Scar contracture is a specific term relating to the tightness of the skin relating to a scar. So, any time a burn wound heals, if it heals relatively quickly and the skin gets back to its normal texture then that’s great, but sometimes a burn may be very deep and may take a long time to heal, and that leads to scar formation and scars tend to be thicker, redder, firmer, than normal skin. They often become tighter, so, they actually become smaller, and especially across joints, such as the elbow or the hand or around the legs, that tightness can restrict movement or make the tissues feel very, very tight. So, a scar contracture is that tight feeling, often patients who have scar contracture need to have scar therapies and there are lots of ways of managing that scar, but in some people to release that tightness they need to have surgery that either moves tissue around or brings more tissue in to make that tightness go away and allow movement to occur normally.

People need to have dressings for their burns because if you imagine the skin has been damaged, and the skin is our protective layer, and without that protective layer we’re much more likely to get an infection of the area and we may also lose lots of fluid. But, protecting it also allows the skin to heal so that we don’t have the outside world interfering with the skin healing as well as preventing infection. Often dressings do need to be changed, but they don’t all need to be changed, certain dressings are almost designed to stay stuck to the burn wound and only separate when the burn wound is healed. That said, quite a lot of dressings do need to be changed and the reason they need to be changed is they often absorb a lot of the fluid that’s coming from the burn and that can become infected if we don’t get rid of it. Keeping the wound as clean as possible helps us prevent infection and allow healing to progress. So, bottom line, burn wounds don’t absolutely have to be dressed, they can be left open and the scab forming, but actually burn wounds tend to heal better and safer and quicker if they are dressed and changing the dressing frequently means that we can keep the burn wound clean to make sure that it doesn’t get infected and we get the burn wound healed as quickly as possible to reduce the chances of scarring. 

People who have been burnt recently are more prone to infection for two reasons, really. For most relatively small burns the skin’s protective ability has been damaged by the burn so bacteria can infect the burn wound much more easily, and so infection from bacteria that are on the skin can occur if the wound isn’t cleaned regularly and doesn’t have its dressings changed regularly. Even if we do that, sometimes burn wounds can get infected and they can make people feel very unwell and so it’s important to be aware of the symptoms of redness, pain, swelling, as well as having a high temperature.
 
In patients who have very large burns, so burns that have become large enough to make them come into hospital, their immune systems might not be quite as strong because of the impact of the burn itself. So they may also be likely to get infections more easily, either through the burn wound itself or through some of the treatments that we use. So we may have drips or we may have lines, or in very rare cases we also have to have patients on ventilators and they may be more prone to getting chest infections as well.

TBSA actually means Total Body Surface Area, or Total Burn Surface Area, people use it interchangeably. But it basically refers to the total in terms of the body’s surface that’s affected by the burn or affecting the body.

So, TBSA is a phrase that I think a lot of people use in burns to define how large a burn is because there are two important things in burns that clinicians need to know. They need to know how large a burn is and how deep a burn is and the way that we work out how large a burn is, is worked out by a percentage, rather than measuring it out in centimetres or inches because everyone’s a different size so something that’s 10cms x 10cms would be quite small on me, but on a very young child, it would be very large. So, we work it out by percentage and the best way to work out percentage is by using the whole palm of a person’s hand. So, if it’s a baby then we use the palm size area of the baby. If it’s an adult, then we use the palm size of the adult. We also have charts that can help us. So, for instance, a whole arm which may have been burnt would be about 9% and a whole leg, including the lower leg and the thigh, would be about 18% all the way around. So, we’ve got lots of ways of trying to work out how large a burn is by using the size of the hand or by using charts and now we’ve even got apps.

But it’s always a percentage. So, a percentage of the body surface area. And a small percentage, such as 1% or 2%, might be something that we can treat as an outpatient. But as we get larger, so 5% of the body’s surface area, might be something that we have to think about managing in the hospital. And certainly over 10%, we would definitely be treating in hospital for a little while at least. Beyond 25%, so a quarter of the body often has quite a significant impact on the body’s heart and lungs and guts, and so that would require much more careful high-dependency care as well as all the other things that we would need to do to treat the burn itself.

The difference between first, second, and third-degree burns really relates to how deep a burn is. In the United kingdom, we tend not to use first, second, and third degree. What I’ll do is explain what they are and then talk about the terms that we use more commonly because they often help us decide how we’re gonna treat a burn as well. First-degree burns really relate to quite a superficial injury, it’s not very deep, and it often doesn’t require any specialist treatment, it’s just redness of the skin. It’s a bit like sunburn without the blisters. It’s something that we don’t have to do too much for. Secondary-degree burns are often deeper and they often either cause blistering or they can make the skin go very pale and reflect a slightly deeper burn. Certainly, we tend to divide second-degree burns into superficial partial-thickness burns, which tend to be pink and blistered, and often require dressings to get healed and heal within a couple of weeks. Whereas deep dermal burns are also considered second-degree burns, but they often require more extensive treatment and may require surgery or may take much longer to heal and may be related to the risk of scarring. Third-degree burns are deeper and they tend to be called full-thickness burns because the whole depth of the skin has been damaged often these do require surgery or prolonged dressings and they are often associated with scarring. You can imagine one burn might have a first-degree, second-degree, third degree, all in the same burn and so we may treat each of the areas differently. As I said, we tend to call them superficial partial-thickness, deep dermal, and full-thickness because they help us decide what kind of treatment, we’re going to use to best manage that burn.