Dr Dylan Prunster1, Dr Peter Meier1, Mr Mark Duncan-Smith1,2
1Fiona Stanley Hospital – State Burns Service of Western Australia , Perth, Australia, 2Australian Medical Association W.A. Branch President
Lymphoedema is uncommon sequelae following extremity burns. The abnormal progressive accumulation of protein-rich fluid in the extremities can result in irreversible changes, profound functional impairment and significant cosmetic issues. The authors present a case of severe chronic lymphoedema in a unilateral hand and forearm following circumferential friction burns resulting in amputation.
A 40-year-old male was referred to the state burns service with chronic stage three lymphoedema to his right hand and forearm after being treated for friction burns post motorcycle accident five years prior (figure1). The gentleman was subsequently lost to follow-up post debridement and split thickness skin grafting, five years post injury he was referred back to the service with chronic wound breakdown and repeated bouts of cellulitis. Past medical history was significant for intravenous drug use, cirrhosis, chronic hepatitis c and non-compliance with burn-scar management. The chronic wounds were biopsied to rule out Marjolin’s ulcer secondary to their chronic nature, given the long standing irreversible lymphoedema and significant social stigma of the appearance of the right hand and forearm the patient requested an amputation (figure 2).
Lymphoedema has been reported following debridement, free tissue transfer and bone grafting of the lower limb.(Seyfer, Lower & Seyfer 1989) There is limited reporting of extremity lymphoedema following burns with only a case series and single case study of the lower limb and a single case study of the upper limb. (Balakrishnan, Webber & Prasad 1994; Anand, Lal & Dhaon 1998; Balakrishnan et al. 2004) A small single centre epidemiological study identifies the prevalence as 1%. (Hettrick et al. 2004). Initial disruption of lymphatics and venous return, in this case, is likely compounded by intravenous drug use and recurrent infections resulting in chronic inflammation and fibrosis of the lymphatic channels. Hypoalbuminaemia as a result of cirrhotic liver will have contributed to peripheral fluid deposition
A rare case of Stage three lymphoedema of the upper extremity following friction burn injury treated with amputation is described.
Dr Dylan Prunster is a surgical service registrar working within the West Australian Health Department with a keen interest in Plastic and Reconstructive Surgery. He obtained his primary medical qualification from the University of Western Australia and subsequently undertook an internship and residency at Royal Perth Hospital.