Case 51 Upper Extremity Burns
51.1 Description
Circumferential burns of variable thickness to the left upper extremity in a pediatric patient
Blistering suggestive of second degree burn, with the possibility of third degree injury
Burn of this variety in 1-year-old patient suspicious for abuse or neglect
51.2 Work-Up
51.2.1 History
Age, gender, handedness, and occupation of the patient
Timing and mechanism of burn injury
Thermal: Type of burn (flame, contact, scald, steam, or grease); associated injuries; suspicion of abuse (especially in elderly and children)
Chemical: Type of chemical (alkali, acid, or organic compound); any attempts at neutralization
Electrical: Type of current (alternating current [AC] or direct current [DC]), voltage, and location of initial contact
Past medical and surgical history
Social history, including tobacco, alcohol, and substance abuse
51.2.2 Physical Examination
Primary survey: Advanced Trauma Life Support (ATLS) protocol and ABCDs.
Hand is scrubbed of any soot, dirt, or debris
Potentially constricting clothing, jewelry, and watches are removed
Acute injury
Location and total body surface area of burn injury (see Chapter 49)
Depth of burn injury: First degree, superficial or deep second degree, or third degree; note exposure of deep structures
Perfusion of upper extremity, hands and fingers
Motor and sensory function
Compartment syndrome: Limb-threatening condition
Circumferential burns; associated crush injury or trauma
Pain out of proportion with movement (finger extension, flexion)
Five P’s (late signs): Pain, pallor, paresthesias, paralysis, and pulselessness
Intracompartmental pressures >30 mmHg require intervention
Secondary reconstruction
Status of soft-tissue coverage (thickness, durability, sensibility, and elasticity)
Contractures, and active and passive range of motion (ROM) of each joint
51.2.3 Pertinent Imaging or Diagnostic Studies
Standard radiography (three views) of the hand, elbow, and humerus
Bloodwork: Complete blood count (CBC), electrolytes, blood urea nitrogen (BUN), creatinine, international normalized ratio (INR), partial thromboplastin time (PTT), glucose, and blood type
Consider arterial blood gases for associated inhalational injuries or certain chemicals
Cardiac enzymes, urine myoglobin, creatine kinase, and 12-lead electrocardiography (hyper K+, electrical burns)
51.3 Consultations
Indications for referral to a burn center (see Table 50.1)
General surgery or critical care team if burns are extensive
Poison control center if chemical is involved and management is unclear
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