Annals of Burns and Fire Disasters - vol. XXVIII - n. 1 - March 2015
OPTIMAL TIMING FOR BURNED HANDS IN CHILDREN DES INDICATIONS POUR TRAITER LES MAINS BRÛLÉES CHEZ LES ENFANTS
ionita D.,2* enescu D.,1,2 Giuvelea S.,2 Stoicescu S.,1,2 mitrache P.2 1 2
“Carol Davila” University of medicine and Pharmacy bucharest, Romania Plastic Surgery Clinic of the emergency hospital for Children “Grigore Alexandrescu”, bucharest, Romania
SUMMArY. Hand burns in children are frequent, severe, and require adequate treatment. A fundamental, though problematic aspect of this treatment is the assessment of the burn depth as this determines the surgical strategy. From a retrospective study of 369 hand burns admitted to our clinic, we were able to identify some patterns. A total of 14.91% required surgery, with varying etiology among these patients. Differences were also noticed in the number of days post-burn prior to surgical intervention. The patterns revealed by our results are reviewed in order to improve therapeutic strategy. Keywords: hand burns, etiology, optimal timing, surgery, rehabilitation
RÉsUMÉ. Les brûlures à la main chez les enfants sont fréquentes et graves, et nécessitent un traitement adéquat. Un aspect fondamental de ce traitement est l’évaluation de la profondeur de la brûlure, car cela détermine la stratégie chirurgicale. D’une étude rétrospective de 369 brûlures à la main admis à notre clinique, nous avons pu identifier certaines tendances. Un total de 14,91% de ces cas, avec des étiologies varies, ont nécessité une chirurgie. On a remarqué également des différences dans le nombre de jours aprés la brûlure avant l’intervention chirurgicale. Ces résultats sont revus afin d’améliorer la stratégie thérapeutique. Mots-clés: brûlures à la main, étiologie, moment optimal, chirurgie, réhabilitation
Introduction
Hand burns in children are frequent; a high percentage of the total burns admitted to our clinic are hand burns. Whether burns involve only the hands or are more extensive, hand burns nonetheless represent a major emergency. in accordance with the American Burns Association severity classification,1 hand burns are admitted to our center for adequate treatment, regardless of the patient’s age or the burn extent, even though sometimes the total body sur3-5 face area involved may be small. The hand has one of the highest densities of sensitive endings, the richest source of tactile feedback and the highest mobility. Adequate treatment is essential for the future development and rehabilitation of children affected by hand burns.2-10 Our retrospective analysis of hand burns, treated in our clinic over a 2-year period, is aimed at highlighting certain characteristics of hand burns for modulating a treatment strategy to achieve optimal rehabilitation.
*
Material and methods
Our study was a retrospective review of 369 upper limb burns admitted to our center from 2012-2013. The appropriate therapeutic protocol was applied according to burn severity, location and extent. initial wound debridement and dressing was performed followed by daily dressing changes. Certain burns required subsequent surgical interventions (necrectomies and covering with skin grafts or flaps). Burn depth was assessed through clinical observation carried out during daily dressing changes; other methods may have been useful but were not available during the period concerned.12-14 For all of the hand burns, as well as for separate groups within them according to etiology, we identified: the average number of days between the burn occurrence and surgical intervention being performed; the most common surgical intervention; the percentage of hand burns requiring surgery; and average length of hospital stay.
Corresponding author: Dr. Dan ionita, The Emergency Hospital for Children ‘grigore Alexandrescu’, Bd. iancu de Hunedoara, nr. 30-32, Sector 1, Bucharest, romania.Tel.: +40213169366/208, +40726527510; fax: +40213127938; email: [email protected] Manuscript: submitted 16/06/2014, accepted 17/07/2014.
29
Annals of Burns and Fire Disasters - vol. XXVIII - n. 1 - March 2015
For hand burns, treatment promptitude and accuracy prevent and minimize sequelae, therefore influencing the future development of child and the social rehabilitation. However, the initial extent of damage may be so severe that irreversible handicaps may be consequent. An important issue in treating burns is the accurate determination of burn depth, as this directly guides the therapeutic process. Therapeutic principles are to be applied in order to prevent further tissue damage. Viable tissue preservation should start from the first moments after the accident. Adequate first aid consists of cooling followed by the application of a dry, clean dressing. proper positioning of the wound helps to prevent microvascular deterioration and reduces edema. Early escharotomies may be necessary. infections should be prevented through debridement, necrectomies, and local and sistemic antibiotic therapy. For full-thickness burns, 15-21 fast skin covering and the use of thicker skin grafts are preferable. Sequelae should be prevented by adequate positioning, splinting, and pressure therapy. For superficial burns, symptomatic treatment, topical antibacterian dressings, correct positioning, and early mobilization should lead us to our objective of spontaneous epithelisation in less than 3 10 days. For full thickness burns and partial deep burns, the local treatment is more complex. Decompression incisions may be necessary if vascular insufficiency is present. Early excision and grafting is often employed during the first 48-72 hours after injury.15-21 results
Most upper limb burns (85.09%) did not require surgical intervention, while the remaining 14.91% required surgery for healing. Depending on etiology, the percentage of burns requiring surgery varied, being highest for flame, followed by electrical burns (including both high and low voltage, as well as electric flame injuries), scalds and contact burns. The most frequent etiology was represented by scalds followed by contact with hot objects, flame and lastly electrical injuries (Table I). The average age of the patients was 3.4 years old. The average length of hospital stay was 5.51 days. For the children requiring surgery, the average surgery day was 8.85 post-injury (Fig. 1). Scalds had the highest incidence (57,18%), affecting patients with an average age of 3.02 years old. The wounds are often partial, superficial or partial deep, and frequently circumferential. Of these, 9.95% required surgery and the average day for intervention was 12,47 days post injury. The average length of hospital stay was 6.18 days. These burns are frequently extensive. Contact with hot objects accounted for 24.66% of the hand burns in children. The average age was 2.12 years old. These burns are usually deep but strictly localised and frequently on the palmar side. The average day of surgery was 10 days post-injury, and only 1.1% required surgery. Flame burns in the studied group were encountered in 30
11.65%. The average age was 7.45 years old. These injuries may be bipolar involving face and hands after an explosion. They are frequently extensive burns. Deep burns have a poor prognosis. The average surgery day was 7.27 days post-burn and 51,16% required surgery. Electrical injuries accounted for 6.5% of the hand burns in the children included in our retrospective study, of whom 45.83% required surgery .The average age was 8.82 years old and the average day for surgery was 5 days post-burn. Discussion
The average number of days from injury to surgical intervention being performed was determined retrospectively. A clear relationship was identified between surgical intervention and precise determination of burn depth through assessment of the wound. The types of injuries which were operated on soonest were those caused by electrical burns, with an average of 5 days between injury and surgical intervention. This result is in accordance with the frequently high need for surgery associated with these injuries. Their local aspect is often suggestive of full thickness burns, even for burns involving deeper structures. Flame burns followed, with surgery taking place an average of 7.27 days post injury. Flame burns are usually deep and generally require surgery. For the studied group, contact burns showed an exception with one such burn which was operated on 10 days post injury. This finding may be interpreted as a temporal variation as we previously identified contact burns as Table I - incidence and surgical necessary for subgroups having different etiological factors Flame Electrical Scalds Contact Total
43 24 211 91 369
incidence 11.65% 6.50% 57.18% 24.66%
requiring surgery 51.16% 45.83% 9.95% 1.10%
fig. 1 - Average surgery day for subgroups having different etiological factors.
Annals of Burns and Fire Disasters - vol. XXVIII - n. 1 - March 2015
requiring surgery in a higher proportion (4.05% up to 8.82%) and the average surgery day was the earliest (day 4 post-burn) compared to the other etiologies.22 This shorter number of days between injury and surgery may have been linked to the burn severity which clearly showed them to be full thickness burns. For scald burns, the average number of days between injury and surgery was greater, which may be linked to the local aspect of the burn wound, but also to the severity of the burn because many of these burns are extensive. For the studied group no other burn etiology was encountered. Hospital stay was not very informative as it was mainly related to the extent of the burn. rehabilitation started from the first day of admission and may have been very advanced for extensive burns requiring serial excision and grafting of other areas, while hand burns may have healed long before discharge from hospital. conclusions
The surgical approach for hand burns in children is ex-
BIBLIoGrAPHY
1. American Burn Association: guidelines for service standards and severity classifications in the treatment of burn injury. Bull Am Coll Surg, 69: 24, 1984. 2. Kamolz lp et al.: The treatment of hand burns. Burns, 35: 32737, 2008. 3. Enescu D, Bratu T, Berechet-Comanescu p, ionita D: An Alternative for local treatment of superficial burns. Ann Burns Fire Disasters, 21: 138–40, 2008. 4. Enescu D, Davidescu i, Enescu M: paediatric burns in Bucharest, romania: 4327 cases over a 5-year period. Burns, 20: 154-6, 1994. 5. Enescu pDD, ionita DD, gutau Di, Alexandru Dr, giuvelea DS, Enescu DM: pediatric burns in romania. Burns, 33: 41-2, 2007. 6. Achauer BM: The burned hand. in: green Dp, Hotchkiss rn, pederson WC (eds): “Operative hand surgery”, 4th ed, Churchill livingstone, philadelphia, 1999. 7. Feller i, Tholen D, Cornell rg: improvements in burn care, 1965 to 1979. JAMA, 244: 2072, 1980. 8. Smith MA, Munster AM, Spence rJ: Burns of the hand and upper limb: A review. Burns, 24: 493-505, 1998. 9. Melhorn J.M., Horner r.l.: Burns of the upper extremity in children; long-term evaluation of function following treatment. J. pediatr. Orthop., 7: 563-7, 1987. 10. pruitt BA: Epidemiology and general considerations. in: Salisbury and pruitt (eds): Burns of the upper extremity. WB Saunders, philadelphia, 1976. 11. Sheridan rl, Hurley J, Smith MA: The acutely burned hand: Management and outcome based on a ten-year experience with 1047 acute hand burns. J Trauma, 38: 406-11, 1995. 12. Heimbach D, Engrav l, grube B: Burn depth: A review. World J Surg, 16: 10-5, 1992.
tremely important. The quality of the results may depend on the optimal sequencing of therapy as well as on the severity of the initial damage. Etiological factors may be particularly important with regard to the following burn characteristics: incidence, average age of patient, depth/time of accurately determining depth, localisation, surgical requirements, and average length of hospitalisation. Sometimes, regardless of etiology, limited burns can cause a significant function deficit. Fast wound closure is very important because the risk of infection, hypertrophic scar formations and contractures increases with a prolonged healing time. important parts of the treatment include early excision and early coverage within the first days after injury. The success of the treatment also depends heavily on infection control and the preservation of the active and passive motion of the hand as well as on an early splinting and functional rehabilitation. The surgical plan, as well as the general treatment has to be suited to each treated child. The interdisciplinary teamwork of surgeons, physiotherapists and occupational therapists, psychologists, motivated health care personnel and consequent treatment strategies can contribute to regaining normal hand function.
13. Hoeksema H et al.: Accuracy of early burn depth assessment by laser Doppler imaging on different days post burn. Burns, 35: 3645, 2008. 14. Mcgill DJ, Sorensen K, MacKay ir, Taggart i, Watson SB: Assessment of burn depth: A prospective, blinded comparison of laser Doppler imaging and videomicroscopy. Burns, 33: 833-42, 2007. 15. Mohammadi AA, Bakhshaeekia Ar, Marzban S, Abbasi S, Ashraf Ar, Mohammadi MK, Toulide Hr, Tavakkolian Ar: Early excision and skin grafting versus delayed skin grafting in deep hand burns (a randomised clinical controlled trial). Burns, 37: 36-41, 2011. 16. Fadaak HA: Experience with early tangential excision in the management of deep dermal burns on the dorsum of the hand. Annals of Burns and Fire Disasters, vol. XiV - n. 1 - March 2001. 17. Mahler D, Benmeir p, Ben Kar et al.: Treatment of the burned hand: Early surgical treatment (1975-85) vs. conservative (196474): A comparative study. Burns, 13: 45-8, 1987. 18. Janzekovie Z: Early excision and immediate grafting of bums. Journal of Trauma, 10: 1103, 1970. 19. Burke JF, Quinby Jr WC, Bondoc CC: primary excision and prompt grafting as routine therapy for the treatment of thermal burns in children. Surg Clin north Amer, 56: 477–94, 1976. 20. Kadry MKM, Bemelmans D, Cate A: Early excision and grafting for burns of the hand. Annals of the MBC, vol. 4 – no. i - March 1991. 21. Muangman p, Sullivan Sr, et al.: The optimal time for early excision in major burn injury. J Med Assoc Thai, 89: 29-36, 2006. 22. ionita D, Enescu DM, giuvelea S, Alexandru r, Ungureanu M, Vaman p, Ungureanu A: Hand burns caused by contact with hot objects in children – potentially extremely severe. Annals of the romanian Association of plastic Surgeons, no. 2, 2012.
31
OPTIMAL TIMING FOR BURNED HANDS IN CHILDREN DES INDICATIONS POUR TRAITER LES MAINS BRÛLÉES CHEZ LES ENFANTS
ionita D.,2* enescu D.,1,2 Giuvelea S.,2 Stoicescu S.,1,2 mitrache P.2 1 2
“Carol Davila” University of medicine and Pharmacy bucharest, Romania Plastic Surgery Clinic of the emergency hospital for Children “Grigore Alexandrescu”, bucharest, Romania
SUMMArY. Hand burns in children are frequent, severe, and require adequate treatment. A fundamental, though problematic aspect of this treatment is the assessment of the burn depth as this determines the surgical strategy. From a retrospective study of 369 hand burns admitted to our clinic, we were able to identify some patterns. A total of 14.91% required surgery, with varying etiology among these patients. Differences were also noticed in the number of days post-burn prior to surgical intervention. The patterns revealed by our results are reviewed in order to improve therapeutic strategy. Keywords: hand burns, etiology, optimal timing, surgery, rehabilitation
RÉsUMÉ. Les brûlures à la main chez les enfants sont fréquentes et graves, et nécessitent un traitement adéquat. Un aspect fondamental de ce traitement est l’évaluation de la profondeur de la brûlure, car cela détermine la stratégie chirurgicale. D’une étude rétrospective de 369 brûlures à la main admis à notre clinique, nous avons pu identifier certaines tendances. Un total de 14,91% de ces cas, avec des étiologies varies, ont nécessité une chirurgie. On a remarqué également des différences dans le nombre de jours aprés la brûlure avant l’intervention chirurgicale. Ces résultats sont revus afin d’améliorer la stratégie thérapeutique. Mots-clés: brûlures à la main, étiologie, moment optimal, chirurgie, réhabilitation
Introduction
Hand burns in children are frequent; a high percentage of the total burns admitted to our clinic are hand burns. Whether burns involve only the hands or are more extensive, hand burns nonetheless represent a major emergency. in accordance with the American Burns Association severity classification,1 hand burns are admitted to our center for adequate treatment, regardless of the patient’s age or the burn extent, even though sometimes the total body sur3-5 face area involved may be small. The hand has one of the highest densities of sensitive endings, the richest source of tactile feedback and the highest mobility. Adequate treatment is essential for the future development and rehabilitation of children affected by hand burns.2-10 Our retrospective analysis of hand burns, treated in our clinic over a 2-year period, is aimed at highlighting certain characteristics of hand burns for modulating a treatment strategy to achieve optimal rehabilitation.
*
Material and methods
Our study was a retrospective review of 369 upper limb burns admitted to our center from 2012-2013. The appropriate therapeutic protocol was applied according to burn severity, location and extent. initial wound debridement and dressing was performed followed by daily dressing changes. Certain burns required subsequent surgical interventions (necrectomies and covering with skin grafts or flaps). Burn depth was assessed through clinical observation carried out during daily dressing changes; other methods may have been useful but were not available during the period concerned.12-14 For all of the hand burns, as well as for separate groups within them according to etiology, we identified: the average number of days between the burn occurrence and surgical intervention being performed; the most common surgical intervention; the percentage of hand burns requiring surgery; and average length of hospital stay.
Corresponding author: Dr. Dan ionita, The Emergency Hospital for Children ‘grigore Alexandrescu’, Bd. iancu de Hunedoara, nr. 30-32, Sector 1, Bucharest, romania.Tel.: +40213169366/208, +40726527510; fax: +40213127938; email: [email protected] Manuscript: submitted 16/06/2014, accepted 17/07/2014.
29
Annals of Burns and Fire Disasters - vol. XXVIII - n. 1 - March 2015
For hand burns, treatment promptitude and accuracy prevent and minimize sequelae, therefore influencing the future development of child and the social rehabilitation. However, the initial extent of damage may be so severe that irreversible handicaps may be consequent. An important issue in treating burns is the accurate determination of burn depth, as this directly guides the therapeutic process. Therapeutic principles are to be applied in order to prevent further tissue damage. Viable tissue preservation should start from the first moments after the accident. Adequate first aid consists of cooling followed by the application of a dry, clean dressing. proper positioning of the wound helps to prevent microvascular deterioration and reduces edema. Early escharotomies may be necessary. infections should be prevented through debridement, necrectomies, and local and sistemic antibiotic therapy. For full-thickness burns, 15-21 fast skin covering and the use of thicker skin grafts are preferable. Sequelae should be prevented by adequate positioning, splinting, and pressure therapy. For superficial burns, symptomatic treatment, topical antibacterian dressings, correct positioning, and early mobilization should lead us to our objective of spontaneous epithelisation in less than 3 10 days. For full thickness burns and partial deep burns, the local treatment is more complex. Decompression incisions may be necessary if vascular insufficiency is present. Early excision and grafting is often employed during the first 48-72 hours after injury.15-21 results
Most upper limb burns (85.09%) did not require surgical intervention, while the remaining 14.91% required surgery for healing. Depending on etiology, the percentage of burns requiring surgery varied, being highest for flame, followed by electrical burns (including both high and low voltage, as well as electric flame injuries), scalds and contact burns. The most frequent etiology was represented by scalds followed by contact with hot objects, flame and lastly electrical injuries (Table I). The average age of the patients was 3.4 years old. The average length of hospital stay was 5.51 days. For the children requiring surgery, the average surgery day was 8.85 post-injury (Fig. 1). Scalds had the highest incidence (57,18%), affecting patients with an average age of 3.02 years old. The wounds are often partial, superficial or partial deep, and frequently circumferential. Of these, 9.95% required surgery and the average day for intervention was 12,47 days post injury. The average length of hospital stay was 6.18 days. These burns are frequently extensive. Contact with hot objects accounted for 24.66% of the hand burns in children. The average age was 2.12 years old. These burns are usually deep but strictly localised and frequently on the palmar side. The average day of surgery was 10 days post-injury, and only 1.1% required surgery. Flame burns in the studied group were encountered in 30
11.65%. The average age was 7.45 years old. These injuries may be bipolar involving face and hands after an explosion. They are frequently extensive burns. Deep burns have a poor prognosis. The average surgery day was 7.27 days post-burn and 51,16% required surgery. Electrical injuries accounted for 6.5% of the hand burns in the children included in our retrospective study, of whom 45.83% required surgery .The average age was 8.82 years old and the average day for surgery was 5 days post-burn. Discussion
The average number of days from injury to surgical intervention being performed was determined retrospectively. A clear relationship was identified between surgical intervention and precise determination of burn depth through assessment of the wound. The types of injuries which were operated on soonest were those caused by electrical burns, with an average of 5 days between injury and surgical intervention. This result is in accordance with the frequently high need for surgery associated with these injuries. Their local aspect is often suggestive of full thickness burns, even for burns involving deeper structures. Flame burns followed, with surgery taking place an average of 7.27 days post injury. Flame burns are usually deep and generally require surgery. For the studied group, contact burns showed an exception with one such burn which was operated on 10 days post injury. This finding may be interpreted as a temporal variation as we previously identified contact burns as Table I - incidence and surgical necessary for subgroups having different etiological factors Flame Electrical Scalds Contact Total
43 24 211 91 369
incidence 11.65% 6.50% 57.18% 24.66%
requiring surgery 51.16% 45.83% 9.95% 1.10%
fig. 1 - Average surgery day for subgroups having different etiological factors.
Annals of Burns and Fire Disasters - vol. XXVIII - n. 1 - March 2015
requiring surgery in a higher proportion (4.05% up to 8.82%) and the average surgery day was the earliest (day 4 post-burn) compared to the other etiologies.22 This shorter number of days between injury and surgery may have been linked to the burn severity which clearly showed them to be full thickness burns. For scald burns, the average number of days between injury and surgery was greater, which may be linked to the local aspect of the burn wound, but also to the severity of the burn because many of these burns are extensive. For the studied group no other burn etiology was encountered. Hospital stay was not very informative as it was mainly related to the extent of the burn. rehabilitation started from the first day of admission and may have been very advanced for extensive burns requiring serial excision and grafting of other areas, while hand burns may have healed long before discharge from hospital. conclusions
The surgical approach for hand burns in children is ex-
BIBLIoGrAPHY
1. American Burn Association: guidelines for service standards and severity classifications in the treatment of burn injury. Bull Am Coll Surg, 69: 24, 1984. 2. Kamolz lp et al.: The treatment of hand burns. Burns, 35: 32737, 2008. 3. Enescu D, Bratu T, Berechet-Comanescu p, ionita D: An Alternative for local treatment of superficial burns. Ann Burns Fire Disasters, 21: 138–40, 2008. 4. Enescu D, Davidescu i, Enescu M: paediatric burns in Bucharest, romania: 4327 cases over a 5-year period. Burns, 20: 154-6, 1994. 5. Enescu pDD, ionita DD, gutau Di, Alexandru Dr, giuvelea DS, Enescu DM: pediatric burns in romania. Burns, 33: 41-2, 2007. 6. Achauer BM: The burned hand. in: green Dp, Hotchkiss rn, pederson WC (eds): “Operative hand surgery”, 4th ed, Churchill livingstone, philadelphia, 1999. 7. Feller i, Tholen D, Cornell rg: improvements in burn care, 1965 to 1979. JAMA, 244: 2072, 1980. 8. Smith MA, Munster AM, Spence rJ: Burns of the hand and upper limb: A review. Burns, 24: 493-505, 1998. 9. Melhorn J.M., Horner r.l.: Burns of the upper extremity in children; long-term evaluation of function following treatment. J. pediatr. Orthop., 7: 563-7, 1987. 10. pruitt BA: Epidemiology and general considerations. in: Salisbury and pruitt (eds): Burns of the upper extremity. WB Saunders, philadelphia, 1976. 11. Sheridan rl, Hurley J, Smith MA: The acutely burned hand: Management and outcome based on a ten-year experience with 1047 acute hand burns. J Trauma, 38: 406-11, 1995. 12. Heimbach D, Engrav l, grube B: Burn depth: A review. World J Surg, 16: 10-5, 1992.
tremely important. The quality of the results may depend on the optimal sequencing of therapy as well as on the severity of the initial damage. Etiological factors may be particularly important with regard to the following burn characteristics: incidence, average age of patient, depth/time of accurately determining depth, localisation, surgical requirements, and average length of hospitalisation. Sometimes, regardless of etiology, limited burns can cause a significant function deficit. Fast wound closure is very important because the risk of infection, hypertrophic scar formations and contractures increases with a prolonged healing time. important parts of the treatment include early excision and early coverage within the first days after injury. The success of the treatment also depends heavily on infection control and the preservation of the active and passive motion of the hand as well as on an early splinting and functional rehabilitation. The surgical plan, as well as the general treatment has to be suited to each treated child. The interdisciplinary teamwork of surgeons, physiotherapists and occupational therapists, psychologists, motivated health care personnel and consequent treatment strategies can contribute to regaining normal hand function.
13. Hoeksema H et al.: Accuracy of early burn depth assessment by laser Doppler imaging on different days post burn. Burns, 35: 3645, 2008. 14. Mcgill DJ, Sorensen K, MacKay ir, Taggart i, Watson SB: Assessment of burn depth: A prospective, blinded comparison of laser Doppler imaging and videomicroscopy. Burns, 33: 833-42, 2007. 15. Mohammadi AA, Bakhshaeekia Ar, Marzban S, Abbasi S, Ashraf Ar, Mohammadi MK, Toulide Hr, Tavakkolian Ar: Early excision and skin grafting versus delayed skin grafting in deep hand burns (a randomised clinical controlled trial). Burns, 37: 36-41, 2011. 16. Fadaak HA: Experience with early tangential excision in the management of deep dermal burns on the dorsum of the hand. Annals of Burns and Fire Disasters, vol. XiV - n. 1 - March 2001. 17. Mahler D, Benmeir p, Ben Kar et al.: Treatment of the burned hand: Early surgical treatment (1975-85) vs. conservative (196474): A comparative study. Burns, 13: 45-8, 1987. 18. Janzekovie Z: Early excision and immediate grafting of bums. Journal of Trauma, 10: 1103, 1970. 19. Burke JF, Quinby Jr WC, Bondoc CC: primary excision and prompt grafting as routine therapy for the treatment of thermal burns in children. Surg Clin north Amer, 56: 477–94, 1976. 20. Kadry MKM, Bemelmans D, Cate A: Early excision and grafting for burns of the hand. Annals of the MBC, vol. 4 – no. i - March 1991. 21. Muangman p, Sullivan Sr, et al.: The optimal time for early excision in major burn injury. J Med Assoc Thai, 89: 29-36, 2006. 22. ionita D, Enescu DM, giuvelea S, Alexandru r, Ungureanu M, Vaman p, Ungureanu A: Hand burns caused by contact with hot objects in children – potentially extremely severe. Annals of the romanian Association of plastic Surgeons, no. 2, 2012.
31
