h after injury—anterior aspect.
Fig. 2. Burnt (L) lower leg and foot 6 h after injury—medial aspect.
Fig. 3. Schematic illustration of design and execution of bipedicled bilateral adipo-fascial flaps based on posterior tibial and peroneal arterial systems (a and b). ‘D’ represents exposed Achilles tendon.
E. Igras et al. / Burns 29 (2003) 287–290
Fig. 4. Post-operative result after 6 months—medial aspect.
289
Fig. 5. Post-operative result after 6 months—posterior aspect. Please note well healed skin graft albeit some evidence of hypertrophy.
2. Discussion To our knowledge, this is the first reported case of burn due to ‘boiling blood’. The mechanism of burn injury is one of the most important determinants of the severity of the tissue damage by burn. Although any hot liquid burn is regarded as scalds, the burn caused by liquids with higher boiling point such as certain oils, can cause significantly deep burn injury. The other important determinant of the severity is the contact period as in case of immersion scalds. In our patient, both these factors played a significant role in causing deep burn. As the boiling point of the pig blood sludge is 104.4 ◦ C (220 ◦ F) it is likely to cause full thickness burn by immediate contact [1]. Lack of overlying subcutaneous tissue makes the distal Achilles tendon prone to exposure after deep burns. This often poses a difficult problem for adequate cover if such exposure of tendon is inevitable. Since there were full thickness burns of the surrounding skin of the ankle as well, no local skin or fascio-cutaneous flaps were available. The only other option for cover of the exposed Achilles tendon at this level, in our opinion, would have been a thin free micro-vascular flap such as a radial artery fascial or a fascio-cutaneous flap or perhaps a superficial temporal fascial flap. Micro-vascular flap transfer is a major procedure with some risk of failure
especially in area traumatised by acute burn. Under these circumstances, we decided to exploit the local adipo-fascial bipedicle flap alternative first. Careful mobilisation of adequate size adipo-fascial bipedicled flaps preserving the perforating vessels from the posterior tibial and the peroneal arterial systems and over grafting of the donor sites and the flaps themselves can be effective ‘life boat’ measures in such circumstances. Although distally based adipofascial flaps based on same perforators have been used for reconstruction of distal leg defects by several authors [2–4], we did not find any mention of bipedicle flaps been used in similar circumstances. In most cases quoted in the literature, however, flaps were harvested from adjacent non-traumatised areas. This obviously was not possible in our case. In dissecting conventionally described adipo-fascial flaps, proximal or distal perforators (depending on where it is based) need division for adequate mobilization of flap for coverage of the defect. In our technique, these perforators are mobilized with utmost care under magnification, lengthening them adequately to achieve sufficient mobility for approximation to each other. In our opinion, bipedicled adipo-fascial flaps provide an excellent option in traumatised or burnt area for suitable defects, as they involve much less dissection and disruption of tissues
290
E. Igras et al. / Burns 29 (2003) 287–290
compared to conventional fascio-cutaneous or adipo-fascial flaps and when successful, can avoid a major reconstructive procedure. The mechanism of the burn sustained by this patient in his workplace environment raises the issue of possible preventative measures. It is noted that a simple boot guard or protective waterproof clothing draped over the boot mouth might have circumvented or in the least, greatly reduced the extent of his burn injury. These precautions would avoid the boot acting as a reservoir of hot liquid around the foot and thus reduce the incidence and extent resultant burn injury. These measures are already being enforced following this tragic incident.
3. Conclusion A unique case of burn injury to distal leg and foot caused by boiling blood is presented. The burn wound was treated with early excision and skin grafting as well as local subcutaneous tissue flaps for cover of tendon Achilles with good
results. Preventive measures for industrial accident are discussed.
Acknowledgements We sincerely acknowledge the Royal Brisbane Hospital Medical Illustration Department for their help with the figures and illustrations. References [1] Salisbury RE. Thermal burns in plastic surgery. In: McCarthy JG, editor. Plastic surgery, vol. 1. Philadelphia: WB Saunders; 1990. p. 787–813. [2] Lee S, Estela CM, Burd A. The lateral distally based adipofascial flap of the lower limb. Br J Plast Surg 2001;54:303–9. [3] Lin SD, Chou CK, Lin TM, Wang HJ, Lai CS. The distally based lateral adipofascial flap. Br J Plast Surg 1998;51:96–102. [4] Worseg AP, Kuzbari R, Alt A, Jahl G, Tschabitscher M, Holle J. The vertically based deep fascia turnover flap of the leg: anatomic studies and clinical applications. Plast Reconstr Surg 1997;100:1746–61.
Case report
Deep burn due to an unusual cause—boiling blood! Emma Igras a , Dilip Gahankari b,∗ , Carlo Yuen c , Michael Fish d , Stuart Pegg e,1 b
a Royal Brisbane Hospital, Queensland, Brisbane, Australia Royal Brisbane Hospital, Brisbane, 44/89 Scott Road, Queensland, Herston 4006, Australia c Nambour General Hospital, Queensland, Nambour, Australia d Townsville General Hospital, Townsville, Queensland, Australia e Burns Unit, Royal Brisbane Hospital, Brisbane, Australia
Accepted 19 November 2002
1. Case report G.B., a 27 years old, previously well, Caucasian male was admitted to our burns unit, transferred from one of the peripheral hospitals with 4% TBSA burns to the left foot and distal left leg approximately 6 h after accident due to boiling blood. The patient was employed in a small town abattoir where he oversees the drying of pigs’ blood for reuse as pig feed in the meat-works. This process involves distilling of blood in a vat heated by steam elements at its base. When the blood has had sufficient fluid distilled off, it is manually transferred into an auger to be further dried into a powder form for use as fodder. The blood sludge from the vat is removed via a release valve on its side. The patient sustained his burns when he attempted to open the faulty valve and spilt boiling blood into his left knee-high boot that had not been protected by a boot guard. Immediately after the incident, both boots were removed and his left lower limb was immersed in cool tap water for 30 min before presenting to the referring hospital. On examination, the patient was found to have full thickness burns of approximately 4% TBSA to his (L) foot and circumferentially around his ankle and distal leg (Figs. 1 and 2). The worst affected area was the dorsal aspect of his foot and around the ankle region including skin on the Achilles tendon. The plantar aspect had relatively superficial dermal burns. The patient underwent tangential excision and split skin grafting on the 3rd post-burn day to his left distal leg and the dorsum of his left foot. Surgery was performed using a proximal tourniquet. Most of the burn wound was found ∗ Corresponding author. Present address: University of Queensland, Queensland, Brisbane, Australia. 1 University of Queensland, Queensland, Australia.
to be deep partial or full thickness. Debridement of full thickness burn over the Achilles tendon left the lower 3 cm of tendon exposed. Two longitudinally oriented bipedicled adipo-fascial flaps each about 8 cm long and 2.5 cm wide, were planned on both sides. These flaps were based on distal perforating vessels from the posterior tibial and peroneal systems. The flaps were raised using loupe magnification. The perforating vessels were carefully dissected and lengthened by gentle teasing until the flaps were able to approximate to each other without tension, covering the entire exposed tendon. This involved side-ways movement of approximately 1.5 cm for each flap. The flaps were sutured to each other with interrupted 4-0 polyglactin sutures. Fig. 3 shows the schematic illustration of the design of these flaps. These flaps as well as the lateral and medial raw areas at their donor sites were then covered with skin grafts meshed 1:1.5. The wound was dressed with Bactigras (Smith and Nephew, Australia), gauze and bandages as usual. Two days later, the SSG on the flaps was found to be well adherent indicating survival of the adipo-fascial flaps beneath the SSG. However, some patchy areas approximating 1% TBSA over the distal leg and foot were noticed to have be inadequately debrided, with loss of overlying SSG. These were addressed on day 12 of burn with repeat debridement and further SSG. Routine regimen of bed rest, elevation, compression bandaging and splinting was advocated for the entire duration of this surgical management. Regrafted areas had good graft take and the patient went on to make a good functional recovery of Achilles function with adequate cosmetic result and complete coverage of the Achilles tendon. He was subsequently provided with a compression garment for long-term use. Follow up at 6 months (Figs. 4 and 5) showed stable skin graft over entire area including that on the Achilles tendon. He has full range of ankle movement and he is back to his old job without any restriction of activities.
0305-4179/03/$30.00 © 2003 Elsevier Science Ltd and ISBI. All rights reserved. doi:10.1016/S0305-4179(02)00308-X
288
E. Igras et al. / Burns 29 (2003) 287–290
Fig. 1. Burnt (L) lower leg and foot 6 h after injury—anterior aspect.
Fig. 2. Burnt (L) lower leg and foot 6 h after injury—medial aspect.
Fig. 3. Schematic illustration of design and execution of bipedicled bilateral adipo-fascial flaps based on posterior tibial and peroneal arterial systems (a and b). ‘D’ represents exposed Achilles tendon.
E. Igras et al. / Burns 29 (2003) 287–290
Fig. 4. Post-operative result after 6 months—medial aspect.
289
Fig. 5. Post-operative result after 6 months—posterior aspect. Please note well healed skin graft albeit some evidence of hypertrophy.
2. Discussion To our knowledge, this is the first reported case of burn due to ‘boiling blood’. The mechanism of burn injury is one of the most important determinants of the severity of the tissue damage by burn. Although any hot liquid burn is regarded as scalds, the burn caused by liquids with higher boiling point such as certain oils, can cause significantly deep burn injury. The other important determinant of the severity is the contact period as in case of immersion scalds. In our patient, both these factors played a significant role in causing deep burn. As the boiling point of the pig blood sludge is 104.4 ◦ C (220 ◦ F) it is likely to cause full thickness burn by immediate contact [1]. Lack of overlying subcutaneous tissue makes the distal Achilles tendon prone to exposure after deep burns. This often poses a difficult problem for adequate cover if such exposure of tendon is inevitable. Since there were full thickness burns of the surrounding skin of the ankle as well, no local skin or fascio-cutaneous flaps were available. The only other option for cover of the exposed Achilles tendon at this level, in our opinion, would have been a thin free micro-vascular flap such as a radial artery fascial or a fascio-cutaneous flap or perhaps a superficial temporal fascial flap. Micro-vascular flap transfer is a major procedure with some risk of failure
especially in area traumatised by acute burn. Under these circumstances, we decided to exploit the local adipo-fascial bipedicle flap alternative first. Careful mobilisation of adequate size adipo-fascial bipedicled flaps preserving the perforating vessels from the posterior tibial and the peroneal arterial systems and over grafting of the donor sites and the flaps themselves can be effective ‘life boat’ measures in such circumstances. Although distally based adipofascial flaps based on same perforators have been used for reconstruction of distal leg defects by several authors [2–4], we did not find any mention of bipedicle flaps been used in similar circumstances. In most cases quoted in the literature, however, flaps were harvested from adjacent non-traumatised areas. This obviously was not possible in our case. In dissecting conventionally described adipo-fascial flaps, proximal or distal perforators (depending on where it is based) need division for adequate mobilization of flap for coverage of the defect. In our technique, these perforators are mobilized with utmost care under magnification, lengthening them adequately to achieve sufficient mobility for approximation to each other. In our opinion, bipedicled adipo-fascial flaps provide an excellent option in traumatised or burnt area for suitable defects, as they involve much less dissection and disruption of tissues
290
E. Igras et al. / Burns 29 (2003) 287–290
compared to conventional fascio-cutaneous or adipo-fascial flaps and when successful, can avoid a major reconstructive procedure. The mechanism of the burn sustained by this patient in his workplace environment raises the issue of possible preventative measures. It is noted that a simple boot guard or protective waterproof clothing draped over the boot mouth might have circumvented or in the least, greatly reduced the extent of his burn injury. These precautions would avoid the boot acting as a reservoir of hot liquid around the foot and thus reduce the incidence and extent resultant burn injury. These measures are already being enforced following this tragic incident.
3. Conclusion A unique case of burn injury to distal leg and foot caused by boiling blood is presented. The burn wound was treated with early excision and skin grafting as well as local subcutaneous tissue flaps for cover of tendon Achilles with good
results. Preventive measures for industrial accident are discussed.
Acknowledgements We sincerely acknowledge the Royal Brisbane Hospital Medical Illustration Department for their help with the figures and illustrations. References [1] Salisbury RE. Thermal burns in plastic surgery. In: McCarthy JG, editor. Plastic surgery, vol. 1. Philadelphia: WB Saunders; 1990. p. 787–813. [2] Lee S, Estela CM, Burd A. The lateral distally based adipofascial flap of the lower limb. Br J Plast Surg 2001;54:303–9. [3] Lin SD, Chou CK, Lin TM, Wang HJ, Lai CS. The distally based lateral adipofascial flap. Br J Plast Surg 1998;51:96–102. [4] Worseg AP, Kuzbari R, Alt A, Jahl G, Tschabitscher M, Holle J. The vertically based deep fascia turnover flap of the leg: anatomic studies and clinical applications. Plast Reconstr Surg 1997;100:1746–61.