Hand Burns 2014

892019 Hand Burns 2014

httpslidepdfcomreaderfullhand-burns-2014 113

SURGICAL TECHNIQUE

Acute Surgical Management of Hand Burns

Winston T Richards MD Edward Vergara Dawood G Dalaly DOLoretta Coady-Fariborzian MD David W Mozingo MD

A hand represents 3 of the total body surface area The hands are involved in close to 80of all burns The potential morbidity associated with hand burns can be substantial Imagine a

patient carrying a pan of 1047298aming cooking oil to the doorway or someone lighting a room-sized

pile of leaves and branches doused with gasoline It is clear how the hands are at risk in these

common scenarios Not all burn injuries will require surgical intervention Recognizing the

need for surgery is paramount to achieving good functional outcomes for the burned hand

The gray area between second- and third-degree burns tests the skill and experience of every

burnhand surgeon Skin anatomy and the size of injury dictate the surgical technique used to

close the burn wound In addition to meticulous surgical technique preoperative and post-

operative hand therapy for the burned hand is essential for a good functional outcome

Recognizing the burn depth is paramount to developing the appropriate treatment plan for any

burn injury This skill requires experience and practice In this article we present an approachto second- and third-degree hand burns (J Hand Surg Am 201439(10)2075e2085

Copyright 2014 by the American Society for Surgery of the Hand All rights reserved)

Key words Burn injury hand acute surgery

H

AND EXPOSURE TO THE ENVIRONMENT makes it

vulnerable to burn injuries that have a high

potential for morbidity In addition differ-

ences in the natural history of second- and third-degree

burns are important in their surgical management

Second-degree burns heal with minimal scarring

whereas deeper wounds develop thick restrictive scars

if not treated surgically Excision and grafting of burn

wounds also has the potential to create restrictive

scars Surgical intervention on a super 1047297cial burn may

create a poor result where observation would not This

difference in the healing process highlights the need

for accurate recognition of second- and third-degree

burns a skill that requires clinical experience1

A large burn is life-threatening and the hands as-

sume lower priority during treatment Preserving

hand function in these situations requires hand ther-

apy during the resuscitation and burn wound

debridement phases and the use of skin substitutes or

allograft to cover the wounds until donor sites have

healed Edema management through limb elevation

orthosis fabrication and dressings is an important

adjunct in this process This highlights the critical

function of the occupational t herapy service in the

management of hand burns2e4

SURGICAL ANATOMY

Skin has 2 distinct layers the epidermis and the

dermis These layers measure 005 to 15 mm for the

epidermis and 03 to 30 mm for the dermis Hair

follicles are present in varying concentrations their

base is in the deep dermis and they have an epithelial

lining Sebaceous glands and sweat glands lined with

epithelium reside in the dermal layer also Glabrous

From the Department of Acute Care Surgery Department of Surgical Critical Care and the

Department of Plastic and Reconstructive Surgery University of Florida at Shands Medical

Center and the Department of Physical and Occupational Therapy Shands Medical CenterGainesville FL

Received for publication June 13 2014 accepted in revised form July 22 2014

No bene1047297ts in any form have been received or will be received related directly or

indirectly to the subject of this article

Corresponding author Winston T Richards MD Department of Acute Care Surgery

University of Florida at Shands Medical Center 1600 SW Archer Rd Gainesville FL 32608

e-mail Winstonrichardssurgeryu1047298edu

0363-5023143910-0035$36000httpdxdoiorg101016jjhsa201407032

2014 ASSH r Published by Elsevier Inc All rights reserved r 2075

S u r g i c a l T e c h n i q u e



skin is naturally hairless and covers the palms and

soles (Fig 1)

Recognition of burn depth is exceptionally dif 1047297-

cult Unevenness in burn injuries skin pigmentation

discoloration from soot adherent clothing blisters

dressings and topical treatments all change the

appearance of burn wounds confounding the accu-

rate identi1047297cation of burn depth In addition burn

wounds tend to progress and demarcate over 24 to

48 hours adding uncertainty to the initial evaluation

FIGURE 1 A cartoon representing the structure of intact skin Notice the dermal capillary bed and nerve endings which 1047297gure promi-

nently in differentiating second- and third-degree burns Also note the epithelial lining of the hair follicles and sweat glands which allow

for rapid healing of super 1047297cial burns (Reprinted with permission from Duffy BJ McLaughlin PM Eichelberger MR Assessment triage

and early management of burns in children Clinical Pediatric Emergency Medicine 7(2)82e93 Copyright 2006 Elsevier Inc)

FIGURE 2 A super 1047297cial second-degree hand burn A The wound bed is moist and painful and blanches when compressed B The

blisters have been removed and the wound bed is bleeding after minor debridement

2076 ACUTE SURGICAL MANAGEMENT OF HAND BURNS

J Hand Surg Am r Vol 39 October 2014

S ur gi c al Tec h ni que



Accurate diagnosis involves serial examinations over

the 1047297rst 48 hours and early wound debridement

removing loose detritus material under sedation

Burn wounds involve the epidermis dermis and

even subcutaneous structures Super 1047297cial second-de-gree burns involve the epidermis and super 1047297cial

dermis They are typically blistered and moist The

nerve endings are intact making them painful to light

touch and the dermal capillary beds are present

blanching on palpation Routinely they heal in 2 to 3

weeks when epithelial cells surrounding the dermal

appendages (hair sebaceous glands and sweat

glands) proliferate and 1047297ll in the burned area

Second-degree burns involving the deep dermis

have few epithelial structures intact They take longer

than 2 to 3 weeks to heal and have an increased risk for

hypertrophic scarring Topical antimicrobial dress-

ings applied to deep second-degree burns allow us

to determine their depth and time to heal Subse-

quently they may require skin grafting Third-

degree burns involve the skinrsquos full thickness

destroying the dermal appendages and leaving no

nests of epidermal cells to proliferate Dermal ves-

sels and super 1047297cial veins may be thrombosed and

visible and the skin is leathery dry desiccated or

carbonized Tangential excision and grafting or

excision and primary closure are the treatments of

choice for these burns (Figs 2e4)

INDICATIONS AND CONTRAINDICATIONS

Burn depth size and time to heal drive the indications

for surgical intervention Super 1047297cial second-degree

FIGURE 3 Examples of deep second-degree burns A A step-off is present between the wound bed and the unburned skin B C A thick

sloughing serum and cream cover a pale wound bed with hemorrhage in the dermis

FIGURE 4 Third- and fourth-degree burns on a hand A The skin is leathery discolored and dry Escharotomies (arrow) released the

constricting circumferential burn B The repose of the resting 1047297ngers suggests burn injury with rupture of the underlying tendons

(transverse arrow 1047297ngers extended) and coagulation of the forearm muscles (oblique arrow 1047297ngers 1047298exed) in this electrical injury

ACUTE SURGICAL MANAGEMENT OF HAND BURNS 2077





burns that heal with time and topical antimicrobials

avoid a donor site and the scarring associated with

tangential excision and grafting The indications for

surgical excision are deep dermal burns that have not

healed in 2 weeks and third- or fourth-degree burnsA relative contraindication to burn wound excision

on the hand occurs in patients with a large total body

surface area (TBSA) burn Survival depends on

excising and grafting the largest burn areas 1047297rst Once

those donor sites have healed one can then harvest a

split-thickness skin graft (STSG) to cover the hands

Temporizing approaches available in this situation

include enzymatic debridement dermal substitutes

allograft and cultured cells allowing coverage of the

hand burns while treating the larger burn wound

Several articles report no difference in the outcome of

late versus early excision of hand burns provided one

continues therapy by means of judicious functional

orthosis fabrication and mainta ining range of motion

(ROM) to wrist and 1047297ngers56

Optimum timing for excision and grafting of burnwounds on the hands is a complex problem often

complicated by extensive burns Shortly after the pa-

tient is resuscitated and the wounds are well demar-

cated one may excise third- and fourth-degree

burn injuries Observation of second-degree burns

while using topical antimicrobial creams or dressings

allows time to determine the depth of injury We then

excise and graft large wounds that granulate or remain

open after 2 weeks In addition aggressive hand

therapy routines before and after surgery improve

hand function1

FIGURE 5 A Weck knife (Tele1047298ex Medical Research Triangle Park NY) used at our institution This knife has a straight razor blade

and multiple 1047297xed guards ranging from 0004 to 0012 inch in depth A Blade and knife handle separate B Blade inserted into handle

and guard in place for right-handed use

FIGURE 6 A deep-second and third-degree burn wound before A and after B surgical debridement Note the pink moist wound bed with

punctate hemorrhage Arrows show hemorrhage Electrocautery was used on the larger bleeding capillaries prior to applying an STSG

Arrows also show sites to cauterize






SURGICAL TECHNIQUE

A major advance in the treatment of burn wounds

was the introduction of tangential excision and

grafting This involves serial excision of thin layers

of burned skin exposing healthy tissue followed by

closing the wound with a skin graft

Weck knives used for excision have a 1047297xed guard

from 0004 to 0012 inch in depth Multiple passes of

the knife used in a sawing fashion at a slight angle to the

surface uncovers healthy tissue A useful excision

technique involves holding traction and countertraction

on the wound while passing the knife over the burn

FIGURE 7 A deep second-degree burn after 2 weeks under Xenograft (pigskin Brennen Medical LLC St Paul MN) The wound had

not completely healed and required excision and grafting A Before debridement B After debridement with the Versajet and hemostasis

with electrocautery We removed small nests of epithelial cells (arrow in A shows small healed area that was removed for uniform

coverage) from the center of the wound to provide a uniform wound bed for grafting (arrow in B shows uniform wound bed)

FIGURE 8 This super 1047297cial second-degree burn was debrided and then covered with Xenograft The proximal graft was secured with

staples and the distal graft on the 1047297ngers was secured with Dermabond (EthiconJohnson amp Johnson Somerville NJ) skin adhesive A

After debridement B Xenograft in place






In addition to the standard knives the Versajet

(Smith amp Nephew Wound Management Hull UK) is

a recently developed adjunct This system uses a

high-pressure jet of water to remove thin layers of

tissue with each pass Used in conjunction with sharp

debridement it smoothens out the wound surface and

is useful on complicated contours in the burn wound

(Fig 5)

A moist glistening surface identi1047297es successful

debridement A healthy dermal capillary bed reveals

punctate bleeding when unroofed As the excision

progresses in depth the space between capillaries

becomes wider When determining the adequacy of

debridement the presence of thrombosed vessels and

tissue hemorrhage suggest further excision Normal-

appearing fat has a yellow wet appearance to it and

healthy muscles once exposed will contract whenstimulated Tourniquet use during this process makes

identifying the level of debridement more dif 1047297cult but

reduces blood loss (Figs 6 7)

Tourniquet use allows more time to debride a

complex wound area on thehand and1047297ngers Elevating

the limb for 2 minutes prior to in1047298ation instead of

exsanguinating with an Esmarch bandage leaves

enough residual blood in the capillaries to evaluate the

depth of excision When using an Esmarch bandage

prior to debridement partial de1047298ation of the tourniquet

may reveal areas that need further excision Finally if the depth of excision is uncertain apply allograft to the

wound as a test If this graft becomes adherent then

there is potential for successful autograft application

otherwise repeat the debridement in several days

Grafting may be performed with xenograft (animal

skin most often pigskin) allograft (cadaver skin

obtained through a tissue bank) or autograft the

patient rsquos own skin Each of these biological coverings

has a speci1047297c place in the acute management of

hand burns In addition skin substitutes and burn

woundespeci1047297c dressings may be used

FIGURE 9 A This third-degree burn wound was excised and covered with allograft Notice the difference in pigmentation B We

covered the larger surface area on the forearm and upper arm with an STSG in a 21 mesh pattern during this operation We removed theallograft in 2 weeks when the patient rsquos donor sites had healed

FIGURE 10 A Third-degree hand burn wound B STSG sheet

graft with hash marks (arrow) A 11 mesh pattern in the STSG

and limited separation of the interstices produces the same effect






Xenograft (pigskin) (Brennen Medical LLC St

Paul MN) covers super 1047297cial second-degree burns It

seals the wound from the environment allowing it to

epithelialize Allograft cadaver skin (AlloSource

Centennial CO) is useful in the management of large

burn injuries We excise the hand burn as soon as

possible and use allograft as a temporary biological

dressing Allograft adheres to the excised wound in a

fashion similar to that of autografted skin In 3 weeks

the cadaver skin separates from the wound bed

FIGURE 11 Example of the use of a dermal substitute

A At this stage the Integra (Integra Life Sciences Plainsboro NJ) has engrafted

on the wound bed as evidenced by the red color of the material B After removing the silicone layer and light debridement of the wound

we applied an STSG

TABLE 1 Dermal Substitutes and Burn-Speci1047297c Wound Dressings With a Description of Their Components

Primary Uses and Company Information

Skin

Substitute Components Primary Use Company Information

Xenograft Porcine Skin Super 1047297cial second-degree burns

temporary covering

Brennen Medical LLC 1290 Hammond

Rd St Paul MN 55110-5959

Biobrane Nylon mesh silicone and

type 1 porcine collagen

Super 1047297cial second-degree burns

temporary covering

Smith amp Nephew Wound Management

PO Box 81 101 Hessle Rd Hull

HU3 2BN UK

Allograft Full-thickness

cadaver skin

Deep second- and third-degree burns

temporary covering

AlloSource 6278 South Troy Circle

Centennial CO 80111

AlloDerm Cadaver dermis Third-degree burns combined with

thin STSG Wound closure

LifeCell Corporation 95 Corporate Dr

Bridgewater NY 08807

Integra Silicone collagen

chondroitin-6-sulfate

Third-degree burns combined with


Two-stage procedure

Integra Life Sciences 311 Enterprise Dr

Plainsboro NJ 08536

Matriderm Collagen elastin Third-degree burns combined with


Dr Oto Suwelack Skin and Health

Care AG Josef-Suwelack-Strasse 48727

Billerbeck Germany

Oasis Porcine small intestinal

submucosa

Second degree burns as a dressing

Wound closure


3909 Hulen St Fort Worth TX 76107

Primatrix Fetal bovine dermis Second- and third-degree burns

may be combined

with STSG Wound closure

TEI Biosciences 100 Winter St Waltham

MA 02451






secondary to in1047298ammation If the allograft initially

adheres to the wound bed then the wound is well

vascularized and bacterial colonization is minimal

When appropriate donor sites become available to

harvest remove the allograft and replace it with a

skin graft (Figs 8 9)

Harvest autograft from nonburned areas for the

treatment of acute burn injuries Choose donor sites

from areas covered by clothing The thighs buttocks

and 1047298anks are good donor sites for covering the

hands 1047297ngers and wrists with sheet grafts Smooth

out bony prominences in a donor site with clysis (ie

in1047297ltration of saline or dilute epinephrine solution to

level out the donor surface to facilitate dermatome

use) Using the widest dermatome guard limits the

number of graft-to-graft seams A sheet graft or 11

meshed graft offers good cosmetic results Meshed

skin grafts are useful in extensive burn injuries where

donor sites are limited When using a meshed graft on

the hand limited stretching of the interstices willlimit the ldquowaf 1047298edrdquo appearance of the healed grafts

STSG harvested at a thickness of 0012 inch pro-

vide well-healing donor sites and a 1047298exible graft with

minimal scar contracture Increasing the thickness of

the donated skin increases the 1047298exibility of the healed

graft reduces contracture at the grafted site but in-

creases the time to donor site healing Full-thickness

skin grafts (FTSG) provide the most 1047298exible grafting

material for a full-thickness burn wound on the hand

They also require primary closure or skin graft closure

of the donor site A prospective randomized controlledtrial of STSG thicknesses of 0015 inch or 0025 inch

did not show a signi1047297cant difference in function once

the wounds healed7

(Fig 10)

Dermal substitutes are available for use in deep

burns Integra is a bilayer material of silicone and

collagenchondroitin-6-sulfate This material provi-

des a moisture- preserving covering and a neodermal

layer Small capillary vessels invade the collagen

layer engrafting the material Once the layer is

adequately vascularized at around 21 days remove

the silicone layer prepare the surface and cover it

FIGURE 12 Example of the dressing process used for hand burns after grafting A Xenograft applied to a second-degree burn wound B

Nonstick layer of wound veil applied over the grafts C Fingers wrapped individually with gauze for a secure dressing with some

1047298exibility for the patient to participate in therapy activities

FIGURE 13 Picture highlights the obvious difference between

the palmar glabrous skin and the FTSG used to revise scar

contractures on this palm






FIGURE 14 A Hypertrophic scarring on the dorsal hand involving the eponychial folds B Scarring in the 1047297rst webspace which limitsthumb function The hypertrophic scarring noted in these 2 cases represents a complication of hand burns that may occur despite

adequate debridement and skin grafting Scar excision and repeat grafting or grafting with dermal substitutes are effective treatments for

this problem

FIGURE 15 Web space syndactyly is another hand burn complication encountered when treating hand burns The 1047297rst case A rep-

resents a low-grade syndactyly B Markings for a planned Z-Plasty to release the second web space C This patient has an almost

complete syndactyly D Intraoperative picture of the dorsal skin 1047298ap resurfacing the web space E Completed closure of the repair with

FTSGs secured with absorbable sutures






with a thin STSG (0008 inch) This 2-part process

which creates a neodermal layer covered by epithe-

lium results in a thick pliable covering over the

wound with limited scarring Dermal substitutes are

useful in the management of large burn wounds

where donor sites are limited on the dorsum of the

hand for deep burns involving the subcutaneous tis-

sue and for scar revision surgery They are dif 1047297cult

to use because the wound bed must be absolutely

clean and well debrided with minimal bacterial

colonization Integra may be meshed in a 11 Bren-nen mesher (Brennen Medical LLC St Paul MN)

and secured in place with a wound VAC negative-

pressure system (Kinetic Concepts Inc San Anto-

nio TX) to control egress of 1047298uids from the wound

and enha nce the apposition of the graft to the wound

surface89

(Fig 11 Table 1)

The 1047297nal critical piece of surgical management of

a burn wound is the dressing This process secures

the grafts in position and protects them from minor

trauma Appropriate dressing techniques allow for

control of 1047298

uids leaking from the wound and decreaselocal edema Wrapping the 1047297ngers individually and

providing some 1047298exibility in the dressing will allow

the patient to begin early therapy Our current prac-

tice is to apply wound veil (DeRoyal Powell TN) a

nonstick dressing to the grafts and wrap them with

Kling (Johnson amp Johnson New Brunswick NJ)

gauze Our nursing staff applies 5 sulfamylon so-

lution to the gauze every 8 hours Once the grafts

have become adherent to the wound bed we then

switch the dressing to wound veil with bacitracin or

mupirocin (Bactroban) ointments (Fig 12)

PERIOPERATIVE MANAGEMENT

Functional recovery of the burned hand is achieved

through early and ongoing intervention both before

and after surgery Many of the anticipated issues in

the postoperative recovery process are the same as

those in the acute phase of injury pain edema skin

and joint contracture joint and sensory impairments

loss of skin integrity and impaired functional hand

use The burn therapist must have a thorough un-

derstanding of the effects of burn injury on anatom-

ical structures and the rehabilitation implications of

both pre- and postsurgical intervention Ongoing

communication and collaboration within the burn

team is essential to the successful management of the

burned hand (Appendix A available on the Journal rsquos

Web site at wwwjhandsurgorg)

PEARLS AND PITFALLS

Recognizing second-degree burns that will heal

without scarring is key to achieving good outcomes for

hand burns Waiting 2 to 3 weeks while the woundheals and the patient performs therapy helps in these

dif 1047297cult to assess injuries Adding donor site morbidity

and graft scarring to a wound that might have

healed well is a major pitfall Accurate and thorough

debridement of appropriate wounds is another im-

portant point to achieving good wound healing

Glabrous skin is the smooth hairless skin on the

palms of the hands and soles of the feet An STSG

harvested from the instep of the foot makes a suitable

graft for a small injury on the palm of the hand A

small graft from the thenar or hypothenar eminence

FIGURE 16 A Before debridement and postgrafting case pictures for the patient presented in the video B The graft is being trimmed

and secured






can cover a small area on the palmar surface of the

1047297ngers An advantage of this technique is to supply

skin with similar characteristics to the wound and

avoid pigment differences and the possibility of hair

growth on the palm (Fig 13)

COMPLICATIONS

Graft failure web space syndactyly 1047298exion or exten-

sion contractures secondary to scarring epithelial

shelves pits and sinuses all represent complications of

burn injuries to the hands In addition mallet and

boutonniere deformities may represent a complication

of the severity of the wound or aggressive debridement

of the burn wound from either damage to tendons or

stretch attenuation There are multiple approaches for

their treatment (Figs 14 15)

CASE ILLUSTRATION

A 44-year-old woman with history of right breast

cancer and lumpectomy sustained burns to her right

arm right hand and left arm after a grease 1047297re 4 days

prior to presentation She initially received silver sul-

fadiazine (Silvadene) cream and pain medicine at an

outside hospital However she returned to that hospital

with purulent drainage fevers nausea and vomiting

After antibiotic treatment she transferred to our fa-

cility for de1047297nitive management of her burns The

following videos highlight her treatment (Fig 16

Videos 1 2 [available on the Journal rsquos Web site at

wwwjhandsurgorg])

REFERENCES

1 Tredget EE Nedelec B Scott PG Ghahary A Hypertrophic scars

keloids and contractures The cellular and molecular basis for ther-

apy Surg Clin North Am 199777(3)701e730

2 Petro JA Salisbury RE Rehabilitation of the burn patient Clin Plast

Surg 198613(1)145e149

3 Sheridan RL Hurley J Smith MA et al The acutely burned hand

management and outcome based on a ten-year experience with 1047

acute hand burns J Trauma 199538(3)406e

4114 Barillo DJ Harvey KD Hobbs CL Mozingo DW Ciof 1047297 WG

Pruitt BA Prospective outcome analysis of a protocol for the surgical

and rehabilitative management of burns to the hands Plast Reconstr

Surg 1997100(6)1442e1451

5 Omar MT Hassan AA Evaluation of hand function after early

excision and skin grafting of burns versus delayed skin grafting a

randomized clinical trial Burns 201137(4)707e713

6 Mohammadi AA Bakhshaeekia AR Marzban S et al Early excision

and skin grafting versus delayed skin grafting in deep hand burns (a

randomized clinical controlled trial) Burns 201137(1)36e41

7 Mann R Gibran NS Engrav LH et al Prospective trial of thick vs

standard split-thickness skin grafts in burns of the hand J Burn Care

Rehabil 200122(6)390e392

8 Lou RB Hickerson WL The use of skin substitutes in hand burns

Hand Clin 200925(4)497e

5099 Ryssel H Germann G Kloeters O Gazyakan E Radu CA Dermal

substitution with Matriderm() in burns on the dorsum of the hand

Burns 201036(8)1248e1253

10 Moore ML William DS Richard RL Rehabilitation of the burned

hand In Klein MB ed Hand Clinics Hand Burns Vol 25 no 4

Philadelphia WB Saunders 2009529e554

11 Kowalske K Outcome assessment after hand burns In Klein MB

ed Hand Clinics Hand Burns Vol 25 no 4 Philadelphia WB

Saunders 2009557e561

12 Smith MA Munster AM Spence RJ Burns of the hand and upper

limbmdasha review Burns 199824(6)493e505

13 Nakamura DY Occupational therapy principles for the burn patient

In Sood R ed Achauer and Sood rsquos Burn Surgery Reconstruction

and Rehabilitation Philadelphia Elsevier 2006370e387

14 Macintyre L Baird M Pressure garments for use in the treatment of hypertrophic scarsmdasha review of the problems associated with their

use Burns 200632(1)10e15






APPENDIX A PERIOPERATIVE MANAGEMENT








use The burn therapist must have a thorough under-

standing of the effects of burn injury on anatomical

structures and the rehabilitation implications of both

pre- and postoperative intervention to joint tendon

and soft tissue structures10

Ongoing communication

and collaboration between the occupational therapist

and the burn team is essential to the successful

management of the burned hand

Dressings

After surgery dressings provide protection whilefacilitating edema reduction Dressings should not

hinder primary goals for proper positioning and

orthosis fabrication As the wounds heal dressings

should be decreased as much as possible to allow for

the most effective positioning and orthosis fabrication

as well as to allow for greater active and passive ROM

of the hand If possible remove dressings during

stretching exercise and ROM sessions to achieve and

record true ROM limits Removing and reapplying

dressings with rehabilitation treatment also serves to

ensure that wounds are evaluated frequently so that

any negative changes are found early on

Positioning and orthosis fabrication

Positioning and orthosis fabrication of the hand is

instr umental throughout all phases of the burn pro-

cess1112

The goal of ongoing postoperative posi-

tioning and orthosis fabrication is to protect and

optimize healing Individualized plans for positioning

and orthosis fabrication need constant management to

accomm odate for changes throughout the healing

process11 Elevating the distal extremity above the

heart coupled with extension of the elbow facilitatespromotion of increased venous return reducing

vascular pressures in the extremity and allowing for

greater freedom of ROM and protection of structures

in the acute postoperative phase Proper positioning

and orthosis fabrication also promotes elongation

forces on healing tissues to prevent contracture and

improve functional hand outcomes It is generally

accepted that for any burned body part allowing the

position of comfort allows for position of contrac-

ture10

There are many approaches to orthosis fabri-

cation of the hand by therapists but the principles for

preserving joint and tendon function along with pre-

venting scar contracture deformity are the same When

fabricating an orthosis for dorsal hand burns the

antideformity position is generally accepted The

orthosis is fabricated with the hand in the intrinsic plus

position placing the wrist in extension the meta-

carpophalaneal (MCP) joints in 1047298exion the proximal

interphalangeal (PIP) and distal interphalangeal (DIP) joints in extension and the thumb in palmar abduction

to preserve the web space With palmar hand burns

the goal is to preserve 1047297nger extension at the MCP

PIP and DIP joints along with thumb radial abduc-

tion Circumferential hand burns require managing

dorsal and volar positioning and orthosis fabrication

techniques that will allow for the best functional

outcomes10

Positioning and orthosis fabrication goals

may change as the hand undergoes the healing pro-

cess and continual management is necessary to pro-

mote the best postoperative outcomes

Active and passive ROM

Treatment plans for hand burns must incorporate

ROM techniques to promote skin elongation joint

function and muscle and tissue strengthening Active

ROM is generally preferred over passive ROM

however a combination of both active ROM active

assisted ROM and passive ROM is often needed for

achieving full potential of recovery1112

Tissue

elongation pliability and joint articulation are

necessary to prevent scar contracture and achieve

maximal hand function Because scar contraction is a constant 24-hour process exercise should be done

frequently throughout the day and multiple exercise

sessions are preferred over a singular intense session

The patient should be taught ROM and strengthening

exercises as soon as possible Patients actively

engaged in their own ROM and exercise programs

will have increased success in the overall return of

function13

Between exercise sessions positioning

and orthosis fabrication plans must continue Evalu-

ation of orthosis fabrication and positioning should

occur frequently to help maintain andor facilitateROM programs Dynamic components to orthosis

fabrication may provide low load stress and elonga-

tion of tissues over time promoting increases in hand

ROM Ultimately the therapist must progress the

patient to be an active and compliant participant in the

rehabilitation process No prescribed treatment plan

will be successful if the patient participates only when

the therapist is present13

The patient must continue to

perform stretching exercise and ROM between

therapy sessions to achieve the greatest functional

outcome

2085e1 ACUTE SURGICAL MANAGEMENT OF HAND BURNS





Several methods are used to assess hand function

and include individual joint active ROM passive

ROM total active motion total passive motion

pinch and grip strength sensation and dexterity

Whereas all of these are important to assess hand

function no single assessment can comprehensively

predict functional outcome in the long term11

At

present the correlation between these objectivemeasurements and hand function has not been

clearly de1047297ned Another measure of hand function is

more qualitative in nature but may provide a more

meaningful measure of ldquofunctionrdquo The patient rsquos

own self-report of activities of daily living inde-

pendence and ability to return to work should be

explored by the occupational therapist and be a

driving factor in setting goals in the rehabilitation

process The occupational therapist is instrumental

not only in optimizing hand function after surgery

but also in the reintegration of the patient to thecommunity and return to work Incorporating both

objective and qualitative measur es of hand function

will facilitate the best outcomes13

Compression garments

Compression is often introduced early in the acute

phase of the burn to control edema and this continues

after surgery The amount of compression will vary

depending on the skin integrity and overall ability of

the hand to tolerate pressure This early process can

also serve to normalize the concept of compression

for the patient as a vital part of the healing process10

Typically compression for the purpose of scar con-

trol starts when a majority of wounds are healed and

the skin is at a point that can tolerate the wearing of

garments Scar compression garments are typically in

the pressure range of 25 to 30 mm Hg and can beboth commercially available and custom fabricated to

therapist measurements14

The compression garment

may fail to provide even pressure owing to its

inability to completely conform to the hand Most

often these areas are in the web spaces between

digits in the palm and at the volar and dorsal wrist It

may be necessary to apply inser ts to keep pressure as

even as possible in all areas10

Manufacturers of

custom compression garments can often incorporate

foam or silicon inserts to selected areas Garments are

typically prescribed with a wear schedule of at least 23 hd1014

Garments are replaced periodically

throughout the 12- to 18-month scar maturation

phase The prescription of constant wear damages the

garment rsquos integrity and compromises the initial

pressures needed to affect scar tissue Assessing the

hand measurements regularly ensures proper garment

1047297tting with anticipated changes in edema skin

integrity ROM and development of hypertrophic

scar14

ACUTE SURGICAL MANAGEMENT OF HAND BURNS 2085e2

J H d S A V l O b




skin is naturally hairless and covers the palms and

soles (Fig 1)

Recognition of burn depth is exceptionally dif 1047297-

cult Unevenness in burn injuries skin pigmentation

discoloration from soot adherent clothing blisters

dressings and topical treatments all change the

appearance of burn wounds confounding the accu-

rate identi1047297cation of burn depth In addition burn

wounds tend to progress and demarcate over 24 to

48 hours adding uncertainty to the initial evaluation

FIGURE 1 A cartoon representing the structure of intact skin Notice the dermal capillary bed and nerve endings which 1047297gure promi-

nently in differentiating second- and third-degree burns Also note the epithelial lining of the hair follicles and sweat glands which allow

for rapid healing of super 1047297cial burns (Reprinted with permission from Duffy BJ McLaughlin PM Eichelberger MR Assessment triage

and early management of burns in children Clinical Pediatric Emergency Medicine 7(2)82e93 Copyright 2006 Elsevier Inc)

FIGURE 2 A super 1047297cial second-degree hand burn A The wound bed is moist and painful and blanches when compressed B The

blisters have been removed and the wound bed is bleeding after minor debridement











































































hand function1












SURGICAL TECHNIQUE































(Fig 5)





















































we applied an STSG



Skin



temporary covering






temporary covering



HU3 2BN UK


cadaver skin


temporary covering


Centennial CO 80111









Two-stage procedure


Plainsboro NJ 08536





Billerbeck Germany


submucosa


Wound closure




may be combined



MA 02451





































the wounds healed7

(Fig 10)






















this problem

























surface89

(Fig 11 Table 1)





control of 1047298




























PEARLS AND PITFALLS















and secured











COMPLICATIONS










CASE ILLUSTRATION












wwwjhandsurgorg])

REFERENCES





Surg 198613(1)145e149







Surg 1997100(6)1442e1451









Rehabil 200122(6)390e392


Hand Clin 200925(4)497e



Burns 201036(8)1248e1253













use Burns 200632(1)10e15























Dressings
















cess1112
















ture10

















outcomes10













Tissue










function13















outcome













At



































Manufacturers of












scar14


J H d S A V l O b









































































hand function1












SURGICAL TECHNIQUE































(Fig 5)





















































we applied an STSG



Skin



temporary covering






temporary covering



HU3 2BN UK


cadaver skin


temporary covering


Centennial CO 80111









Two-stage procedure


Plainsboro NJ 08536





Billerbeck Germany


submucosa


Wound closure




may be combined



MA 02451





































the wounds healed7

(Fig 10)






















this problem

























surface89

(Fig 11 Table 1)





control of 1047298




























PEARLS AND PITFALLS















and secured











COMPLICATIONS










CASE ILLUSTRATION












wwwjhandsurgorg])

REFERENCES





Surg 198613(1)145e149







Surg 1997100(6)1442e1451









Rehabil 200122(6)390e392


Hand Clin 200925(4)497e



Burns 201036(8)1248e1253













use Burns 200632(1)10e15























Dressings
















cess1112
















ture10

















outcomes10













Tissue










function13















outcome













At



































Manufacturers of












scar14


J H d S A V l O b

































hand function1












SURGICAL TECHNIQUE































(Fig 5)





















































we applied an STSG



Skin



temporary covering






temporary covering



HU3 2BN UK


cadaver skin


temporary covering


Centennial CO 80111









Two-stage procedure


Plainsboro NJ 08536





Billerbeck Germany


submucosa


Wound closure




may be combined



MA 02451





































the wounds healed7

(Fig 10)






















this problem

























surface89

(Fig 11 Table 1)





control of 1047298




























PEARLS AND PITFALLS















and secured











COMPLICATIONS










CASE ILLUSTRATION












wwwjhandsurgorg])

REFERENCES





Surg 198613(1)145e149







Surg 1997100(6)1442e1451









Rehabil 200122(6)390e392


Hand Clin 200925(4)497e



Burns 201036(8)1248e1253













use Burns 200632(1)10e15























Dressings
















cess1112
















ture10

















outcomes10













Tissue










function13















outcome













At



































Manufacturers of












scar14


J H d S A V l O b




SURGICAL TECHNIQUE































(Fig 5)





















































we applied an STSG



Skin



temporary covering






temporary covering



HU3 2BN UK


cadaver skin


temporary covering


Centennial CO 80111









Two-stage procedure


Plainsboro NJ 08536





Billerbeck Germany


submucosa


Wound closure




may be combined



MA 02451





































the wounds healed7

(Fig 10)






















this problem

























surface89

(Fig 11 Table 1)





control of 1047298




























PEARLS AND PITFALLS















and secured











COMPLICATIONS










CASE ILLUSTRATION












wwwjhandsurgorg])

REFERENCES





Surg 198613(1)145e149







Surg 1997100(6)1442e1451









Rehabil 200122(6)390e392


Hand Clin 200925(4)497e



Burns 201036(8)1248e1253













use Burns 200632(1)10e15























Dressings
















cess1112
















ture10

















outcomes10













Tissue










function13















outcome













At



































Manufacturers of












scar14


J H d S A V l O b











(Fig 5)





















































we applied an STSG



Skin



temporary covering






temporary covering



HU3 2BN UK


cadaver skin


temporary covering


Centennial CO 80111









Two-stage procedure


Plainsboro NJ 08536





Billerbeck Germany


submucosa


Wound closure




may be combined



MA 02451





































the wounds healed7

(Fig 10)






















this problem

























surface89

(Fig 11 Table 1)





control of 1047298




























PEARLS AND PITFALLS















and secured











COMPLICATIONS










CASE ILLUSTRATION












wwwjhandsurgorg])

REFERENCES





Surg 198613(1)145e149







Surg 1997100(6)1442e1451









Rehabil 200122(6)390e392


Hand Clin 200925(4)497e



Burns 201036(8)1248e1253













use Burns 200632(1)10e15























Dressings
















cess1112
















ture10

















outcomes10













Tissue










function13















outcome













At



































Manufacturers of












scar14


J H d S A V l O b

















we applied an STSG



Skin



temporary covering






temporary covering



HU3 2BN UK


cadaver skin


temporary covering


Centennial CO 80111









Two-stage procedure


Plainsboro NJ 08536





Billerbeck Germany


submucosa


Wound closure




may be combined



MA 02451





































the wounds healed7

(Fig 10)






















this problem

























surface89

(Fig 11 Table 1)





control of 1047298




























PEARLS AND PITFALLS















and secured











COMPLICATIONS










CASE ILLUSTRATION












wwwjhandsurgorg])

REFERENCES





Surg 198613(1)145e149







Surg 1997100(6)1442e1451









Rehabil 200122(6)390e392


Hand Clin 200925(4)497e



Burns 201036(8)1248e1253













use Burns 200632(1)10e15























Dressings
















cess1112
















ture10

















outcomes10













Tissue










function13















outcome













At



































Manufacturers of












scar14


J H d S A V l O b



































the wounds healed7

(Fig 10)






















this problem

























surface89

(Fig 11 Table 1)





control of 1047298




























PEARLS AND PITFALLS















and secured











COMPLICATIONS










CASE ILLUSTRATION












wwwjhandsurgorg])

REFERENCES





Surg 198613(1)145e149







Surg 1997100(6)1442e1451









Rehabil 200122(6)390e392


Hand Clin 200925(4)497e



Burns 201036(8)1248e1253













use Burns 200632(1)10e15























Dressings
















cess1112
















ture10

















outcomes10













Tissue










function13















outcome













At



































Manufacturers of












scar14


J H d S A V l O b






this problem

























surface89

(Fig 11 Table 1)





control of 1047298




























PEARLS AND PITFALLS















and secured











COMPLICATIONS










CASE ILLUSTRATION












wwwjhandsurgorg])

REFERENCES





Surg 198613(1)145e149







Surg 1997100(6)1442e1451









Rehabil 200122(6)390e392


Hand Clin 200925(4)497e



Burns 201036(8)1248e1253













use Burns 200632(1)10e15























Dressings
















cess1112
















ture10

















outcomes10













Tissue










function13















outcome













At



































Manufacturers of












scar14


J H d S A V l O b



















surface89

(Fig 11 Table 1)





control of 1047298




























PEARLS AND PITFALLS















and secured











COMPLICATIONS










CASE ILLUSTRATION












wwwjhandsurgorg])

REFERENCES





Surg 198613(1)145e149







Surg 1997100(6)1442e1451









Rehabil 200122(6)390e392


Hand Clin 200925(4)497e



Burns 201036(8)1248e1253













use Burns 200632(1)10e15























Dressings
















cess1112
















ture10

















outcomes10













Tissue










function13















outcome













At



































Manufacturers of












scar14


J H d S A V l O b









COMPLICATIONS










CASE ILLUSTRATION












wwwjhandsurgorg])

REFERENCES





Surg 198613(1)145e149







Surg 1997100(6)1442e1451









Rehabil 200122(6)390e392


Hand Clin 200925(4)497e



Burns 201036(8)1248e1253













use Burns 200632(1)10e15























Dressings
















cess1112
















ture10

















outcomes10













Tissue










function13















outcome













At



































Manufacturers of












scar14


J H d S A V l O b





















Dressings
















cess1112
















ture10

















outcomes10













Tissue










function13















outcome













At



































Manufacturers of












scar14


J H d S A V l O b











At



































Manufacturers of












scar14


J H d S A V l O b


Documents

Hand Burns 2014