BURNS OF THE HAND *

BY

P. H. JAYES

From the E.M.S. Plastic Surgery Centre, East Grinstead

It is incumbent upon the industrial medical officerto acquaint himself fully with the modern treatmentof burns, and to pay special attention to burns ofthe hands. Burns of the exposed areas of the body,especially the hands, frequently occur among factoryworkers and it is of paramount importance thatthese cases should receive expert treatment from theearliest stages. In many instances only a smallpercentage of the body surface is involved and thereis very little disturbance in the general condition ofthe patient. But if the hands are affected vitalissues are at stake. Errors of treatment may resultin persistent stiffness, contractures, and permanentdisablement; whereas proper care and attentioncan restore full function in the majority of caseseven when the skin of the entire hand is destroyed.

In recent years many different methods have beenadvocated for the treatment of burns and fantasticclaims have been made for a wide variety of lotionsand ointments. It must be realized that successfulresults are dependent on close observance of thefundamental principles of wound treatment ratherthan on the application of a specific chemical sub-stance. The choice of dressing for a burn variesunder different circumstances but provision mustalways be made for free surgical drainage and theearly separation of dead tissue. Furthermore, thetechnique adopted must aim at the control ofinfection combined with the preservation of functionin joints and tendons.

First- and second-degree burns heal satisfactorilywith almost any method of treatment, but third-degree cases present many difficulties and are thecrux of the whole problem. In these cases skinreplacement is perhaps the most important singlefactor in treatment. If a burn results in a lossof skin on the hand or fingers extending over anarea of more than a few square centimetres, a skingraft must be applied at the earliest opportunity toensure a full functional result. Unless the skinwhich has been destroyed is replaced by a graft,healing can take place only by epithelium graduallygrowing in from the edges of the affected area untilthe whole surface is covered. This is a slow process.and inevitably results in contractures and cripplingdeformity. Any method of treatment which is

* A paper read at a meetin of the Association of IndustrialMedical Officers, January 22nd, 1944.

advocated for third-degree burns must be regardedWith suspicion unless it encourages the removal ofsloughs and enables raw surfaces to be graftedsuccessfully at an early stage.

Industrial burns of the hand are commonlylocalized, in contra-distinction to war burns whichusually involve the entire hand. Many procedureswhich are advocated for encircling burns must bemodified when the localized type- is under considera-tion. Prognosis for function is dependent on thedistribution of the burn as well as on the extent anddepth of tissue destruction. Burns which affect thepalm and flexor surfaces of the fingers are generallymore serious than burns confined to the dorsum ofthe hand.

First-Aid TreatmentIf the burn is of sufficient severity to necessitate

hospital treatment, first-aid measures are confinedto a minimum. The affected areas are coveredwith sterile gauze dressings (or clean linen, if steriledressings are not available) and the patient trans-ported to hospital as quickly as possible. In thiscountry the patient can always be admitted tohospital within an hour or two of the accident andthere is no indication for elaborate first-aid treat-ment. Attempts at cleaning or the application ofointments under such conditions increase the risksof infection and serve no useful purpose.

Treatment on Admission to HospitalThe patient must be examined and the treatment

carried out under full aseptic conditions. Undermorphine analgesia the affected areas are thoroughlybut gently cleansed and for this purpose 1 per cent.'Cetavlon' solution (cetyl-trimethyl-ammoniumbromide) is most useful. Cetavlon is a detergentantiseptic solution which has considerable bacteri-cidal power, and it deals effectively with any patho-genic organisms which are present on the surface ofthe burn or surrounding skin. Blisters are openedand loose epithelium carefully trimmed away withscissors. The burn is covered with a single layerof tulle gras, and them gauze wrung out in normalsaline is applied and kept in place with bandages.The fingers must be dressed individually, opposingraw surfaces being kept apart by the dressings.

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BURNS OF THE HANDThis treatment should be carried out quickly withas little exposure of the burns as possible. Generalanaesthesia is usually unnecessary and should beemployed only in exceptional circumstances, forexample when required for associated injurio6.

Subsequent Treatment1. Dressings. If the general condition of the

patient is poor the initial dressing is sometimesallowed to remain in position for three to four daysbut thereafter the dressings are changed twice daily.The outer layers of gauze are removed and the handis immersed in normal saline at 1000 F. If the burn

Right Hand:I 2

from the bath and a dressing of tulle gras and gauzewrung out in saline again applied.

2. Splinting and Elevation. With burns of thehand oedema is a prominent feature in the first fewdays and it is necessary to elevate the limb untilthe oedema has subsided. The hand is placed ona splint (plaster-of-paris or malleable metal) and thesplint suspended from a Balkan beam to give therequired elevation. The hand is splinted in theposition of function, but this position will varyaccording to the distribution of the burn. Whenthe entire hand is affected the fingers are placed inhalf flexion at the metacarpophalangeal and inter-

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1 2Left Hand:

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FIG. 1.-Severe third-degree bums of both hands-palms not involved.Right hand.-I. Extensor tendons exposed and proximal interphalangeal joints open. Sloughs still present. 2. Raw

surface ready for grafting. 3. Completely healed after application of large graft. Fifth finger hyperextended-amputated later. 4. and 5. Result. Proximal interphalangeal joints ankylosed in good position. Fullmovement in metacarpophalangeal joints. Grip good. Useful hand.

Left hand.-I. Extensor tendons exposed but joints not involved. 2. Tendons covered by granulation tissue.3. Healed but scar tissue is tight and unstable-webs contracted. Movement at metacarpophalangeal jointslimited by tight scar. 4. and 5. Result. Full movement following replacement of scar by graft.

is confined to the hands, arm baths are used butwhen the burn also involves other parts of the bodya total immersion,-bath is moreeconvenient. In thebath the gauze and tulle gras float away from theraw surfaces and the patient suffers very little dis-comfort from removal of the dressing. Epithelialdebris and grease tend to collect at the margins ofthe burn and gentle swabbing is required to keepthe whole area scrupulously clean. The time ofimmersion varies with the individual case, but afterapproximately 30 minutes the hand is withdrawn

phalangeal joints, the tip of the thumb being inapposition with the index finger. When the burnis confined to the flexor surface the fingers andwrist are placed in the extended position. Greatattention must be paid to these details for if anystiffness occurs the disability will be minimal if thehand has been treated in the position of function.

3. Movement. It is advisable to keep the fingersat rest until the oedema has subsided, but through-out the remaining period of treatment muchemphasis is placed on active movement. The saline

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BRITISH JOURNAL OF INDUSTRIAL MEDICINE

bath is a great help in the preservation of functionas finger exercises can be performed with little dis-comfort while the hand is immersed in the saline.

In some third-degree burns the extensor tendonsare exposed in the fingers, and occasionally thetendons are destroyed over the proximal inter-phalangeal joints. Division of the extensor expan-sions at this point results in exposure of the jointsand ankylosis usually occurs later. In these casesit is very important to splint the fingers in theposition of function, otherwise they become fullyflexed owing to the unopposed-action of the flexorsand ankylosis takes place in the flexed position withdisastrous consequences from the functional stand-point.

Complications of this type may necessitatesplinting for an extended period but the averageburn of the hand is only immobilized for two orthree days while the oedema is subsiding; thepatient is then encouraged to move his fingers asmuch as possible. With this regime 'the frozenhand' is never seen and final healing is frequentlycoincident with a full range of movement in thefingers.

4. Preparation of Raw Surfaces for Grafting.One of the advantages of the saline method is thatsloughs separate rapidly so that most third-degreeburns are ready for grafting by the twenty-first day.Grafts cannot be applied until all dead tissue hasbeen removed and healthy granulations are present.The granulations should be flat, firm and pink in

3

colour with the epithelium growing in rapidly atthe edge of the raw area. If they are oedematous,hypertrophic and spongy it is useless to apply graftsas these will float off in the pus which exudes fromthe susface. The bacteriology of the wound isdetermined and efforts are made to control infectionbefore operation is undertaken. The organismsmost frequently present are haemolytic streptococci,staphylococci, B. pyocyaneus and B. proteus.Streptococcal infection is the most frequent causeof failure of grafts. The local application of sul-phanilamide powder to the burn is often successfulin getting rid of haemolytic streptococci, but somestrains of this organism are resistant to the drug.Sulphanilamide-resistant streptococci can usuallybe eliminated with propamidine or penicillin, butthe latter substance is not yet available for routineuse.Although in some cases it is necessary to employ

special drugs, as a general rule raw sur:aces can beprepared for grafting by the method already de-scribed without additional aids. Success is largelydependent on a careful dressing technique and theprevention of cross-infection.

5. Grafting. Skin replacement is so importantin the hand that all raw areas should be grafted assoon as possible, irrespective of their size. Splitskin grafts are placed on the raw surfaces andcovered with tulle gras, wool and gauze. Thedressings are fixed with a crepe bandage and remainin position for about five days. At the end of this

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6FIG. 2.

1. Healed burn-tight, unstable on dorsum of hand with limitation of movement. 2. Removal of scar.3. Cutting of graft with Padgett dermatome. 4. Graft sewn in position. 5. and 6. Result-full function.

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BURNS OF THE HANDtime the grafts are inspected and if they have takensuccessfully healing will be practically complete.The hand is covered for a few more days while thenew skin is consolidating, and exercises and activemovements are continued.

6. Restoration of Function. A patient with first-or second-degree burns should be able to move hisfingers through their full range as soon as the skinis completely healed. If there is residual stiffnessit is a serious reflection on the treatment of thecase. Limitation of movement at this stage isusually attributable to prolonged and unnecessaryimmobilization in the preceding period and thesurgeon rather than the patient should be blamed.With third-degree bums, although the primary

object is to obtain a completely healed hand, thetreatment continues until maximum function ispresent and the patient is fit to return to work. Insome cases an intensive course of physiotherapy isrequired before the patient regains full power inthe hand with proper co-ordination in finger move-ments. The methods used to help restore functioninclude active exercises, paraffin wax baths, andoccupational therapy of a suitable type. Passivemovement or manipulation of the fingers is neverpermitted under any circumstances.

7. late Surgical Treatment. The surgical treat-ment of bums of the hands should be considered in

two separate phases. In the early period grafts areused to cover raw areas and expedite healing, andin the late stages operation may be required torelieve contractures and improve function. Theinitial grafting is done in the third or fourth week,but no further operative treatment is usually con-templated until two or three months later. At thisstage the case is reviewed and if function is stillimpaired operation is frequently indicated. Per-sistent limitation of finger movement is often causedby tight scars and insufficient skin on the dorsum orpalm of the hand, and in these cases the patientwill be greatly improved by the insertion of a graft.The other indication for grafting is thin, unstablescar tissue at the site of the burn'which breaks downon the slightest injury, so that while a full range ofmovement may be present, incapacity is just asmarked as in the cases where there is limitation ofmovement. Replacement of such unstable scarsinvariably produces the desired result.The late operative treatment of the burned hand

sometimes includes other procedures such as cap-sulotomy, arthrodesis, and tendon repair, but spacedoes not permit discussion of these methods.

I am greatly indebted to my teacher Mr. A. H.Mclndoe for much help and encouragement in thepreparation of this paper.

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