Introduction

Burns are still a major health problem in developingcountries.1 The reasons for the high incidence includewidespread ignorance of fire prevention, the rapid increaseof poor socio-economic conditions, and the persistence ofold traditions and customs.2-4

In Cambodia and Bangladesh the most frequent caus-es of burns are accidents in the home, the use of outdoorcoal fires or gas stoves, and land mine explosions. Addi-tionally, there is the serious problem of chemical burnsdue to acids as the result of quarrels or domestic law suits.5,6

These are serious and debilitating lesions and their fre-quent non-treatment may cause terrifying scars.

The risk of keloids is extremely high in these popu-lations because of genetic factors (dark complexion).7

In this study we analysed 200 patients with post-burnscars. The purpose of our study was to present the envi-ronmental factors and the demographic characteristics as-sociated with burn damage in Cambodia and Bangladesh,8,9-24

and to show that with good technical skills it is possiblein these countries to obtain the same results as those ob-tained in modern well-equipped medical facilities.

Materials and methods

This study was carried out in civilian war victim hos-pitals in Battambang and in Dhaka in 2002 and 2003. Al-together, 200 post-burn patients with scars were retro-spectively analysed in detail. Patient age ranged from 3 to60 yr. Both sexes were represented, with a predominanceof males.

Fig. 1 illustrates the annual distribution of burn ad-missions. In the first quarter we treated 18 burns sequelae

cases (9%), in the second quarter 53 cases (26.5%), in thethird quarter 20 cases (10%), and in the fourth quarter 109cases (54.5%). This last highest proportion occurred dur-ing hot and moist climatic conditions.

Our particular interest was in serious post-burn injurieswith severely compromised functionality. The method ofrating whole person impairment (WPI) used in this studyis that described by the American Medical Association.

There are five classes of skin rating, ranging from 0to 95% impairment.

a) Class I (0-9 % WPI) - patients in whom signs andsymptoms of skin disorder are present or intermittentlypresent, who have no limitations in their daily activities,and who require either intermittent or no medical treat-ment.

b) Class II (10-24% WPI) - patients with present orintermittently present signs and symptoms whose perfor-mance of some activities of daily life is limited and who

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Fig. 1 - Annual distribution of burn patient admissions.

RETROSPECTIVE ANALYSIS OF 200 SEVERE POST-BURN CASES IN CAMBODIAAND BANGLADESH

Borghese L.,1 Latorre S.,1 Montagnese A.,2 De Stefano C.2

1 Department of Plastic and Reconstructive Surgery, Bambino Gesù Paediatric Hospital, Rome, Italy2 Department of Plastic and Reconstructive Surgery, A. Gemelli Polyclinic, Rome

SUMMARY. The experience is reported of two years’ surgical activity carried out in hospitals for civil war victims in Battam-bang (Cambodia) and in an NGO hospital in Dhaka (Bangladesh) with regard to the treatment of non-acute burn patients. The aimof this report is to demonstrate that work in field hospitals deficient in means and equipment achieves the same results as thoseusually obtained in western hospitals. Our experience covers the surgical treatment of 200 patients with scars due to fire, acids,and land mines. We mainly treated patients with scars compromising or preventing the normal activity of limbs and extremities,

require intermittent constant treatment.c) Class III (25-54% WPI): signs and symptoms are

intermittently present, the performance of many activitiesof daily life is limited, and treatment needs may be inter-mittent to constant.

d) Class IV (55-84% WPI): signs and symptoms ofskin disorders are constantly present; the patients are lim-ited in many activities of daily life, their treatment needsmay be intermittent to constant, and they may require homeconfinement.

e) Class V (85-95% WPI): constant signs and symp-toms of skin disorder, limitation of most daily activities,and occasional to constant home confinement for inter-mittent to constant medical treatment.

The medical treatment of WPI includes rehabilitationcare with “passive and active physical exercises” in or-der to attenuate post-burn skin scar adherence.15-18

In our experience these procedures are important inpost-burn care at a later moment after surgical proceduresin order to restore a normal anatomy as early as possible.22-26

The surgical techniques used to correct burns seque-lae include skin expander insertion, dermoabrasion, autol-ogous skin graft insertion, local or distance pedicle flaps,Z-plasty, and microsurgical free flaps.29-33 To compensatefor the backward technology in Cambodia and Bangladesh,we used surgical procedures based on Z- or W-plasty, au-tologous skin grafts, and local and pedicle flaps.

These techniques, compared with the other above-

mentioned surgical procedures, are rapid and simple intheir execution, have low morbidity and a low incidenceof complications, are well tolerated by patients, and offergood final results (Figs. 2a,b,c).

Results

The following parameters were evaluated retrospectively:1. age2. sex3. causes of burns4. organs affected by burns5. size of burns

1. AgeThe present study covers 57 children between the ages

of 0 and 10 yr (28.5%), 88 adolescents and young adultsaged between 11 and 40 yr (44%), and 55 patients agedover 40 yr (27.5%) (Table I).

2. SexAmong children (0-10 yr), males were predominantly

affected, with a male:female ratio of 3:1. Among adoles-cents, males were also more affected than females (male:fe-male = 2:1). Among adults aged 20-40 yr, males and fe-males were equally affected (male:female = 1:1). Amongpatients aged over 40 yr, there was a male predominance,with a male:female of 3:2 (Table I).

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Fig. 2a - Post-burn dorsal hand contracture. Fig. 2b - Preparation of distance pedicle ab-dominal ap.

Fig. 2c - Release of contracture and coverageof raw area with abdominal pedicle ap.

3. Causes of burnsThe most frequent cause of burns was flame in acci-

dents in the home, which were more common in femalesaged 18-40 yr. Flame burns were caused by direct flameinjury, clothes catching fire during cooking, outdoor coalfires, and gas stove explosions. A small proportion of burns- more frequent in males - are due to land mine explo-sions in civil wars, an ever-present risk in these countriesstill today. It is calculated that in Cambodia there are5,000,000 mines in the fields. A high percentage, morefrequent in females, is represented by chemical burns fromacids. This is a widespread custom practised for senti-mental reasons (adultery and resistance to sexual relations)and because of judicial matters and domestic lawsuits(Table II).

4. Organs affected by burnsThe parts of the body most affected were the hands,

the scapulohumeral and popliteal joints, the inguinal folds,the eyelids, the oral cavity, and the nostrils (Table III).

5. Size of burnsWith regard to the size of the burns, we classified them

in five groups, on the basis of WPI:

Class I: 34%Class II: 20%Class III: 28%Class IV: 10%Class V: 8%

Discussion

The main objective of this study is to demonstrate thatin underdeveloped countries like Bangladesh and Cambo-dia it is possible, using basic surgical techniques, to ob-tain results in the correction of chronic burn damage thatare equivalent to those obtained in modern, well-equippedmedical structures.1-7 The best way to compensate for lackof technology is to perform early, simple, and reliablesurgery with a low rate of morbidity and post-operativecomplications, yet without sacrificing good cosmetic re-sults. The surgical procedures we performed were basedon Z- or W-plasty, autologous skin grafts, and local andpedicle flaps (Table IV). The presence of fibrous tissuesand retraction and a compromised vascular condition canhave negative consequences on the results of the surgeryperformed. The most frequent post-operative complicationswe encountered were skin necrosis (5 patients, 2.5%), hy-povascularization of wound edges (3 patients, 1.5%), non-take of skin grafts (4 patients, 2%), and infection (2 pa-tients, 1%) (Table V).

The sex and age of patients are linked to develop-mental and behavioural patterns, and are important deter-minants of risk in serious burn injury. The majority of thestudy population in our investigation were male, a findingthat was consistent with other reports.8-10 We found that therisk of severe burn injury decreased with age in femalechildren. In males, although the rate of risk fell in the 5-9 years age group compared to younger boys, it increasedagain after 10 years of age, reaching the highest peak inthe group aged 20-40 years. At this stage of life, peopleare more exposed to burn injury both at home and in the

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Cause Male Female Total number PercentageFlame 11 60 71 35.5Mine explosion 37 30 67 33.5Acids 22 40 62 31.0Total 70 130 200 100

Table II - Classication of most frequent burn causes

Part of body Male Female Total number PercentageHands 50 42 92 46.0Scapulohumeral joint 25 4 29 14.5Popliteal joint 0 9 9 4.5Inguinal folds 0 11 11 5.5Eyelids 4 18 22 11.0Oral cavity 8 14 22 11.0Nose (nostrils) 4 11 15 7.5

Table III - Classication of parts of body affected

Surgical procedure Number of patientsZ- and W-plasty 95Pedicle aps 40Skin grafts 65

Table IV - Surgical procedures used

Complication Number PercentageSkin necrosis 5 2.5Ischaemic aps 3 1.5Non-take of skin grafts 4 2.0Infections 2 1.0

Table V - Post-operative complications

Age (yr) Male Female Total number Percentage0-10 49 8 57 28.510-20 24 12 36 18.020-40 26 26 52 26.0>40 41 14 55 27.5Total 120 60 200 100

Table I - Patient distribution by age and sex

work environment.11-14 Many studies on children19-21 havedemonstrated that boys are more often the victims of burnsassociated with bone and joint deformities caused by de-layed surgical treatment and by subsequent alteration ofnormal bone development29-31 - we observed deformity ofthe radius and the metacarpophalangeal joints, deformity ofthe jaw and oral cavity secondary to neck burns, and de-formity and deflection of the vertebral column (Figs. 3a,b).

Another important finding in our study was a high per-centage of chemical burns (31%). Females were more fre-quently involved than males, in a proportion of 2 to 1.22,23

The agents responsible for this type of burn were mainlyacids (hydrochloric acid, sulphuric acid, nitric acid, phos-phoric acid, and acetic acid) and organic solvents such asphenol. The tissue damage caused by these substances ap-pears to be related to the action of cation hydrogen, whichdetermines severe alteration of the tissue proteins, as infourth-degree burns in muscles and bones (Fig. 4).

The most frequent complication is local infection.25-27

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Fig. 3a - Post-burn contracture of anteromedial surface of leftforearm.

Fig. 3b - Release of contracture and coverage of raw area with Z-plasty and split-thickness skin graft.

Fig. 4 - Young femaleburned with sulphuricacid. The patient wassubjected to various sur-gical treatments: Z-plas-ty for oral commissuresand nostril contracture,and multiple skin graftsfor eyelid contracture.

The incidence of wound infection is very high inBangladesh and Cambodia, mainly owing to the local so-cial and economic situation; also, personal hygiene veryoften appears to be inadequate, while weather conditionsfacilitate bacterial growth.25 Such factors are rarely presentin countries with a moderate climate, as in Europe andNorth America.

Conclusions

The factors and demographic characteristics of burndamage differ from region to region, and it is thereforevery important that every country should carry out epi-demiological studies with the aim of promoting educationcampaigns on care and on the prevention of the commonestcauses of burns, in order to reduce their incidence in the

population. This is also true of Cambodia and Bangladesh,but the message rarely reaches members of the poorest andleast educated social classes, who are so numerous in thesecountries.

Our experience in the treatment of burns sequelae hasenabled us establish the following guidelines:

a. priority treatment of fibrous tissue retraction, espe-cially when this affects the eyelids, nostrils, mouth,and extensor folds;

b. use of the simplest and fastest surgical techniquessuch as skin grafts, which are still considered to bethe first choice, followed by local and pedicle flapsand Z- and W-plasties;

c. use of absorbable monofilament sutures, as thesepresent a lower risk of infection and do not needto be removed.

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RÉSUMÉ. Les Auteurs présentent leur expérience de deux années d’activité chirurgicale effectuée dans les hôpitaux pour les vic-times de la guerre civile à Battambang (Cambodge) et dans un hôpital d’une organisation non-gouvernementale à Dhaka (Bangla-desh) pour ce qui concerne le traitement des patients brûlés non aigus. Ils se proposent de démontrer que le succès du travail dansles hôpitaux de campagne même dépourvus de moyens et d’équipement est égal à celui que l’on observe normalement dans leshôpitaux du monde occidental. Les expériences décrites couvrent le traitement chirurgical de 200 patients atteints de cicatrices cau-sées par le feu, l’acide et les mines terrestres. La plupart des patients traités présentaient des cicatrices qui compromettaient ou em-pêchaient l’activité normale des membres et des extrémités. Le but du traitement était la restauration d’une fonctionnalité correcteet d’un aspect esthétiquement satisfaisant.

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This paper was received on 27 September 2004.

Address correspondence to: Dr Lorenzo Borghese, M.D.,Department of Plastic and Reconstructive Surgery, Os-pedale Pediatrico Bambino Gesù, Piazza S. Onofrio 4,00165 Rome, Italy. Tel.: 3906 68592201; fax: 390668592030; e-mail: borghese@opbg.net