Upper Extremity Burns in the Developing World: A Neglected Epidemic

Introduction

Burns are devastating injuries that cause significant morbidity, emotional distress, and reduced quality of life. Advances in care have improved survival and functional outcomes over the last several decades; however, burns remain a major public health problem in developing countries. Globally, over 11 million people seek medical attention for burns each year.¹ Burns are among the leading causes of death and disability worldwide.^2,3

The burden of burn injury falls predominantly on the poor. Over 95% of burns occur in low- and middle- income countries (LMIC) where education, safety regulations, prevention programs, and access to basic health care are lacking.⁴ Treatment is often delayed, inappropriate, or inadequate. Follow-up is problematic and rehabilitation services are non-existent. The sequelae of un- and under-treated burns are often severe enough to cause permanent disability. In developing countries, this can mean unemployment, family abandonment, social segregation, and extreme poverty.

Though each hand accounts for only 3% of total body surface area, they are involved in over 80% of severe burns.⁵ Appropriate treatment of upper extremity burns is a priority – even small burns to the hand can result in severe functional disability. Scarring, joint contractures, stiffness, and chronic pain are devastating in the upper extremity due to the dependence on hand function for productivity and financial independence.

The purpose of this article is to review upper extremity burn epidemiology, risk factors, prevention strategies, and treatment options in resource-limited settings.

Epidemiology

National and public health registries, hospital data, community surveys, and a variety of additional sources are used to gather information on burn epidemiology. The accuracy and availability of this data varies considerably. Most published literature characterizing the etiology, severity, risk factors, and outcomes of burns is based on populations of patients treated at burn centers. Patients treated in primary care facilities, rural settings, or at home represent a large portion of injuries and often go unaccounted for. This section presents available information on burn epidemiology.

Incidence

Burns are the fourth most common cause of injury worldwide, following traffic accidents, falls, and interpersonal violence.¹ Over 30 million people are affected each year. Although 300,000 deaths are caused by burns and fires annually, the vast majority of burn injuries are non-fatal.⁴

The overall incidence of acute burns and prevalence of chronic sequelae have both decreased since 1990.⁶ This is attributed to legislative changes, widespread prevention strategies, increased workplace safety, and improved guidelines for referral to burn centers in the developed world.⁷ Demographic changes since 1990, including longer life expectancy and a shift in the age distribution towards an older populace, accentuate this decline. The incidence of burns in the developing world remains alarmingly high.⁸ Regional variations in social, political, and environmental factors, discussed later, result in an unequal worldwide distribution.

Morbidity and Sequelae

Non-fatal burns are a leading cause of prolonged hospitalization, chronic pain, disfigurement, and disability. Burn patients typically benefit from long-term therapy and may require multiple reconstructive procedures to facilitate recovery. In the developing world, resources and access to care are limited. Patients travel long distances for treatment, making follow-up care impractical or impossible. Many survivors receive no further medical services after discharge. Undertreated extremity burns result in severe contractures.

It is estimated that over 18 million people currently live with the sequelae of hand burns.⁹ Many face lifelong disability and extreme poverty as the result of functional impairment and loss of vocational capacity. Social and financial support services are rare in developing countries.

Burden of disease

The direct cost of medical care varies widely throughout the world. Burn care is generally expensive due to long hospital stays, specialized dressings, multiple surgeries, and the need for intensive care in severe injuries. In the U.S., inpatient care costs $3000 to $5000 per day.⁴ Mean total cost of care over a patient’s lifetime is $88,218 in high-income countries.¹⁰ Indirect costs, such as lost wages, travel, and costs related to emotional and physical rehabilitation, contribute significantly to the overall economic impact of disease.

The disability-adjusted life-year (DALY) is a metric commonly used to quantify the harmful effect of an injury or disease. Introduced in the World Development Report in 1993, DALY is the sum of the years of life lost (YLL) and years of life lived with disability (YLD).^11,12 Burns are among the leading causes of DALYs lost in LMIC.⁴ Although burns reduce an individual’s overall life expectancy, YLD contributes more to DALY calculations for upper extremity burns.

Risk Factors

Over 80% of severe burns involve the upper extremity. Hands are generally exposed, used in protective reflexes, and most likely to come into contact with hot substances, chemicals, electrical current, and moving parts (friction). This section reviews risk factors for burn injury.

Socioeconomic

Burns disproportionately affect the poor. Over 95% of burn injuries occur in low and middle income regions.⁴ Southeast Asia, the Eastern Mediterranean, and Africa have the highest rates of burn mortality worldwide. Even in high income counties, individuals living in areas of deprivation are more likely to suffer severe burns requiring hospitalization.^7,13 Inferior quality of housing, the absence of preventive devices such as smoke detectors, sprinklers, hot water temperature regulators, and increased rates of smoking, drug, and alcohol abuse in low-income areas place these communities at risk.^14,15

Race and ethnicity

In the United States, the rate of non-fatal burns is 122 per 100,000 in black Americans versus 91 per 100,000 in white non-Hispanics.¹⁶ The age-adjusted death rate from burns is also highest in blacks (1.6 per 100,000) compared to American Indians (1.4), Caucasians (0.9), and Asians (0.3).¹⁷ Studies show similar trends for other minority and Aboriginal populations worldwide.^18,19 Differences are the result of cultural, educational, and socioeconomic factors that disparately affect minorities.

Gender

Behavior affects injuries within the first year of life. Boys are 70% more likely to die by injury than girls.²⁰ Differences in burn injuries follow a similar pattern; a recent systematic review shows that burns are 56% more common in males compared to females in the pediatric population worldwide.⁸ Reasons for this are multifactorial. Studies show that boys are socialized differently than girls. They are given more independence at younger ages.^21,22 Boys have higher activity levels, engage in more risk-taking behavior, and are more impulsive than girls, increasing their risk of injury.²³

Gender differences in burns are also observed in adults but trends vary with burn etiology. Men are more likely to suffer electrical and chemical burns; women are affected by scald and flame injuries.⁷ Burns are the only injury more common in middle-aged women compared to men.⁴ In LMIC, high risk in adult females is associated with open flame and ground level cooking, loose-fitting clothing which can easily ignite, and interpersonal violence.

Age

Children

Over 70% of burns affect children.²⁴ Young children explore the world through their hands but lack the judgement necessary to avoid hazards. Infants and children younger than 5 years are at the highest risk.^7,25-28 Many burns are minor, but serious burns in childhood cause lifelong suffering and disability. Risk factors are related to parental education and supervision. Children of parents who have less than a high school education, are younger than 20 years old, or have three or more other children are at significantly greater risk.²⁹

Elderly

Age-related deterioration in judgement, poor coordination and balance, and slowed responsiveness place the elderly at high risk. Older patients suffer from larger and more severe burns and have higher rates of inhalational injuries compared with younger patients.²⁵ Additionally, burns are poorly tolerated by seniors. Reduced physiologic capacity due to malnutrition and medical comorbidities makes older patients more susceptible to infections, metabolic complications, and death. Many elderly patients living independently before injury are forced into nursing facilities after hospitalization.³⁰

Comorbidities

Epilepsy, peripheral neuropathy, and mobility-limiting conditions, and cognitive disabilities are risk factors for burns. In many areas of the world, epilepsy is untreated. Burns precipitated by epileptic seizures are common throughout Africa and Asia.^31,32 If an individual falls into an open flame or onto a hot object during a seizure, bystanders are reluctant to offer help due to traditional beliefs that the disease is contagious. Consequently, burn injuries in are often severe.^33,34 Peripheral neuropathy secondary to leprosy and diabetes is common worldwide. Scalds and contact burns due to sensory deficits result from absence of the normal pain reflex. Neurologic and psychiatric disorders, including muscle and spinal cord conditions, dementia, and intellectual disability, affect mobility and judgement and increase risk of burn injury.

Occupation

Health and safety in the workplace are neglected in many LMIC. Regulations, when they exist, are often not enforced. Many workers are unaware of the dangers of electricity and wear little or no protective equipment.³⁵ The burden of upper extremity burn injuries may increase in LMIC with growing industrial development.

Regional factors

Social habits, traditions, religious celebrations, and medicinal practices affect burn patterns. In many LMIC, open flames are used for cooking, kerosene lanterns are used for lighting, and coal embers are used for heating - all of which are common causes of burns.³⁶ Practices specific to particular regions put individuals at risk for unique injuries. Examples are noted below:

• Steel chopsticks are popular in Korea. Hand burns occur when young children insert them into electrical sockets.³⁷

• In a Southern Indian tradition, devotees rub camphor on their palms and set it on fire to enter a trance and make requests of the gods. This practice often results in full thickness burns to the palms.^38,39

• Lantern festivals Asian countries including China and Thailand put participants at risk for upper extremity burns. Flame burns when lighting candle wicks deeply recessed within lanterns, contact burns from holding hot lanterns, and burns from dripping or boiling wax are all common.⁴⁰

• Celebrations with fireworks occur throughout the world. Examples include New Year’s celebrations in Europe, Fourth of July events in the U.S., Greek Orthodox Easter, Jewish Purim festival, and Muslim Eid Elfitr/al-Adha feasts.^41,42 Firework-related hand burns and blast injuries often result in severe deformity or amputation.

• Crushed garlic is a pain remedy used by naturopathic providers worldwide. Garlic contains diallyl disulfide and allicin which can cause chemical burns at the site of application or to the hands of the provider with prolonged exposure.⁴³

• “Cupping” and “coining” are traditional pain relief practices in Asia and the Middle East. The ancient Greeks believed that congestion of the organs was relieved by attracting the causative pathology to the skin surface. A cup is heated with the aid of an accelerant, then placed on the affected region. Providers and patients are at risk for contact and flame burns.⁴⁴ Coining involves the application of a hot, mentholated oil. A coin is then vigorously rubbed on the affected area. Scald and friction burns often result.⁴⁵

Acute burn care

Much of burn morbidity can be prevented through appropriate care in the acute setting. American Burn Association guidelines mandate that hand burns be referred to a high-volume burn center for multi-disciplinary, team care⁴⁶. Although access to formal emergency medical services and certified burn centers is limited in the developing world, public education and immediate medical evaluation significantly improves pre-hospital and acute care.

Pre-hospital Care

The aims of burn first aid are to stop the burning process, cool the burn, provide pain relief, and cover the injured area. Immediate treatment reduces burn depth and improves outcome. First responders are often relatives with minimal medical knowledge. Inexperience, misconceptions, and tradition cause bystanders to provide inadequate or inappropriate care.

Appropriate first aid measures include:

• Ensure responder safety and prevent further injury: extinguish flames, switch off electrical current, wear gloves to protect against chemicals

• Stop the burning process by removing clothing and copiously irrigating wounds with cool water

• Cover the burn to provide pain relief. Dressings should be pliable, non-adherent, and impermeable. Plastic kitchen wrap is suitable, inexpensive, and widely-available. Circumferential dressings should be avoided.

• Keep the patient warm

• Seek immediate medical care

Do NOT:

• Apply pastes, oils, aloe, or other topical agents (aside from water) prior to seeking medical care

• Apply cotton dressings or any other cover that may become adherent or infected

• Apply ice directly – this may lead to further tissue damage and increase the risk of hypothermia

• Burst blisters with non-sterile needles or pins

Public education programs on burn first aid have been successfully implemented in many LMIC.^47-49 Health education in schools and communities and targeted newspaper, radio, and television campaigns increase awareness and promote the use of correct first aid measures. Low-cost interventions are possible in most countries, regardless of income level, through partnerships with the Red Cross, Red Crescent, and existing infrastructure for first aid training.

Hospital Care

Primary hospital-based treatment of a burn patient includes airway stabilization and fluid resuscitation. Estimation of burn depth and percentage of total body surface area (TBSA) affected guide treatment. When intravenous access and crystalloids are available, the Parkland formula is used to estimate fluid requirements in the first 24 hours. In limited-resource settings, oral rehydration therapy is routinely used and may be successful in burns up to 40% TBSA.^50-52 Oral rehydration salts can be prepared from common ingredients (salt, sugar, baking soda, clean water) or locally available substitutes such as salted rice water or lassi, a yogurt-based drink popular in the Indian subcontinent.⁵³

When possible, a thorough history should be elicited from the patient to include the mechanism of burn, setting in which it occurred, duration of contact, and, for upper extremity burns, hand dominance, occupation, and previous injuries. Examination of upper extremity burns focuses initially on vascular assessment, looking for weak or absent pulses, slow capillary refill, diminished sensation, and cool temperature. Circumferential burns, electrical and chemical burns, and burns involving crush injures are at high risk for vascular compromise. When vascular compromise is present or threatened, immediate escharotomy is performed. Escharotomies may be performed in the operating room or at bedside and require only a scalpel or electrocautery (Figure 1). Fasciotomies are performed in cases of compartment syndrome or when pulses do not return after escharotomy.

Figure 1.

High voltage electrical burn. (A) Vascular compromise at presentation to emergency room. (B) Finger escharotomy. (C) Hand and forearm fasciotomies.

Prevention of infection is the next priority. Burn wounds become colonized within 48 hours of injury.⁵⁴ After thorough cleansing and debridement of blisters, wounds should be dressed to minimize bacterial counts and provide a moist environment for healing. In high-resource settings, hydrocolloids, silver-impregnated gauze, and biosynthetic skin substitutes are commonplace. Topical agents such as silver sulfadiazine, aloe vera, and petroleum are effective, inexpensive alternatives. Honey, an ancient remedy for wounds, has known antimicrobial properties due to its osmotic gradient, acidity, and inhibines.⁵⁵ Honey inhibits Pseudomonas, a common cause of burn wound cellulitis, and is at least as effective as silver sulfadiazine in preventing infection.⁵⁶ Banana leaves and boiled potato peel are also proven therapies. Banana leaf dressings are non-adherent due to their waxy surface, making dressing changes less painful. Boiled potato peels are placed with the inner side down on the open wound. Both banana leaves and boiled potato peel dressings reduce wound desiccation and hasten epithelial regeneration.^57,58

Some authors advocate enzymatic debridement with topical agents in lieu of tangential excision for partial thickness burns.⁵⁹ When available, collagenase derivatives are used. In the tropics, pastes made from pineapple, papaya, and kiwi are inexpensive alternatives.^60-62

Deep partial and full thickness burns require early excision and skin grafting within the first few days after injury to promote healing. A variety of instruments (i.e. Weck blades and dermatomes) promote safe and effective management of burn wounds in most healthcare settings. Excisional debridement risks considerable blood loss; tumescent infiltration and tourniquets are useful adjuncts when blood products are limited. Early excisional debridement and grafting reduces the risk of infection and scar contractures and improves functional results. This is especially useful in upper extremity burns over joints.

Rehabilitation

Studies show that hand function is the strongest predictor of quality of life after burn in the developing world.⁶³ As wounds heal, restoration to pre-injury status and return to society become of primary importance. Rehabilitation begins on day one and includes pain management, occupational therapy, and counseling. Multidisciplinary teams of nurses, physical and occupational therapists, psychologists, and physiatrists supervise efforts in developed countries. In contrast, rehabilitation services in LMIC are rudimentary and long-term follow-up is problematic. Lack of coordinated care creates anxiety, depression, and post-traumatic stress in patients, and often leads to feelings of hopelessness – that nothing can be done to relieve suffering. Emotional withdraw is common.⁶⁴ Lack of activity and poor participation in care exacerbate secondary deformities. Fortunately, an increasing number of health care facilities worldwide are developing rehabilitation services for burn victims in both urban and rural locations.^65,66

Uncontrolled pain is a major problem; it causes long-term psychological issues and can impede other aspects of rehabilitation. Pain management must address three components: 1) Background pain - continuously present at baseline, 2) Breakthrough pain – occurs with general movement and activities of daily living, and 3) Procedural pain – associated with dressing changes and therapy. A combination of long- and short-acting opioids, nonsteroidal anti-inflammatory agents, acetaminophen, and gabapentin is recommended. Successful management requires ongoing evaluation of the wound burden and progress with therapy. In general, as mobility increases, pain decreases. Many burn survivors require no routine medications long-term.⁶⁷

Occupational therapy for upper extremity burn patients has two primary goals: to maintain mobility and prevent contractures. These goals are addressed concurrently with stretching and strengthening exercises and pressure garments. Early active and passive range of motion and splinting should begin as soon as possible. Splints can be constructed using any available rigid materials including plaster, Styrofoam, wood, or leather.⁶⁸ Pressure garments can be fashioned out of any elastic material. With proper instruction, patients and families can perform many of these therapies at home.

Deformity, disfigurement, and loss of independence have a profound emotional impact on burn survivors. Dependence on hand function for productivity in LMIC makes upper extremity burns particularly devastating. Psychological support and counseling is essential throughout the course of recovery. Burn survivor support groups are a low-cost solution that have been implemented in several LMIC. ^69-72 Peer groups offer emotional and practical support in improving self-esteem, regaining independence, and reintegrating into the community.

Post-burn reconstruction

Post-burn scars are inevitable. Even with the best treatment, all partial and full thickness burns heal by scarring. Scar contractures are a common and debilitating complication in the upper extremity. Contractures occur naturally during healing to help close wounds but have a tendency to occur over joints, compromising range of motion and overall function. The severity of a burn contracture depends on the location and depth of the burn, timing and type of initial treatment, splinting, rehabilitation, and scar care during the maturation process.⁷³ Contracture rates following major burns treated appropriately are as high as 39% in adults.^74-76

Untreated, severe burns to the hands result in a characteristic posture of wrist extension, metacarpophalangeal joint hyperextension, and interphalangeal joint flexion, commonly referred to as the burn claw deformity (Figure 2). This results from direct thermal injury to the dorsal skin and extensor apparatus and is potentiated by immobility, edema, joint distention, and vascular compromise. In children, volar contact burns are common (Figure 3).⁷⁷ Scarred or grafted skin does not grow at the same rate as the child and patients who are asymptomatic initially may develop problems over time.

Figure 2.

Volar contact burn in child treated with dressing changes. (A) Five days after injury. (B) One month after injury.

Figure 3.

(A) Mild burn claw deformity with metacarpal phalangeal joint hyperextension and (B) interphalangeal joint flexion.

Patients with symptomatic burn scar contractures present at various times after injury. Those presenting early (within months) may benefit from simple, inexpensive techniques such as compression garments, splints, and scar massage. If significant limitation in range of motion already exists, early operative intervention is advised.

Principles of upper extremity burn reconstruction include:

1. Excision of scarred or contracted tissue and correction of deforming forces

   Burn deformities occur due to skin injury, but over time, secondary changes occur in the muscles, ligaments, tendons, and joints. To effectively correct burn contractures, one must assess and address the contribution of each type of tissue.

2. Soft tissue coverage

   Large skin defects result after burn scar contracture release. Skin grafts and flaps are frequently required to achieve wound closure (Figures 4 & 5).

3. Restoration of function

   Surgery on the burned upper extremity should restore shoulder abduction, elbow extension, key pinch, and power grip. The hand must have an adequate first webspace for grasp and the thumb must oppose adjacent fingers. Fusion of joints in a functional position is often beneficial in severe or long-standing deformities (Figure 6).

4. Release proximal contractures first

   Hand function is not useful without shoulder and elbow mobility.

5. Post-operative rehabilitation

   Splinting, therapy, and scar control is mandatory after burn reconstruction to achieve optimal outcomes and prevent contracture recurrence.

Figure 4.

Ring finger flexion contracture treated with adjacent tissue rearrangement. (A) Pre-operative. (B) Z-plasty design and inset. (C) Two months after surgery.

Figure 5.

Full thickness dorsal hand burn treated with a pedicled flap. (A) Pre-operative. (B) After burn excision. (C) Groin flap design. (D) Flap inset. (E) Flap division at 4 weeks. (F) Seven months after surgery.

Figure 6.

Proximal interphalangeal joint fusion. (A) Severe hand burn resulting in flexion contracture at proximal interphalangeal joints. (B) Middle finger proximal interphalangeal joint fusion.

Many reconstructive techniques are possible in resource-limited settings. Skin grafts, adjacent tissue rearrangement, and pedicled flaps (groin or abdominal) require no specialized equipment. Fusions can be performed with Kirschner wires or Steinmann pins. Splints can be constructed from available materials. Patients can perform home therapy and scar massage.

Conclusions

Upper extremity burns are a neglected epidemic. Limited healthcare resources, poor infrastructure, and a lack of trained providers pose major challenges to burn treatment in the developing world. Survivors face lifelong disability with few avenues for support. Despite these obstacles, much of burn-related suffering can be prevented or minimized through education, simple interventions, and basic care. Advocacy and improved access to care are mandatory.

KEY POINTS.

• The majority of burns occur in low- and middle- income countries where access to basic health care is limited.

• The upper extremity is involved in over 80% of burns. Delayed, inappropriate, or inadequate treatment of upper extremity burns causes severe disability.

• Many burn survivors face extreme poverty as the result of functional impairment, loss of employment, and poor public support.

• Much of burn-related suffering can be prevented through education, simple interventions, and basic care.

SYNOPSIS.

Burns are devastating injuries that cause significant morbidity, emotional distress, and reduced quality of life. Advances in care have improved survival and functional outcomes, however, burns remain a major public health problem in developing countries. Over 95% of burns occur in low and middle income countries where access to basic health care is limited. The upper extremity is involved in the majority of severe burn injuries. The purpose of this article is to review upper extremity burn epidemiology, risk factors, prevention strategies, and treatment options in resource-limited settings.