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Although many studies have described burn abuse in detail, burns that have occurred as a result of neglect have been studied to a much lesser degree. A retrospective study of 440 hospitalised paediatric burns patients during 2000-2002 inclusive was performed. A multidisciplinary team investigation of suspicious cases was used. This included a home assessment. There were 41 cases of neglect (9.3%) and 395 cases of accidental burning (89.8%). Parental drug abuse, single parent families, delay to presentation and a lack of first aid were statistically more prevalent in the 'neglect' group than in the 'accidental' group. Children in the 'neglect' group were also statistically more likely to have deeper burns and require skin grafting. 82.9% of children whose burns were deemed to be due to neglect had a previous entry on the child protection register. 48.8% were transferred into foster care. This study shows that burning by neglect is far more prevalent than abuse. We advocate a multidisciplinary investigation coupled with the use of home assessments to aid diagnosis. It may be possible to target preventative strategies on the children with the above risk factors. [ABSTRACT FROM AUTHOR]

Severe thermal injury significantly impacts upon hemostasis and is associated with classical changes to the circulating platelet count with a nadir followed by a rebound thrombocytosis at days ~3 and ~15 post-injury, respectively. To date, few studies have assessed platelet function following thermal injury as platelet tests often require large quantities of blood, are not representative of normal platelet pathophysiology, and are usually dependent on a normal platelet count. The purpose of this study was to measure platelet thrombus formation in vitro using a whole blood flow chip-based system following thermal injury and to study how platelet counts may impact upon the measurement. Adult (≥16 years) patients ( N  = 10) with ≥ 20% total burn surface area (TBSA) burn were recruited within 24 h of injury. Healthy controls ( N  = 25) were also recruited. Whole blood counts were measured using a hematology analyzer (Sysmex XN-1000). Platelet function was measured using the Total Thrombus-formation Analyzer System (T-TAS) within chips coated with tissue factor and collagen at shear rates of either 600 sec -1 (AR chips) or 1200 sec -1 (HD chips), the latter test being independent of platelet count. We confirmed the classical nadir in platelet counts following severe thermal injury at days 2, 3, 4 ( p  < 0.0001) and day 5 ( p  < 0.01) post-injury compared to healthy controls. Physiological platelet thrombus formation was significantly ( p  < 0.01) abnormal at day 3 post-injury using the AR chips but was related to the platelet count. However, although platelet dysfunction was not significant using HD chips, some of the results were independent of platelet count. A small number of samples, however, still gave abnormal results suggesting that there can be an underlying acquired platelet functional abnormality. Furthermore, the AR chip Area Under the Curve (AUC) was significantly lower on day 1 post-injury and negatively associated with severity of injury (TBSA, p  < 0.05) and higher platelet function (AUC) positively associated with survival ( p  < 0.05). This study suggests that measuring platelet dysfunction within a more physiological in vitro test may have potential clinical utility. Larger studies are required to fully understand the impact of platelet dysfunction following severe thermal injury.

Background: Traumatic and thermal injuries result in a state of systemic immune suppression, yet the mechanisms that underlie its development are poorly understood. Released from injured muscle and lysed red blood cells, heme is a damage associated molecular pattern with potent immune modulatory properties. Here, we measured plasma concentrations of total heme in over 200 traumatic and thermally-injured patients in order to examine its relationship with clinical outcomes and post-injury immune suppression., Methods: Blood samples were collected from 98 burns (≥15% total body surface area) and 147 traumatically-injured (injury severity score ≥8) patients across the ultra-early (≤1 hour) and acute (4-72 hours) post-injury settings. Pro-inflammatory cytokine production by lipopolysaccharide (LPS) challenged whole blood leukocytes was studied, and plasma concentrations of total heme, and its scavengers haptoglobin, hemopexin and albumin measured, alongside the expression of heme-oxygenase-1 (HO-1) in peripheral blood mononuclear cells (PBMCs). LPS-induced tumour necrosis factor-alpha (TNF-α) production by THP-1 cells and monocytes following in vitro heme treatment was also examined., Results: Burns and traumatic injury resulted in significantly elevated plasma concentrations of heme, which coincided with reduced levels of hemopexin and albumin, and correlated positively with circulating levels of pro and anti-inflammatory cytokines. PBMCs isolated from trauma patients 4-12 and 48-72 hours post-injury exhibited increased HO-1 gene expression. Non-survivors of burn injury and patients who developed sepsis, presented on day 1 with significantly elevated heme levels, with a difference of 6.5 µM in heme concentrations corresponding to a relative 52% increase in the odds of post-burn mortality. On day 1 post-burn, heme levels were negatively associated with ex vivo LPS-induced TNF-α and interleukin-6 production by whole blood leukocytes. THP-1 cells and monocytes pre-treated with heme exhibited significantly reduced TNF-α production following LPS stimulation. This impairment was associated with decreased gene transcription, reduced activation of extracellular signal-regulated kinase 1/2 and an impaired glycolytic response., Conclusions: Major injury results in elevated plasma concentrations of total heme that may contribute to the development of endotoxin tolerance and increase the risk of poor clinical outcomes. Restoration of the heme scavenging system could be a therapeutic approach by which to improve immune function post-injury., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision., (Copyright © 2024 Tullie, Nicholson, Bishop, McGee, Asiri, Sullivan, Chen, Sardeli, Belli, Harrison, Moiemen, Lord and Hazeldine.)

Background: Burn damage to skin often results in scarring; however in some individuals the failure of normal wound-healing processes results in excessive scar tissue formation, termed 'hypertrophic scarring'. The most commonly used method for the prevention and treatment of hypertrophic scarring is pressure-garment therapy (PGT). PGT is considered standard care globally; however, there is continued uncertainty around its effectiveness., Objectives: To evaluate the benefits and harms of pressure-garment therapy for the prevention of hypertrophic scarring after burn injury., Search Methods: We used standard, extensive Cochrane search methods. We searched CENTRAL, MEDLINE, Embase, two other databases, and two trials registers on 8 June 2023 with reference checking, citation searching, and contact with study authors to identify additional studies., Selection Criteria: We included randomised controlled trials (RCTs) comparing PGT (alone or in combination with other scar-management therapies) with scar management therapies not including PGT, or comparing different PGT pressures or different types of PGT., Data Collection and Analysis: At least two review authors independently selected trials for inclusion using predetermined inclusion criteria, extracted data, and assessed risk of bias using the Cochrane RoB 1 tool. We assessed the certainty of evidence using GRADE., Main Results: We included 15 studies in this review (1179 participants), 14 of which (1057 participants) presented useable data. The sample size of included studies ranged from 17 to 159 participants. Most studies included both adults and children. Eight studies compared a pressure garment (with or without another scar management therapy) with scar management therapy alone, five studies compared the same pressure garment at a higher pressure versus a lower pressure, and two studies compared two different types of pressure garments. Studies used a variety of pressure garments (e.g. in-house manufactured or a commercial brand). Types of scar management therapies included were lanolin massage, topical silicone gel, silicone sheet/dressing, and heparin sodium ointment. Meta-analysis was not possible as there was significant clinical and methodological heterogeneity between studies. Main outcome measures were scar improvement assessed using the Vancouver Scar Scale (VSS) or the Patient and Observer Scar Assessment Scale (POSAS) (or both), pain, pruritus, quality of life, adverse events, and adherence to therapy. Studies additionally reported a further 14 outcomes, mostly individual scar parameters, some of which contributed to global scores on the VSS or POSAS. The amount of evidence for each individual outcome was limited. Most studies had a short follow-up, which may have affected results as the full effect of any therapy on scar healing may not be seen until around 18 months. PGT versus no treatment/lanolin We included five studies (378 participants). The evidence is very uncertain on whether PGT improves scars as assessed by the VSS compared with no treatment/lanolin. The evidence is also very uncertain for pain, pruritus, adverse events, and adherence. No study used the POSAS or assessed quality of life. One additional study (122 participants) did not report useable data. PGT versus silicone We included three studies (359 participants). The evidence is very uncertain on the effect of PGT compared with silicone, as assessed by the VSS and POSAS. The evidence is also very uncertain for pain, pruritus, quality of life, adverse events, adherence, and other scar parameters. It is possible that silicone may result in fewer adverse events or better adherence compared with PGT but this was also based on very low-certainty evidence. PGT plus silicone versus no treatment/lanolin We included two studies (200 participants). The evidence is very uncertain on whether PGT plus silicone improves scars as assessed by the VSS compared with no treatment/lanolin. The evidence is also very uncertain for pain, pruritus, and adverse events. No study used the POSAS or assessed quality of life or adherence. PGT plus silicone versus silicone We included three studies (359 participants). The evidence is very uncertain on the effect of PGT plus silicone compared with silicone, as assessed by the VSS and POSAS. The evidence is also very uncertain for pain, pruritus, quality of life, adverse events, and adherence. PGT plus scar management therapy including silicone versus scar management therapy including silicone We included one study (88 participants). The evidence is very uncertain on the effect of PGT plus scar management therapy including silicone versus scar management therapy including silicone, as assessed by the VSS and POSAS. The evidence is also very uncertain for pain, pruritus, quality of life, adverse events, and adherence. High-pressure versus low-pressure garments We included five studies (262 participants). The evidence is very uncertain on the effect of high pressure versus low pressure PGT on adverse events and adherence. No study used the VSS or the POSAS or assessed pain, pruritus, or quality of life. Different types of PGT (Caroskin Tricot + an adhesive silicone gel sheet versus Gecko Nanoplast (silicone gel bandage)) We included one study (60 participants). The evidence is very uncertain on the effect of Caroskin Tricot versus Gecko Nanoplast on the POSAS, pain, pruritus, and adverse events. The study did not use the VSS or assess quality of life or adherence. Different types of pressure garments (Jobst versus Tubigrip) We included one study (110 participants). The evidence is very uncertain on the adherence to either Jobst or Tubigrip. This study did not report any other outcomes., Authors' Conclusions: There is insufficient evidence to recommend using either PGT or an alternative for preventing hypertrophic scarring after burn injury. PGT is already commonly used in practice and it is possible that continuing to do so may provide some benefit to some people. However, until more evidence becomes available, it may be appropriate to allow patient preference to guide therapy., (Copyright © 2024 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

Aim: The study aims to identify whether factors such as time to initiation of laser therapy following scar formation, type of laser used, laser treatment interval and presence of complications influence burn scar outcomes in adults, by meta-analysis of previous studies., Methods: A literature search was conducted in May 2022 in seven databases to select studies on the effects of laser therapy in adult hypertrophic burn scars. The study protocol was registered with PROSPERO (CRD42022347836)., Results: Eleven studies were included in the meta-analysis, with a total of 491 patients. Laser therapy significantly improved overall VSS/POSAS, vascularity, pliability, pigmentation and scar height of burn scars. Vascularity improvement was greater when laser therapy was performed >12 months (-1.50 [95%CI = -2.58;-0.42], p = 0.01) compared to <12 months after injury (-0.39 [95%CI = -0.68; -0.10], p = 0.01), the same was true for scar height ((-1.36 [95%CI = -2.07; -0.66], p<0.001) vs (-0.56 [95%CI = -0.70; -0.42], p<0.001)). Pulse dye laser (-4.35 [95%CI = -6.83; -1.86], p<0.001) gave a greater reduction in VSS/POSAS scores compared to non-ablative (-1.52 [95%CI = -2.24; -0.83], p<0.001) and ablative lasers (-0.95 [95%CI = -1.31; -0.59], p<0.001)., Conclusion: Efficacy of laser therapy is influenced by the time lapse after injury, the type of laser used and the interval between laser treatments. Significant heterogeneity was observed among studies, suggesting the need to explore other factors that may affect scar outcomes., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Ma et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Burn injuries are the fourth most common type of trauma and are associated with substantial morbidity and mortality. The impact of burn injury is clinically significant as burn injuries often give rise to exuberant scarring. Hypertrophic scarring (HTS) is a particular concern as up to 70% of burns patients develop HTS. Laser therapy is used for treating HTS and has shown positive clinical outcomes, although the mechanisms remain unclear limiting approaches to improve its effectiveness. Emerging evidence has shown that fibroblasts and senescent cells are important modifiers of scarring. This study aims to investigate the cellular kinetics in HTS after laser therapy, with a focus on the association of scar reduction with the presence of senescent cells., Methods: We will conduct a multicentre, intra-patient, single-blinded, randomised controlled longitudinal pilot study with parallel assignments to achieve this objective. 60 participants will be recruited to receive 3 interventional ablative fractional CO2 laser treatments over a 12-month period. Each participant will have two scars randomly allocated to receive either laser treatment or standard care. Biopsies will be obtained from laser-treated, scarred-no treatment and non-scarred tissues for immune-histological staining to investigate the longitudinal kinetics of p16INK4A+-senescent cells and fibroblast subpopulations (CD90+/Thy1+ and αSMA+). Combined subjective scar assessments including Modified Vancouver Scar Scale, Patient and Observer Scar Assessment Scale and Brisbane Burn Scar Impact Profile; and objective assessment tools including 3D-Vectra-H1 photography, DermaScan® Cortex, Cutometer® and ColoriMeter®DSMIII will be used to evaluate clinical outcomes. These will then be used to investigate the association between senescent cells and scar reduction after laser therapy. This study will also collect blood samples to explore the systemic biomarkers associated with the response to laser therapy., Discussion: This study will provide an improved understanding of mechanisms potentially mediating scar reduction with laser treatment, which will enable better designs of laser treatment regimens for those living with HTS., Trial Registration: ClinicalTrials.gov: NCT04736251., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Chen et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction: Burn-induced changes in the phenotype and function of neutrophils, cells which provide front-line protection against rapidly dividing bacterial infections, are emerging as potential biomarkers for the early prediction of sepsis. In a longitudinal study of adult burns patients, we recently demonstrated that a combined measurement of neutrophil phagocytic capacity, immature granulocyte (IG) count and plasma cell-free DNA (cfDNA) levels on the day of injury gave good discriminatory power for the prediction of later sepsis development. However, limited by a small sample size, single-centre design and focus on adult burns patients, these biomarkers require prospective validation in a larger patient cohort. The Scientific Investigation of the Biological Pathways Following Thermal Injury-2 study aims to prospectively validate neutrophil phagocytic activity, IG count and plasma cfDNA levels as early prognostic biomarkers of sepsis in thermally injured adult and paediatric patients., Methods and Analysis: This multicentre, longitudinal, observational cohort study will enrol 245 paediatric and adult patients with moderate to severe burns within 24 hours of injury. Blood samples will be obtained at 19 postinjury time points (days 1-14, day 28, months 3, 6, 12 and 24) and analysed for neutrophil phagocytic activity, IG count and cfDNA levels. Patients will be screened daily for sepsis using the 2007 American Burn Association diagnostic criteria for sepsis. In addition, daily multiple organ dysfunction syndrome and Sequential Organ Failure Assessment Scores will be recorded relationships between neutrophil phagocytic activity, IG count and plasma cfDNA levels on day 1 of injury and the development of sepsis will be examined using logistic regression models., Ethics and Dissemination: This study received ethics approval from the West Midlands, Coventry and Warwickshire Research Ethics Committee (REC reference:16/WM/0217). Findings will be presented at national and international conferences, and submitted for publication in peer-reviewed journals., Trial Registration Number: NCT04693442., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Background: Research into the treatment of hypertrophic burn scar is hampered by the variability and subjectivity of existing outcome measures. This study aims to measure the inter- and intra-rater reliability of a panel of subjective and objective burn scar measurement tools., Methods: Three independent assessors evaluated 55 scar and normal skin sites using subjective (modified Vancouver Scar Scale [mVSS] & Patient and Observer Scar Assessment Scale [POSAS]) and objective tools. The intra-class correlation coefficient was utilised to measure reliability (acceptable when >0.70). Patient satisfaction with the different tools and scar parameter importance were assessed via questionnaires., Results: The inter-rater reliabilities of the mVSS and POSAS were below the acceptable limit. For erythema and pigmentation, all of the Scanoskin and DSM II measures (except the b* value) had acceptable to excellent intra and inter-rater reliability. The Dermascan ultrasound (dermal thickness, intensity) had excellent intra- and inter-rater reliability (>0.90). The Cutometer R0 (firmness) had acceptable reliability but not R2 (gross elasticity). All objective measurement tools had good overall satisfaction scores. Patients rated scar related pain and itch as more important compared to appearance although this finding was not sustained when corrected for multiple comparisons., Conclusion: The objective scar measures demonstrated acceptable to excellent intra- and inter-rater reliability and performed better than the subjective scar scales., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Autologous cell transplantation was introduced to clinical practice nearly four decades ago to enhance burn wound re-epithelialisation. Autologous cultured or uncultured cells are often delivered to the surface in saline-like suspensions. This delivery method is limited because droplets of the sprayed suspension form upon deposition and run across the wound bed, leading to uneven coverage and cell loss. One way to circumvent this problem would be to use a gel-based material to enhance surface retention. Fibrin systems have been explored as co-delivery system with keratinocytes or as adjunct to 'seal' the cells following spray delivery, but the high costs and need for autologous blood has impeded its widespread use. Aside from fibrin gel, which can exhibit variable properties, it has not been possible to develop a gel-based carrier that solidifies on the skin surface. This is because it is challenging to develop a material that is sprayable but gels on contact with the skin surface. The manuscript reports the use of an engineered carrier device to deliver cells via spraying, to enhance retention upon a wound. The device involves shear-structuring of a gelling biopolymer, gellan, during the gelation process; forming a yield-stress fluid with shear-sensitive behaviours, known as a fluid gel. In this study, a formulation of gellan gum fluid gels are reported, formed with from 0.75 or 0.9% (w/v) polymer and varying the salt concentrations. The rheological properties and the propensity of the material to wet a surface were determined for polymer modified and non-polymer modified cell suspensions. The gellan fluid gels had a significantly higher viscosity and contact angle when compared to the non-polymer carrier. Viability of cells was not impeded by encapsulation in the gellan fluid gel or spraying. The shear thinning property of the material enabled it to be applied using an airbrush and spray angle, distance and air pressure were optimised for coverage and viability. STATEMENT OF SIGNIFICANCE: Spray delivery of skin cells has successfully translated to clinical practice. However, it has not yet been widely accepted due to limited retention and disputable cell viability in the wound. Here, we report a method for delivering cells onto wound surfaces using a gellan-based shear-thinning gel system. The viscoelastic properties allow the material to liquefy upon spraying and restructure rapidly on the surface. Our results demonstrate reduced run-off from the surface compared to currently used low-viscosity cell carriers. Moreover, encapsulated cells remain viable throughout the process. Although this paper studies the encapsulation of one cell type, a similar approach could potentially be adopted for other cell types. Our data supports further studies to confirm these results in in vivo models., (Crown Copyright © 2019. Published by Elsevier Ltd. All rights reserved.)

Background: The early diagnosis of infection or sepsis in burns are important for patient care. Globally, a large number of burn centres advocate quantitative cultures of wound biopsies for patient management, since there is assumed to be a direct link between the bioburden of a burn wound and the risk of microbial invasion. Given the conflicting study findings in this area, a systematic review was warranted., Methods: Bibliographic databases were searched with no language restrictions to August 2015. Study selection, data extraction and risk of bias assessment were performed in duplicate using pre-defined criteria. Substantial heterogeneity precluded quantitative synthesis, and findings were described narratively, sub-grouped by clinical question., Results: Twenty six laboratory and/or clinical studies were included. Substantial heterogeneity hampered comparisons across studies and interpretation of findings. Limited evidence suggests that (i) more than one quantitative microbiology sample is required to obtain reliable estimates of bacterial load; (ii) biopsies are more sensitive than swabs in diagnosing or predicting sepsis; (iii) high bacterial loads may predict worse clinical outcomes, and (iv) both quantitative and semi-quantitative culture reports need to be interpreted with caution and in the context of other clinical risk factors., Conclusion: The evidence base for the utility and reliability of quantitative microbiology for diagnosing or predicting clinical outcomes in burns patients is limited and often poorly reported. Consequently future research is warranted., (Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.)

This review gives an updated overview on keratinocyte transplantation in burn wounds concentrating on application methods and future therapeutic cell delivery options with a special interest in hydrogels and spray devices for cell delivery. To achieve faster re-epithelialisation of burn wounds, the original autologous keratinocyte culture and transplantation technique was introduced over 3 decades ago. Application types of keratinocytes transplantation have improved from cell sheets to single-cell solutions delivered with a spray system. However, further enhancement of cell culture, cell viability and function in vivo, cell carrier and cell delivery systems remain themes of interest. Hydrogels such as chitosan, alginate, fibrin and collagen are frequently used in burn wound care and have advantageous characteristics as cell carriers. Future approaches of keratinocyte transplantation involve spray devices, but optimisation of application technique and carrier type is necessary., (Copyright © 2017 The Author(s). Published by Elsevier B.V. All rights reserved.)

Objective: The aim of this study was to measure neutrophil function longitudinally following burn injury and to examine the relationship between neutrophil dysfunction and sepsis., Background: Sepsis prevalence and its associated mortality is high following burn injury, and sepsis diagnosis is complicated by the ongoing inflammatory response. Previous studies have suggested that neutrophil dysfunction may underlie high infection rates and sepsis postburn; however, neutrophil dysfunction has not been thoroughly characterized over time in burns patients., Methods: Neutrophil phagocytosis, oxidative burst capacity, and neutrophil extracellular trap (NET) generation (NETosis) were measured from 1 day to up to 1 year postburn injury in 63 patients with major burns (≥15% total body surface area). In addition, immature granulocyte (IG) count, plasma cell-free DNA (cfDNA), and plasma citrullinated histone H3 (Cit H3) levels were measured., Results: Neutrophil function was reduced for 28 days postburn injury and to a greater degree in patients who developed sepsis, which was also characterized by elevated IG counts. Plasma cfDNA and Cit-H3, a specific marker of NETosis, were elevated during septic episodes. The combination of neutrophil phagocytic capacity, plasma cfDNA levels, and IG count at day 1 postinjury gave good discriminatory power for the identification of septic patients., Conclusion: Neutrophil function, IG count, and plasma cfDNA levels show potential as biomarkers for the prediction/early diagnosis of sepsis postburn injury and neutrophil dysfunction may actively contribute to the development of sepsis. Targeting neutrophil dysfunction and IG release may be a viable therapeutic intervention to help reduce the incidence of nosocomial infections and sepsis postburn.

Unlabelled: Antimicrobial medicated dressings (AMD) are often used to reduce bacterial infection of burns and other wounds. However, there is limited literature regarding comparative efficacies to inform effective clinical decision making., Objectives: Following on from a previous study where we demonstrated good antibiofilm properties of acetic acid (AA), we assessed and compared the in vitro anti-biofilm activity of a range of AMDs and non-AMDs to AA., Methods: Laboratory experiments determined the ability of a range of eleven commercial AMD, two nAMD, and AA, to prevent the formation of biofilms of a panel of four isolates of Pseudomonas aeruginosa and Acinetobacter baumannii., Results: There is a large variation in ability of different dressings to inhibit biofilm formation, seen between dressings that contain the same, and those that contain other antimicrobial agents. The best performing AMD were Mepilex(®) Ag and Acticoat. AA consistently prevented biofilm formation., Conclusions: Large variation exists in the ability of AMD to prevent biofilm formation and colonisation of wounds. A standardised in vitro methodology should be developed for external parties to examine and compare the efficacies of commercially available AMDs, along with robust clinical randomised controlled trials. This is essential for informed clinical decision-making and optimal patient management., (Copyright © 2015 Elsevier Ltd and ISBI. All rights reserved.)

Background: Sepsis from burn injuries can result from colonisation of burn wounds, especially in large surface area burns. Reducing bacterial infection will reduce morbidity and mortality, and mortality for severe burns can be as high as 15 %. There are various quantitative and semi-quantitative techniques to monitor bacterial load on wounds. In the UK, burn wounds are typically monitored for the presence or absence of bacteria through the collection and culture of swabs, but no absolute count is obtained. Quantitative burn wound culture provides a measure of bacterial count and is gaining increased popularity in some countries. It is however more resource intensive, and evidence for its utility appears to be inconsistent. This systematic review therefore aims to assess the evidence on the utility and reliability of different quantitative microbiology techniques in terms of diagnosing or predicting clinical outcomes., Methods/design: Standard systematic review methods aimed at minimising bias will be employed for study identification, selection and data extraction. Bibliographic databases and ongoing trial registers will be searched and conference abstracts screened. Studies will be eligible if they are prospective studies or systematic reviews of burn patients (any age) for whom quantitative microbiology has been performed, whether it is compared to another method. Quality assessment will be based on quality assessment tools for diagnostic and prognostic studies and tailored to the review as necessary. Synthesis is likely to be primarily narrative, but meta-analysis may be considered where clinical and methodological homogeneity exists., Discussion: Given the increasing use of quantitative methods, this is a timely systematic review, which will attempt to clarify the evidence base. As far as the authors are aware, it will be the first to address this topic., Trial Registration: PROSPERO, CRD42015023903.

Introduction: Localised infections, and burn wound sepsis are key concerns in the treatment of burns patients, and prevention of colonisation largely relies on biocides. Acetic acid has been shown to have good antibacterial activity against various planktonic organisms, however data is limited on efficacy, and few studies have been performed on biofilms., Objectives: We sought to investigate the antibacterial activity of acetic acid against important burn wound colonising organisms growing planktonically and as biofilms., Methods: Laboratory experiments were performed to test the ability of acetic acid to inhibit growth of pathogens, inhibit the formation of biofilms, and eradicate pre-formed biofilms., Results: Twenty-nine isolates of common wound-infecting pathogens were tested. Acetic acid was antibacterial against planktonic growth, with an minimum inhibitory concentration of 0.16-0.31% for all isolates, and was also able to prevent formation of biofilms (at 0.31%). Eradication of mature biofilms was observed for all isolates after three hours of exposure., Conclusions: This study provides evidence that acetic acid can inhibit growth of key burn wound pathogens when used at very dilute concentrations. Owing to current concerns of the reducing efficacy of systemic antibiotics, this novel biocide application offers great promise as a cheap and effective measure to treat infections in burns patients.

Diphoterine(®) is an amphoteric irrigating agent for the treatment of chemical burns and rapidly neutralises both acids and alkalis faster than water alone. Diphoterine(®) is widely used as a first aid agent in a wide range of industries globally. This is a retrospective review of the clinical use of Diphoterine(®) on chemical burns in an adult tertiary referral burn centre, often with a delay of several hours after the injury. patients admitted with chemical burns within 24 hours of the incident with an abnormal wound pH or in pain, were treated with Diphoterine(®) spray. Over a 32-month period, 1,875 burn referrals were admitted of which 131 (7%) were chemical burns. Diphoterine(®) was used in 47 patients (36%). The male to female ratio for the 131 patients was 4:1. Alkaline burns were the commonest (55%). patients who received Diphoterine(®) were significantly younger (38 vs 43 years; p=0.05) and presented earlier (0.5 vs 2.55 days; p=0.004). There was a significant change in the wound pH pre- and post-application of Diphoterine(®), compared to patients who were treated with water irrigation only, with a pH change of 1.076 vs 0.4 (p <0.05). There was no significant difference in the time to healing, the length of hospital stay, or need for surgery. in conclusion, based on our retrospective cohort, Diphoterine(®) could be a valuable tool for use in hospital settings to neutralise both alkaline and acid burns.

Objectives: Pseudomonas aeruginosa is a common nosocomial pathogen responsible for significant morbidity and mortality internationally. Patients may become colonised or infected with P. aeruginosa after exposure to contaminated sources within the hospital environment. The aim of this study was to determine whether whole-genome sequencing (WGS) can be used to determine the source in a cohort of burns patients at high risk of P. aeruginosa acquisition., Study Design: An observational prospective cohort study., Setting: Burns care ward and critical care ward in the UK., Participants: Patients with >7% total burns by surface area were recruited into the study., Methods: All patients were screened for P. aeruginosa on admission and samples taken from their immediate environment, including water. Screening patients who subsequently developed a positive P. aeruginosa microbiology result were subject to enhanced environmental surveillance. All isolates of P. aeruginosa were genome sequenced. Sequence analysis looked at similarity and relatedness between isolates., Results: WGS for 141 P. aeruginosa isolates were obtained from patients, hospital water and the ward environment. Phylogenetic analysis revealed eight distinct clades, with a single clade representing the majority of environmental isolates in the burns unit. Isolates from three patients had identical genotypes compared with water isolates from the same room. There was clear clustering of water isolates by room and outlet, allowing the source of acquisitions to be unambiguously identified. Whole-genome shotgun sequencing of biofilm DNA extracted from a thermostatic mixer valve revealed this was the source of a P. aeruginosa subpopulation previously detected in water. In the remaining two cases there was no clear link to the hospital environment., Conclusions: This study reveals that WGS can be used for source tracking of P. aeruginosa in a hospital setting, and that acquisitions can be traced to a specific source within a hospital ward., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Burn injuries are one of the most common and devastating afflictions on the human body. In this article we look back at how the treatment of burns has evolved over the centuries from a primarily topical therapy consisting of weird and wonderful topical concoctions in ancient times to one that spans multiple scientific fields of topical therapy, antibiotics, fluid resuscitation, skin excision and grafting, respiratory and metabolic care and nutrition. Most major advances in burn care occurred in the last 50 years, spurred on by wars and great fires. The use of systemic antibiotics and topical silver therapy greatly reduced sepsis related mortality. This along with the advent of antiseptic surgical techniques, burn depth classification and skin grafting allowed the excision and coverage of full-thickness burns which resulted in greatly improved survival rates. Advancements in the methods of assessing the surface area of burns paved way for more accurate fluid resuscitation, minimising the effects of shock and avoiding fluid over-loading. The introduction of metabolic care, nutritional support and care of inhalational injuries further improved the outcome of burn patients. We also briefly discuss some future directions in burn care such as the use of cell and pharmalogical therapies.

Introduction: Hydrotherapy is widely used in burns management however there are risks associated with its use, in particular cross-infection. Data regarding indications and techniques in common use is deficient. This study aimed to investigate hydrotherapy practices in the UK and Ireland., Methods: A survey of the hydrotherapy practice of major burn care providers was performed by e mail and where necessary, follow up telephone contact., Results: The survey included 28 burn care providers. 27 reported using hydrotherapy. Only 11 (41%) had defined indication criteria with 4 (15%) implementing a specific protocol. Variations in hydrotherapy practice were seen., Conclusion: Hydrotherapy is used nationwide, however considerable variation in practice exists. One area worthy of further consideration is the need for appropriate standards of infection control., (Copyright © 2013 Elsevier Ltd and ISBI. All rights reserved.)

Background: Although commercial skin substitutes are widely available, its use remains challenging at surgery and postoperatively. The high cost is also prohibitive. We designed and characterized a scaffold for dermal replacement, using advanced nanocomposite materials, which are known to have unique nanoscale features that enhance cellular behavior., Methods: A bilayered scaffold was developed using the nanocomposite, polyhedral oligomeric silsesquioxane, incorporated into poly(caprolactone-urea)urethane, resulting in a mechanically robust bioabsorbable polymer; forming the inner layer, which was designed with a range of porosities. The removable outer layer contained nanosilver. Tensile testing, surface tension, permeability, and scanning electron microscopy were performed. Optimal pore morphology for cellular proliferation was elucidated through adipose tissue-derived stem cell culture and a cell viability assay. All tests were repeated on Integra Dermal Regeneration Template., Results: The physical construct was easy to handle and clinically applicable. Macroporosity and permeability of scaffolds was demonstrated, confirmed by scanning electron microscopy. Both tensile strength and surface tension were comparable with skin; outer layer demonstrated hydrophobicity and inner layer showed hydrophilicity. Cell assay confirmed cellular proliferation onto the scaffold, comparable with Integra., Conclusions: We demonstrate that a porous bilayered dermal scaffold could form the basis of a new generation of skin substitute that is both mechanically robust and harbors the ability for enhancing cell regeneration., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background. Tissue expansion has been a major advance in reconstructive burn surgery. The conventional tissue expander requires serial filling with the possibility of painful procedures, which can be a major challenge and source of anxiety in children. The osmotic self-inflating tissue expander, on the other hand, is a device that does not require external filling, offering apparent benefits particularly in the paediatric population. We used Osmed(TM) tissue expanders for secondary burn reconstruction in children and teenagers who had sustained burns during childhood. Methods. Patients who were treated with Osmed(TM) expanders for secondary burns reconstruction were recorded. Patient demographics (i.e. burn injury data, indications for surgery), Osmed(TM) tissue expander data (i.e. operative data, complications, problems encountered during and after treatment, explantation time, final expander volume) and overall success were recorded. Results. Twelve Osmed(TM) self-inflating tissue expanders were used in patients for secondary burns reconstruction between October 2007 and January 2009. All our patients sustained their burns during childhood. There were three females and one male; the age range was 14-19 yr (mean age, 16 yr). Tissue expanders were removed on average at 6-7 weeks except in two patients. We noted four complications in our cohort. Overall the mean expansion was 65% of the proposed final volume. Discussion. We found the Osmed(TM) tissue expander simple to implant and well tolerated by our patients. However, none of the devices achieved full expansion and overexpansion was not possible. We believe conventional tissue expanders are still the gold standard, although osmotic expanders may have a role in burn reconstruction in younger children.

Despite widespread use of wound dressings containing silver, few studies have investigated patients' serum silver levels. An earlier study of Acticoat use in small burns showed transient elevations of serum silver. The aim of this study was to examine the serum silver profile when Acticoat is used in major burns. A prospective study of 6 patients with burns greater than 20% total body surface area (TBSA). All burn wounds, including grafted and non-grafted areas and skin graft donor sites, were dressed with Acticoat or Acticoat Absorbent. Patients' serum silver levels, biochemistry and haematology were examined before, during and after the application of the silver dressings. The median total wound size (including donor sites) was 46.1% TBSA. The median maximum serum silver level recorded, 200.3 μg/L, reached at a median of 9.5 days following initial silver dressing application. This decreased to a median of 164.8 μg/L at the end of the treatment period and to a median of 8.2 μg/L at the end of follow-up. One adverse event, partial skin graft loss was thought to be dressing related. In this small study, serum silver levels were elevated but remained similar to that reported following the use of silver sulfadiazine. This study confirmed our view that Acticoat is safe to use on patients with burns, even when they are extensive., (Copyright © 2010 Elsevier Ltd and ISBI. All rights reserved.)

Introduction: Helicopter emergency medical services play a valuable role in the transfer of critically ill patients. This paper reviews the role of air ambulance services in the provision of regional burns care and suggests guidelines for their use., Methods: A retrospective review of patients treated at the Midlands Adult Burns Centre over a 3-year period., Results: 27 adult burns patients were transported by air ambulance during the study period. Patients were aged 19-89 years (average 41.3 years) with an estimated burn size of 5-70% TBSA. Distance travelled was 11-79 miles (average 41.2 miles). All patients were appropriately referred to the burns centre according to national referral guidelines but in 7 cases (26%) it was felt that transport by air ambulance was not clinically indicated and land transfer would have been safe and appropriate., Conclusion: Air ambulances offer a fast and effective means of transferring patients to a regional burns centre in selected cases. There is limited data for the beneficial effects of helicopters and survival benefit is seen only in the most severely injured patients. We suggest criteria for the use of air ambulances in burns patients in order to maximise the benefit and reduce unnecessary flights., (Copyright © 2010 Elsevier Ltd and ISBI. All rights reserved.)

Introduction: Hydroxyethylstarches (HES) are thought to be beneficial in trauma and major surgery management, due to their volume expansion and anti-inflammatory properties. This study examined the use of 6% (HES) in burn resuscitation., Methods: 26 adult patients with burns exceeding 15% total body surface area (TBSA) were randomised to either crystalloid (Hartmann's solution) or a colloid-supplemented resuscitation regime, where 1/3 of the crystalloid-predicted requirement was replaced by 6% HES., Results: There was no difference in age, gender or TBSA between the two groups. The median (95% CI) fluid volume/%TBSA received in the first 24 h was 307 ml and 263 ml for the crystalloid only and HES-supplemented group respectively (p=0.0234, Mann-Whitney). Body weight gain within the first 24 h after injury was significantly lower in the HES-supplemented group 2.5 kg versus 1.4 kg respectively (p=0.0039). The median (95% CI) serum C-reactive protein at 48 h after injury was 210 (167-257) and 128 (74-145) mg/L for the crystalloid only and HES-supplemented group respectively (p=0.0001). Albumin-creatinine ratio per % burn (ACR, a marker of capillary leak) was lower in the HES-supplemented group at 12h after burn (p=0.0310)., Conclusions: Patients treated with HES-supplemented resuscitation required less fluid, showed less interstitial oedema and a dampened inflammatory response compared to patients receiving isotonic crystalloid alone., (Crown Copyright © 2010. Published by Elsevier Ltd. All rights reserved.)

Background: The use of topical negative pressure (TNP) dressings with dermal regeneration template (DRT), Integra, has improved outcomes and simplified aftercare. Previous clinical studies have suggested accelerated vascularisation; with a reduction in the duration of the 1st stage after the application of Integra, from 2 to 4 weeks to as little as 4 days, but with no histological evidence. However, histological studies, without TNP, have shown that vascularisation occurs between the second and the fourth week. This study set out to examine histologically the rate of DRT neovascularisation when combined with TNP., Methods: Eight patients with nine reconstruction sites were enlisted. Unmeshed Integra and fibrin sealant to promote adherence were used. TNP was applied for the duration between the 1st and the 2nd stages. Patients underwent serial biopsies on days 7, 14, 21 and 28 post-application. The biopsies were stained with H&E and endothelial markers CD31 and CD34. Template vascularisation was assessed as a percentage of the template depth in which patent, canalised vascular channels could be demonstrated., Results: The median percentage of the template depth which demonstrated canalised channels was 0%, 20%, 61% and 80% for days, 7, 14, 21 and 28, respectively., Conclusion: The application of TNP dressings to dermal templates can reduce shearing forces, restrict seroma and haematoma formation, simplify wound care and improve patient tolerance. However, this study could not demonstrate that TNP accelerates neovascularisation as verified by the presence of histologically patent vascular channels., (Crown Copyright 2010. Published by Elsevier Ltd. All rights reserved.)

Objectives: To determine the number of patients attending an Emergency Department with burns and to establish the epidemiology, management and outcome of these cases., Method: A retrospective study of all patients attending an Emergency Department with a diagnosis of "burn" during 2004., Results: Seven hundred and eighty-five patients presented with a diagnosis of burns, accounting for 1% of all attendances. Fifty-three percent of patients were male and most were young adults of working age. Scalds and flame injuries were the most common causes of injury. Only 30% of patients performed adequate first aid. The majority of burns were small and did not require admission to hospital. Assessment and documentation by the Emergency Department staff was found to be generally poor and this may reflect a lack of experience in managing burns., Conclusion: Burns remain a relatively uncommon presenting complaint in the Emergency Department, even in a hospital accepting tertiary referrals. Most injuries are minor and are managed within the department. This study suggests that there is a role for better education of less experienced staff in the management of burns. There remains a need for public education in the prevention and first aid of burns.

Objective: To audit the referral patterns of burns in an emergency department compared with national referral guidelines., Methods: A retrospective case note audit of patients attending an emergency department with a diagnosis of "burn" in a 1-year period., Results: Only one quarter of the patients were managed according to the suggested national referral criteria for burns. Large and full thickness burns were managed appropriately but those at important anatomical sites and in patients at the extremes of age were managed less well., Conclusion: Increased awareness of the national referral guidelines, along with further education of staff within this department, may improve management of burn injuries. It is likely that referral patterns are similar in other emergency departments and may be improved by training staff in the assessment and management of burns. Increased adherence to the guidelines is likely to improve patient outcome at the expense of increased patient numbers and workloads in regional burns units that have implications for funding and service provision.

Introduction: Systemic endothelial dysfunction characterises both burn injury and surgery and can be monitored by serial immunoassay of urine albumin (microalbuminuria). The aim of this study was to assess microalbuminuria before and during burn excision and identify factors that may influence it., Methods: Serial half-hourly urine albumin/creatinine ratio (ACR, normal <2.3mg/mmol) was measured in 25 adult patients during 44 burn-excision procedures, at a median of 5 days post-injury. Median total body surface area (TBSA) excised was 12%., Results: Pre-operative median ACR was normal rising to 3.25mg/mmol at 1.5h of surgery (p<0.05). Per-operative ACR at 0.5, 1, 2 and 2.5h were all associated with % TBSA burn excised (p<0.04). Median intraoperative ACR at 1h was 2.3mg/mmol for surgery within 48h post-injury, 1.6 for surgery at 2-7 days and 25.5 during excisions later than 1 month after injury (p<0.05). ACR at 1h was associated with CRP at 48h post-surgery (p=0.04). Per-operative ACR was also significantly correlated with post-operative complications., Conclusion: Systemic endothelial dysfunction of acute thermal injury assessed by microalbuminuria recurs with surgery, is minimal at 2-7 days post-burn and affected by % TBSA burn excised and post-operative complications.

Introduction: Wound dressings containing silver have been in widespread use for many years. However, there are few quantitative data on the systemic absorption of silver or whether there is associated clinical risk., Objectives: To assess systemic silver levels when Acticoat dressings containing nanocrystalline silver were used, and to determine whether increases in such levels were associated with haematological or biochemical indicators of toxicity., Method: A prospective, single-centre, open-label study of 30 patients with relatively small burns that required skin grafting. Serum silver levels were measured before, during and at discontinuation of the use of the Acticoat dressings, and again at 3 and 6 months following completion of treatment., Results: The median total postoperative wound size was 12% of the total body surface area. The median time to maximum silver levels was 9 days. The median maximum serum silver level was 56.8 microg/l. The median serum level at 6 months was 0.8 microg/l. There were no haematological or biochemical indicators of toxicity associated with the silver absorption observed in this study., Conclusion: This study has confirmed our view that Acticoat products are safe for use on burns and they remain a standard part of treatment at our centre.

Introduction: Systemic endothelial dysfunction (SED) and capillary leak occur following severe burn. SED can be assessed as low-level albuminuria (microalbuminuria) detectable only by sensitive immunoassay. This study compared the magnitude and duration of microalbuminuria with burn surface area and associated aggravating factors., Methods: Serial urine specimens were collected from 2 to 36 h after injury from 43 adult burn patients with a mean total body surface area (TBSA) of 32% (range 15-68%) and during 44 episodes of wound manipulation within the same period. Urinary albumin was expressed as the albumin/creatinine ratio (ACR, normal <2.3 mg/mmol)., Results: Median ACR was highest 2h after injury (12.3 range 1.8-118 mg/mmol) returning to normal within 6 h. Full thickness burns (mean 17%) showed a significant association with ACR between 3 and 7h after burn. ACR was higher for up to 8 h in the presence of inhalation injury, alcohol intoxication or accelerant (p<0.05). ACR rose within 30 min of escharotomy or wound scrubbing (p<0.01)., Conclusion: Severe burn produces variable SED which recurs with wound manipulation. Inhalation injury, alcohol intoxication and accelerant all showed a stronger association with SED than TBSA. Microalbuminuria provides a means of monitoring microvascular integrity during the early after injury period.

Introduction: This retrospective study, analyses aetiology and factors affecting the outcome of burns in patients over 65 years of age., Methods: Sixty-three consecutive patients, over 65 years of age, were admitted to a Burns Unit over a period of 3 years. Retrospective data was analyzed, taking into account aetiology, burn thickness and area, co-morbid factors. Also, surgery as a factor-affecting outcome was examined., Results: There was a significant difference of total body surface area burn (TBSA), Abbreviated Burn Severity Index (ABSI), Baux score and the number of pre-existing co-morbid factors between survivors and non-survivors. Age and surgery were not significant to the outcome. Patients undergoing surgery had increased hospital stay without any difference in mortality. The timing of surgery did not have any impact on hospital stay or survival., Conclusion: This study shows a positive correlation between the number of co-morbid conditions and mortality. Early surgery after careful patient selection does not have any negative impact on patient survival.

Background: Yannas and Burke developed the concept of the dermal regeneration template in the 1970s. It is now a widely accepted tool in the treatment of burns as well as in reconstructive surgery., Methods: The authors present a previously published study of Integra used in 20 consecutive patients to reconstruct 30 anatomical sites and then analyze the histologic and clinical outcomes. Wound healing was evaluated by examination of weekly punch biopsy specimens with standard and immunohistochemical stains. Patient satisfaction was assessed using a visual analogue scale, and scar appearance was assessed using a modified Vancouver Scar Scale., Results: Four distinct phases of dermal regeneration could be demonstrated histologically: imbibition, fibroblast migration, neovascularization, and remodeling and maturation. Full vascularization of the neodermis occurred at 4 weeks. Patients reported increased range of movement and improvement in appearance compared with their preoperative states., Conclusions: The color of the matrix reflected the stage of neodermal vascularization. No adnexa, nerve endings, or elastic fibers were seen in any of the specimens. The new collagen was histologically indistinguishable from normal dermal collagen. The authors also present their current protocol and experience with using Integra for a range of reconstructive procedures.

Integra artificial skin was introduced in 1981 and its use in acute surgical management of burns is well established, but Integra has also been used in patients undergoing reconstructive surgery. Over a period of 25 months, the authors used Integra to cover 30 anatomic sites in 20 consecutive patients requiring reconstructive surgery and then analyzed the clinical and histologic outcomes. The most common reason for surgery was release of contracture followed by resurfacing of tight or painful scars. The authors assessed patients' satisfaction using a visual analog scale and scar appearance using a modified Vancouver Burn Index Scale. They evaluated the progress of wound healing by examining weekly punch-biopsy specimens with standard and immunohistochemical stains. Patients reported a 72 percent increase in range of movement, a 62 percent improvement in softness, and a 59 percent improvement in appearance compared with their preoperative states. Pruritus and dryness were the main complaints, and neither was improved much. Four distinct phases of dermal regeneration could be demonstrated histologically: imbibition, fibroblast migration, neovascularization, and remodeling and maturation. Full vascularization of the neodermis occurred at 4 weeks. The color of the wound reflected the state of neodermal vascularization. No adnexa, nerve endings, or elastic fibers were seen in any of the specimens. The new collagen was histologically indistinguishable from normal dermal collagen. The authors conclude that Integra is a useful tool in reconstructive surgery. The additional cost of its use can be justified by its distinct benefits compared with current methodology.

Eighteen cases of turret exostoses of the hand have been reported, all associated with dorsal injuries. We present a case of turret exostosis involving the volar aspect of the thumb., (Copyright 2000 The British Association of Plastic Surgeons.)

This paper presents an analysis of the results of repair of 102 complete flexor tendon disruptions in zone 1 which were rehabilitated by an early active mobilization technique during a 7 year period from 1992 to 1998. These injuries were subdivided into: distal tendon divisions requiring reinsertion; more proximal tendon divisions but still distal to the A4 pulley; tendon divisions under or just proximal to the A4 pulley; and closed avulsions of the flexor digitorum profundus tendon from the distal phalanx. Assessment by Strickland's original criteria showed good and excellent results of 64%, 60%, 55% and 67% respectively in the four groups. However, examination of the results measuring the range of movement of the distal interphalangeal (DIP) joint alone provided a more realistic assessment of the affect of this injury on DIP joint function, with good and excellent results of only 50%, 46%, 50% and 22% respectively in the four groups.

This study investigated the outcome of composite graft replacement of 50 amputated digital tips in 50 children over a period of 3 years and 6 months. Eleven of 18 tips (61%) which were replaced within 5 hours survived completely while none of 32 digital tips replaced after 5 hours survived completely. This difference was highly significant. The mean delay time between amputation and replacement in the successful group was 3.9 hours and in the others was 7.2 hours. This difference was also statistically significant. The implications of the findings of this series to the use of this treatment are discussed.

The successes of composite grafting of fingertips in the early years of plastic surgery have been repeated in the few studies of this treatment which have been reported during the last 50 years. The early and recent history of this subject are reviewed in the light of the increasingly pessimistic view of composite graft replacement of fingertips taken by recent reviewers.

A modification of the flap first described in 1935 by Tranquilli-Leali and described again by Atasoy et al (1970) is presented. The relative indications for use of the original and the modified flap are examined in the light of our experience of 116 flaps over a period of 4 years.

A series of 233 patients with complete divisions of flexor tendons in zones 1 and 2 underwent operation following emergency admission over a period of 3.5 years. These included 203 patients with 317 divided tendons in 224 fingers injuries in zones 1 and 2 and 30 patients with 30 complete divisions of the flexor pollicis longus tendon in zones 1 and 2. All of these patients were mobilized post-operatively in a controlled active motion regimen. 13 (5.8%) fingers and five (16.6%) thumbs suffered tendon rupture during the post-operative period. Patients treated during the last year of the study were followed prospectively for a minimum period of 3 months; ten of the 16 (62.5%) fingers with zone 1 repairs, 50 of the 63 (79.4%) fingers with zone 2 repairs, all three (100%) FPL divisions in zone 1 and three of four (75%) FPL divisions in zone 2 had good and excellent results on assessment by the original Strickland criteria (Strickland and Glogovac, 1980). These results confirm the safety of this regimen as an alternative to other regimens of post-operative flexor tendon repair mobilization in zone 1 and 2 finger injuries. However, in the unmodified form used in this series, this regimen has too high a rupture rate for FPL mobilization.