How To Assess And Manage Burn Injuries Of The Foot
Burn injuries are among the most devastating wounds a clinician may be asked to treat. Burn medicine is a critical care, specialized field of medicine, surgery and rehabilitation, all of which are intertwined and interdependent for successful outcomes. Precise awareness of modern wound management, skin function, infectious disease issues and crisis decision capabilities are hallmarks of burn injury care. Significantly, as more podiatrists become experts at wound management, many DPMs will find themselves becoming an integral part of the modern burn team. In the United States, there are approximately 125 recognized burn centers that admit a total of 22,500 burn patients annually. In the last 35 years, the severity and number of burn admissions has declined due in part to the more sophisticated training of burn clinicians, advances in pre-hospital emergency medicine and the evolution of wound medicine into a well-recognized medical and surgical specialty. Published reports indicate the number of deaths from burn sepsis has declined due to the improvement in antimicrobial dressings. However, in spite of promising advances, proper education of the public, other health care providers and community organizations would help reduce burn injuries and accidents even further. Who Do Burn Injuries Affect The Most? Who is prone to burn injury? These injuries tend to occur more with patients at extreme age levels, namely the elderly and the young. Forty-five percent of burn patients are children under the age of 8. Burns are the leading cause of death for those under the age of 2. Seventy-five percent of pediatric burn admissions are males and African-American children are three times more likely to be burned than Caucasian children. Socioeconomic issues are directly related to burn injuries, as they may result from living in more confined domestic quarters and less use of smoke detectors. “Reach and pull” scalding injuries are classic injuries incurred by young boys. One will typically see burns to the lower extremities and feet after a child reaches up to grab at the stove or table that has hot liquids or foods. Of the 100,000 scald burns recorded each year, there are reportedly 5,000 scald injuries to the feet. These injuries tend to be bilateral in presentation. Burn injuries to those age 65 and older result in a three- to fourfold higher mortality rate than younger patients who sustain critical burns. Poor agility, inability to "stop, drop and roll," preexisting medical conditions, atrophic skin, lack of smoke detectors and cooking with loose fitting clothing all predispose elderly patients to a more severe outcome. In regard to the death rate, clothing fires are the number one cause of death in this age group, due to smoking in bed and cooking with loose garments. Simply advising this group to cook with rolled-up sleeves can go a long way toward preventing burn injuries. Why A Strong Understanding Of Lower Extremity Skin Facilitates Appropriate Treatment Of Burn Injuries Burn management requires clinicians to have a full understanding of the layers of the skin and their function in order to assess the burn injury properly. (See “A Pertinent Primer On Skin Layer Function” below.) This, in turn, enables one to arrive at a more focused treatment plan. Anatomically, the dorsal skin of the foot is thin by design, facilitating the required gliding motion for the tendons to function without obstruction. Due to this inherent thin tissue, one must carefully assess the burns of the dorsum for tendon exposure. If you are dealing with exposed tendon, you need to rapidly determine the quality of the tissue. One can preserve healthy tendon via appropriate dressing selection, negative wound pressure therapy and properly timed skin grafting or other coverage procedures. Devitalized tissue warrants surgical excision in order to reduce the risk of infection from desiccated or necrotic tendon. Plantar foot burns are less common, due to the thicker skin layers as well as a unique fat pad construction. The thick tissue known as glabrous tissue is often uninjured in cases of bathtub scalds when a patient stands in hot water. The resiliency of this tissue is unique. When significant burns do occur to the plantar aspect of the foot, reconstruction is more challenging as attempts to recreate this anatomy designed for shock absorption and biomechanical stress is difficult at best.