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Burn surgery — escharotomy, early excision and grafting
A deep partial-thickness or full-thickness burn will not heal in a reasonable time, so it is excised early — usually in the first week — and covered with autograft; a circumferential full-thickness burn of a limb or the chest requires urgent escharotomy.
Why it matters in the exam
Early excision and grafting reduced infection, length of stay and mortality compared with waiting for spontaneous separation of the eschar. Tangential excision removes thin layers until bleeding tissue is reached and preserves viable tissue; excision to fascia is faster and loses less blood but leaves a deformity. Blood loss during excision is significant, so the area per operation is limited and tourniquets and topical adrenaline are used. In extensive burns where donor skin is insufficient, widely meshed autograft covered with cadaver skin (allograft), skin substitutes or the Meek technique are used. Escharotomy is made along the mid-axial lines of the limb and in a shield pattern on the chest, when there are signs of compartment syndrome or difficulty ventilating.
Topical treatment before excision: silver sulfadiazine (transient leukopenia, avoid in sulfa allergy), mafenide (penetrates eschar — good for ears and cartilage, but painful and causes metabolic acidosis by inhibiting carbonic anhydrase), silver nitrate (hyponatraemia and black staining) and modern silver dressings. After grafting: hypertrophic scar is common in burns that healed after more than 3 weeks and is treated with pressure garments, silicone and laser; contractures are released with Z-plasty or grafts. A Marjolin ulcer is a squamous cell carcinoma that develops in a chronic burn scar after many years, and it is aggressive — biopsy every non-healing wound in an old scar. Heterotopic ossification occurs mainly at the elbow in extensive burns. Hypermetabolism in extensive burns is treated with early feeding, propranolol and oxandrolone.
Key points
- Early excision and grafting — less infection and mortality.
- Escharotomy — circumferential full-thickness burn.
- Mafenide — acidosis; silver nitrate — hyponatraemia.
- Marjolin — SCC in a chronic burn scar.
- Healing beyond 3 weeks — risk of hypertrophic scar.
Summary table
| Topic | Principle | Key detail |
|---|---|---|
| Escharotomy | Circumferential full-thickness burn with impaired flow or ventilation | Mid-axial lines; chest — shield pattern |
| Early excision | Deep partial and full thickness, in the first week | Tangential to bleeding tissue |
| Coverage | Autograft; in extensive burns — meshed with allograft | Meek and skin substitutes when donor skin is limited |
| Topical treatment | Silver sulfadiazine, mafenide, silver nitrate | Mafenide — acidosis; silver nitrate — hyponatraemia |
| Late complications | Hypertrophic scar, contracture, Marjolin, heterotopic ossification | Marjolin — biopsy a chronic wound in a scar |
Free exam questions
? בחולי כוויות, איזה משפט הוא הנכון Heterotopic ossification בנושא (the question as examined, in Hebrew)
- א. 2% שכיחות המחלה בצורתה האמיתית נמוכה ועומדת על פחות מ
- ב. האטיולוגיה אינה ידועה אולם נמצא כי מיקום והיקף הכוויה משמעותיים יותר מחומרתה
- ג. המרפק ואחריו הכתף והברך הינם המקומות השכיחים ביותר להתפתחותה
- ד. חודשים מהכוויה 3 מופיעה בממוצע סביב
מה מהבאים הכי מתאים לטיפול בהרעלת ציאניד כתוצאה משאיפת עשן? (the question as examined, in Hebrew)
- א. Dicobalt edetate
- ב. Calcium gluconate
- ג. Sodium nitrite
- ד. Calcium bisphosphonate
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Sources
- American Burn Association Practice Guidelines, 2023 (current set) — Burn wound excision, escharotomy and grafting
- International Society for Burn Injuries (ISBI) Practice Guidelines for Burn Care, 2016 and 2018 — Surgical management and scar care
- Israeli Ministry of Health national burn care guidance, current — Referral to burn centres
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.
See also: Burns