Scandinavian Journal of Plastic and Reconstructive Surgery
ISSN: 0036-5556 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/iphs18
Burn Wound Biopsy Multiple Uses in Patient Management Arthur M. Kahn, Virginia L. McCrady & Victor J. Rosen To cite this article: Arthur M. Kahn, Virginia L. McCrady & Victor J. Rosen (1979) Burn Wound Biopsy Multiple Uses in Patient Management, Scandinavian Journal of Plastic and Reconstructive Surgery, 13:1, 53-56, DOI: 10.3109/02844317909013020 To link to this article: http://dx.doi.org/10.3109/02844317909013020
Published online: 08 Jul 2009.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=iphs18 Download by: [Universität Osnabrueck]
Date: 16 March 2016, At: 06:26
Scand J Plast Reconstr Surg 13: 53-56, 1979
BURN WOUND BIOPSY Multiple Uses in Patient Munugement
Arthur M. Kahn, Virginia L. McCrady and Victor J. Rosen
Downloaded by [Universität Osnabrueck] at 06:26 16 March 2016
From the Birrn Center, Brotman Memorial Hospital, Culver City, California, USA
Abstract. It is often exceedingly difficult to initially evaluate the depth of a bum wound and thus inaugurate appropriate definitive therapy. The clinical picture of the bum wound may not always correlate with the true histologic depth of the injury. For this reason we have undertaken a program of obtaining punch biopsies of bum wounds in patients where the depth of the bum wound is equivocal. In such cases the biopsy has proven to be useful in guiding subsequent therapy. In addition to establishing the anatomic depth of injury, there are several other valuable uses of bum wound biopsies. The other uses are: diagnosis of invasive infection, quantitative bacterial culture, medical-legal values, psychological values and forensic utility.
Thermally injured patients pose many diagnostic and therapeutic difficulties. Of all the various problems encountered in the burn patient, none are more difficult to assess than the accurate determination of the depth of the burn or the diagnosis of the extent and type of burn wound infection. Biopsy of burn wounds has attracted limited attention over the past several years. Most of the attention has been focused on the utility of bum wound biopsy as a part of quantitative bacteriologic study (Loebl, Marvin, Heck, Curreri & Baxter, 1974). Pruitt & Foley (1973) have stressed the importance and utility of burn wound biopsy for the diagnosis of microbial bum wound infection, and they suggested a detailed histopathologic classification of the severity of burn wound infection. In addition, other uses of bum wound biopsy were mentioned in their paper. The purpose of this paper is to share our experiences with biopsy of the bum wound as a safe and valuable diagnostic tool. A useful technique for obtaining the biopsy is described. The multiple uses of bum wound biopsy listed in Table I will be discussed in detail.
PROCEDURE In our Bum Unit the biopsy is performed by the physician in the treatment room following the patient’s hydrotherapy. The area to be biopsied is carefully examined and one or various representative sites are selected. Betadine Swabsticks (the h r d u e Frederick Company) are used to prepare the area, and it is then draped with sterile towels. Local anesthesia is used unless the tissue is anesthetic as a result of the bum injury. Usually a conventional skin punch biopsy instrument is employed. After coring the site with the punch biopsy instrument, the specimen often remains adherent to the subcutaneous tissue at the base. When this occurs it is severed by elevating the specimen with a number 25-gauge needle, rather than forceps, to avoid crush artifact. Then the specimen is severed at the level of the subcutaneous tissue with a number I 1 scalpel blade. With this technique we have not observed much artifact caused by avulsing eschar from underlying subcutaneous tissue. Also adequate samples of subcutaneous tissue can be obtained. If there is bleeding at the biopsy site, it is readily controlled by closing the resultant defect with a single 4-0 nylon stitch. In our experience, closure of the biopsy site with a suture has not resulted in local abscess formation. The suture used to close the biopsy site functions as an excellent marker for identifying the site of the biopsy. The appearance of the wound and the site of biopsy is then recorded by taking a color Polaroid photograph. The specimen is placed in formalin and sent to the Pathology Department along with clinical information and the photograph.
Table I. Uses of burn wound biopsy 1. Determine depth of bum 2. Determine presence and extent of microbial infection 3. Determine adequacy of surgical excisions 4. Quantitative bacteriologic cultures 5 . Medical-legal 6. Forensic 7. Psychological value 8. Miscellaneous Srund J P/ris/ Rrconsrr Siirg 13
Downloaded by [Universität Osnabrueck] at 06:26 16 March 2016
54
A . M. KNhn et al.
Figs. 1-3. Histologic section of a mid level second degree burn showing coagulation necrosis of the upper dermis with loss of the epithelium and necrosis with associated inflammation at the level of the mid dermis. Skin appendage structures (sweat glands) show viability and regenerative activity. H&E, x40. (2) Deep second degree bum. There is a coagulated hair shaft with necrotic follicu-
RESULTS AND DISCUSSION There is definite clinical correlation between the character and the amount of purulent burn wound drainage and clinical signs and symptoms of sepsis. The quantity and anatomic position of bacteria or other microorganisms beneath the burn wound surface have been shown to be of diagnostic and
Fig. 4 . Photomicrograph showing pyknosis, spindling and polarization of nuclei of a skin appendage (sweat gland) typical of electrical injury. H&E, x75.
lar elements. There is a deep sweat gland showing some viable tubular cells. H&E, x 150). ( 3 ) Histologic section of a third degree bum showing coagulation necrosis and effacement of all appendage structures in the dermis. There is some inflammatory reaction in the septa of the subcutaneous fat. H&E, ~ 5 0 .
prognostic value (Pruitt & Foley). The technique of quantitative burn wound culture has been described (Loebl et al.). It has been suggested that histologic assessment may be of even greater diagnostic and prognostic value. Pruitt & Foley have presented a detailed classification based upon histopathologic observations. They observed a close clinical corre-
Fig. 5 . Section of skin showing "fixation" of skin and appendage structures. There is refractile coagulum filling all blood vessels as the only histologic manifestation of the full thickness injury. H&E, x 18.
Downloaded by [Universität Osnabrueck] at 06:26 16 March 2016
lation with the various histological grades of microbial invasiveness. In their opinion the histological examination is a reliable method of differentiating microbial colonization from invasive burn wound infection. The extent of skin damage. recorded as a percent of the total body surface, is easily obtained from charts such as that described by Lund and Browder. In contrast, the severity or depth of a burn injury is often not immediately apparent. At times a differentiation of a deep second degree skin injury from a full-thickness skin loss can take as long as three to four weeks. Sometimes with extensive injuries, the rapid differentiation between deep second degree and third degree burns is not always necessary. On the other hand, there are situations when early and accurate determination of the depth of bum wound would allow one to make a prompt choice of a treatment modality that may lead to a more favorable and expeditious outcome. For example, examination of biopsies from burned hands has been extremely valuable in the subsequent management of these injuries in our bum center. Occasionally, lesions which were clinically suspected to be full-thickness or deep second degree burns and requiring total excision or tangential excision have been shown histologically to be healing moderate depth second degree burns and therefore, unnecessary operative procedures have been eliminated. Occasionally, frozen section study of specimens in the operating room has been useful in guiding the extent of surgical excision. For example, when excising full-thickness dorsal hand burns, it is sometimes difficult to determine when one has reached margins that are capable of healing satisfactorily and frozen section of the margins can be very useful in making this determination. When tangential excision must be carried into subcutaneous fat, a less optimal surface for immediate split-thickness skin grafting exists and in this situtation excision to the fascia with grafting may be preferable. If the surgeon knows the depth of the bum wound before the scheduled operative procedure, it may influence his choice of the type of excision he will employ. The histopathologic evaluation of burn wound material requires a well-fixed and carefully processed specimen to avoid artifact which would confuse the evaluation of the finer details. Most of the evaluations can be made with the Hematoxylin and Eosin stain. Occasionally special stains for microorganisms including fungi and bacteria can be
helpful. All elements of the skin must be evaluated including the status of the collagen in both the papillary and reticular dermis, the status and viability of the subcutaneous fat with the presence or absence of inflammatory infiltrate, and the degree of viability of the epidermis itself. In most of the bums chosen for biopsy, the epidermis itself is lost or necrotic and this is obvious clinically. The nature of the skin appendages can be the most telling and informative aspect to the observer. Sweat glands and ducts with the epithelium and sebaceous glands and ducts as well as hair shafts may survive and show viable and proliferating epithelium even after widespread destruction of the papillary dermis and its epithelium has occurred. When most of the appendages in a biopsy show complete necrosis of the epithelium and only an isolated appendage shows a few viable cells, the biopsy is best characterized biologically as a third degree burn. The various morphologic patterns of injury, including mid depth and deep second degree burn and third degree burn are demonstrated (Figs. 1, 2, 3). Specific changes can be recognized in certain types of burn. In the electrical burn, there will often be a coagulation necrosis with preservation of the non-viable epidermis, but the epidermis is frequently detached at the papillary layer and shows a palisading or polarization of nuclei in the direction of the current (Gonzales, Vance, Helpern & Umberger, 1954). This polarization may also be seen in the skin appendages (Fig. 4). A superficial examination may suggest viability of the epithelium, but the polarized pyknotic nuclear change is definitely not compatible with viability. In certain types of chemical bums, such as hydrofluoric acid, preservation of the cellular elements by fixation with the acid can simulate viable epidermis. In one case a fourth degree burn caused by hydrofluonc acid at first glance resembled normal skin (Fig. 5 ) . The telling sign of death of tissue was a coagulation and eosinophilia of the blood and serum within vessels and this coagulation occurred to the level of the subcutaneous fat. It is very important to evaluate blood vessels and their contents in determining the viability of burned tissue. The hydrofluoric acid bum demonstrated this very graphically. The knowledge gained from bum wound biopsy may enable the surgeon to determine preoperatively his choice of operation. This knowledge may enable the surgeon to provide the patient with a more accurate and informed consent and, therefore, a more
56
A . M . K d t n er ul.
Downloaded by [Universität Osnabrueck] at 06:26 16 March 2016
realistic expectation of the results. Partial thickness and full-thickness burn injuries often have similar initial appearance. Where that is the case, the patient and family are told that we cannot accurately assess the depth of the burn wound at the time of admission to the hospital. This information may cause the patient and family to maintain hope that all areas of the bum are partial thickness and therefore have the capacity to heal without scarring or pigmentary changes. In selected patients, prior to scheduling an operation, histopathologic confirmation of burn wound depth may dispel unrealistic expectations by the patient and therefore establish
increased confidence in the physician as well as a better understanding of the need for an operation.
REFERENCES Gonzales, T. A,, Vance. M.. Helpern. M. & Umberger, C. J. 1954. Legal Medicine pathology and toxicology. 2nd ed.. p. 543. Appleton-Century-Crofts. New York. Loebl, E. C . , Marvin, J. A., Heck, E. L.. Curreri, P. W . & Baxter, C. R . 1974. The method of quantitative burnwound biopsy culture and its routine use in the care of the burned patient. Am J Clin Pathol61. 20. Pruitt, B. A . & Foley, F. D. 1973. The use of biopsies in bum patient care. Surgery 73, 887.
ISSN: 0036-5556 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/iphs18
Burn Wound Biopsy Multiple Uses in Patient Management Arthur M. Kahn, Virginia L. McCrady & Victor J. Rosen To cite this article: Arthur M. Kahn, Virginia L. McCrady & Victor J. Rosen (1979) Burn Wound Biopsy Multiple Uses in Patient Management, Scandinavian Journal of Plastic and Reconstructive Surgery, 13:1, 53-56, DOI: 10.3109/02844317909013020 To link to this article: http://dx.doi.org/10.3109/02844317909013020
Published online: 08 Jul 2009.
Submit your article to this journal
Article views: 19
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=iphs18 Download by: [Universität Osnabrueck]
Date: 16 March 2016, At: 06:26
Scand J Plast Reconstr Surg 13: 53-56, 1979
BURN WOUND BIOPSY Multiple Uses in Patient Munugement
Arthur M. Kahn, Virginia L. McCrady and Victor J. Rosen
Downloaded by [Universität Osnabrueck] at 06:26 16 March 2016
From the Birrn Center, Brotman Memorial Hospital, Culver City, California, USA
Abstract. It is often exceedingly difficult to initially evaluate the depth of a bum wound and thus inaugurate appropriate definitive therapy. The clinical picture of the bum wound may not always correlate with the true histologic depth of the injury. For this reason we have undertaken a program of obtaining punch biopsies of bum wounds in patients where the depth of the bum wound is equivocal. In such cases the biopsy has proven to be useful in guiding subsequent therapy. In addition to establishing the anatomic depth of injury, there are several other valuable uses of bum wound biopsies. The other uses are: diagnosis of invasive infection, quantitative bacterial culture, medical-legal values, psychological values and forensic utility.
Thermally injured patients pose many diagnostic and therapeutic difficulties. Of all the various problems encountered in the burn patient, none are more difficult to assess than the accurate determination of the depth of the burn or the diagnosis of the extent and type of burn wound infection. Biopsy of burn wounds has attracted limited attention over the past several years. Most of the attention has been focused on the utility of bum wound biopsy as a part of quantitative bacteriologic study (Loebl, Marvin, Heck, Curreri & Baxter, 1974). Pruitt & Foley (1973) have stressed the importance and utility of burn wound biopsy for the diagnosis of microbial bum wound infection, and they suggested a detailed histopathologic classification of the severity of burn wound infection. In addition, other uses of bum wound biopsy were mentioned in their paper. The purpose of this paper is to share our experiences with biopsy of the bum wound as a safe and valuable diagnostic tool. A useful technique for obtaining the biopsy is described. The multiple uses of bum wound biopsy listed in Table I will be discussed in detail.
PROCEDURE In our Bum Unit the biopsy is performed by the physician in the treatment room following the patient’s hydrotherapy. The area to be biopsied is carefully examined and one or various representative sites are selected. Betadine Swabsticks (the h r d u e Frederick Company) are used to prepare the area, and it is then draped with sterile towels. Local anesthesia is used unless the tissue is anesthetic as a result of the bum injury. Usually a conventional skin punch biopsy instrument is employed. After coring the site with the punch biopsy instrument, the specimen often remains adherent to the subcutaneous tissue at the base. When this occurs it is severed by elevating the specimen with a number 25-gauge needle, rather than forceps, to avoid crush artifact. Then the specimen is severed at the level of the subcutaneous tissue with a number I 1 scalpel blade. With this technique we have not observed much artifact caused by avulsing eschar from underlying subcutaneous tissue. Also adequate samples of subcutaneous tissue can be obtained. If there is bleeding at the biopsy site, it is readily controlled by closing the resultant defect with a single 4-0 nylon stitch. In our experience, closure of the biopsy site with a suture has not resulted in local abscess formation. The suture used to close the biopsy site functions as an excellent marker for identifying the site of the biopsy. The appearance of the wound and the site of biopsy is then recorded by taking a color Polaroid photograph. The specimen is placed in formalin and sent to the Pathology Department along with clinical information and the photograph.
Table I. Uses of burn wound biopsy 1. Determine depth of bum 2. Determine presence and extent of microbial infection 3. Determine adequacy of surgical excisions 4. Quantitative bacteriologic cultures 5 . Medical-legal 6. Forensic 7. Psychological value 8. Miscellaneous Srund J P/ris/ Rrconsrr Siirg 13
Downloaded by [Universität Osnabrueck] at 06:26 16 March 2016
54
A . M. KNhn et al.
Figs. 1-3. Histologic section of a mid level second degree burn showing coagulation necrosis of the upper dermis with loss of the epithelium and necrosis with associated inflammation at the level of the mid dermis. Skin appendage structures (sweat glands) show viability and regenerative activity. H&E, x40. (2) Deep second degree bum. There is a coagulated hair shaft with necrotic follicu-
RESULTS AND DISCUSSION There is definite clinical correlation between the character and the amount of purulent burn wound drainage and clinical signs and symptoms of sepsis. The quantity and anatomic position of bacteria or other microorganisms beneath the burn wound surface have been shown to be of diagnostic and
Fig. 4 . Photomicrograph showing pyknosis, spindling and polarization of nuclei of a skin appendage (sweat gland) typical of electrical injury. H&E, x75.
lar elements. There is a deep sweat gland showing some viable tubular cells. H&E, x 150). ( 3 ) Histologic section of a third degree bum showing coagulation necrosis and effacement of all appendage structures in the dermis. There is some inflammatory reaction in the septa of the subcutaneous fat. H&E, ~ 5 0 .
prognostic value (Pruitt & Foley). The technique of quantitative burn wound culture has been described (Loebl et al.). It has been suggested that histologic assessment may be of even greater diagnostic and prognostic value. Pruitt & Foley have presented a detailed classification based upon histopathologic observations. They observed a close clinical corre-
Fig. 5 . Section of skin showing "fixation" of skin and appendage structures. There is refractile coagulum filling all blood vessels as the only histologic manifestation of the full thickness injury. H&E, x 18.
Downloaded by [Universität Osnabrueck] at 06:26 16 March 2016
lation with the various histological grades of microbial invasiveness. In their opinion the histological examination is a reliable method of differentiating microbial colonization from invasive burn wound infection. The extent of skin damage. recorded as a percent of the total body surface, is easily obtained from charts such as that described by Lund and Browder. In contrast, the severity or depth of a burn injury is often not immediately apparent. At times a differentiation of a deep second degree skin injury from a full-thickness skin loss can take as long as three to four weeks. Sometimes with extensive injuries, the rapid differentiation between deep second degree and third degree burns is not always necessary. On the other hand, there are situations when early and accurate determination of the depth of bum wound would allow one to make a prompt choice of a treatment modality that may lead to a more favorable and expeditious outcome. For example, examination of biopsies from burned hands has been extremely valuable in the subsequent management of these injuries in our bum center. Occasionally, lesions which were clinically suspected to be full-thickness or deep second degree burns and requiring total excision or tangential excision have been shown histologically to be healing moderate depth second degree burns and therefore, unnecessary operative procedures have been eliminated. Occasionally, frozen section study of specimens in the operating room has been useful in guiding the extent of surgical excision. For example, when excising full-thickness dorsal hand burns, it is sometimes difficult to determine when one has reached margins that are capable of healing satisfactorily and frozen section of the margins can be very useful in making this determination. When tangential excision must be carried into subcutaneous fat, a less optimal surface for immediate split-thickness skin grafting exists and in this situtation excision to the fascia with grafting may be preferable. If the surgeon knows the depth of the bum wound before the scheduled operative procedure, it may influence his choice of the type of excision he will employ. The histopathologic evaluation of burn wound material requires a well-fixed and carefully processed specimen to avoid artifact which would confuse the evaluation of the finer details. Most of the evaluations can be made with the Hematoxylin and Eosin stain. Occasionally special stains for microorganisms including fungi and bacteria can be
helpful. All elements of the skin must be evaluated including the status of the collagen in both the papillary and reticular dermis, the status and viability of the subcutaneous fat with the presence or absence of inflammatory infiltrate, and the degree of viability of the epidermis itself. In most of the bums chosen for biopsy, the epidermis itself is lost or necrotic and this is obvious clinically. The nature of the skin appendages can be the most telling and informative aspect to the observer. Sweat glands and ducts with the epithelium and sebaceous glands and ducts as well as hair shafts may survive and show viable and proliferating epithelium even after widespread destruction of the papillary dermis and its epithelium has occurred. When most of the appendages in a biopsy show complete necrosis of the epithelium and only an isolated appendage shows a few viable cells, the biopsy is best characterized biologically as a third degree burn. The various morphologic patterns of injury, including mid depth and deep second degree burn and third degree burn are demonstrated (Figs. 1, 2, 3). Specific changes can be recognized in certain types of burn. In the electrical burn, there will often be a coagulation necrosis with preservation of the non-viable epidermis, but the epidermis is frequently detached at the papillary layer and shows a palisading or polarization of nuclei in the direction of the current (Gonzales, Vance, Helpern & Umberger, 1954). This polarization may also be seen in the skin appendages (Fig. 4). A superficial examination may suggest viability of the epithelium, but the polarized pyknotic nuclear change is definitely not compatible with viability. In certain types of chemical bums, such as hydrofluoric acid, preservation of the cellular elements by fixation with the acid can simulate viable epidermis. In one case a fourth degree burn caused by hydrofluonc acid at first glance resembled normal skin (Fig. 5 ) . The telling sign of death of tissue was a coagulation and eosinophilia of the blood and serum within vessels and this coagulation occurred to the level of the subcutaneous fat. It is very important to evaluate blood vessels and their contents in determining the viability of burned tissue. The hydrofluoric acid bum demonstrated this very graphically. The knowledge gained from bum wound biopsy may enable the surgeon to determine preoperatively his choice of operation. This knowledge may enable the surgeon to provide the patient with a more accurate and informed consent and, therefore, a more
56
A . M . K d t n er ul.
Downloaded by [Universität Osnabrueck] at 06:26 16 March 2016
realistic expectation of the results. Partial thickness and full-thickness burn injuries often have similar initial appearance. Where that is the case, the patient and family are told that we cannot accurately assess the depth of the burn wound at the time of admission to the hospital. This information may cause the patient and family to maintain hope that all areas of the bum are partial thickness and therefore have the capacity to heal without scarring or pigmentary changes. In selected patients, prior to scheduling an operation, histopathologic confirmation of burn wound depth may dispel unrealistic expectations by the patient and therefore establish
increased confidence in the physician as well as a better understanding of the need for an operation.
REFERENCES Gonzales, T. A,, Vance. M.. Helpern. M. & Umberger, C. J. 1954. Legal Medicine pathology and toxicology. 2nd ed.. p. 543. Appleton-Century-Crofts. New York. Loebl, E. C . , Marvin, J. A., Heck, E. L.. Curreri, P. W . & Baxter, C. R . 1974. The method of quantitative burnwound biopsy culture and its routine use in the care of the burned patient. Am J Clin Pathol61. 20. Pruitt, B. A . & Foley, F. D. 1973. The use of biopsies in bum patient care. Surgery 73, 887.
