Burns of the Hand
- Burn Management:
- Chemical Burns:
- Electrical Burns:
- Frost Bite:
- Burn Depth:
- first degree:
- typical "sun burn" injury;
- injury is limited to the dermis, do not blister, and appear erythematous;
- these injuries will often heal within a week;
- hands are immersed in ice chilled water for at least one hour and consider indomethacin to limit inflammation and pain;
- partial thickness burns:
- full thickness burns:
- 4th degree:
- dermis + deep tissue (muscle, tendon, bone, nerve)
- treatment amputation or flap coverage and lateral reconstruction;
- consider external fixation;
- Management Objectives:
- edema prevention
- avoid prolonged immobilization and poor position;
- prevent infection
- preserve viable tissue;
- prevent contractures:
- consider insertion of K wires to keep the MP joints flexed to 70 deg and PIP joints held in mild flexion;
- Surgical correction of postburn flexion contractures of the fingers in children.
- Correction of postburn syndactyly: analysis of children with introduction of VM-plasty and postoperative pressure inserts.
- Surgical Considerations:
- initial debridement:
- compartment syndrome: (pts w/ electrical burns are at high risk);
- compartment syndromes of the hand and forearm:
- due to circumferential eschar + deep tissue;
- treatment due to fasciotomy and esharotomy
- arm and forearm medial and lateral esharotomy;
- intrinsic decompression;
- indicated for circumferential burns with objective evidence of inadequate perfusion;
- look for decreased skin temperature, increased tissue firmness, and decreased capillary refill;
- in the forearm and arm, axially oriented medial and lateral incisions are made through the eschar tissue (care taken to
avoid injuring the ulnar nerve/artery and radial artery);
- sequential check for digit perfusion are made, realizing that the escharotomy will have to progress distally (from wrist, to
hand, to digits) as necessary to restore perfusion;
- in the hand, axial incisions over the radial and ulnar aspects of the digits;
- The adequacy of limb escharotomies-fasciotomies after referral to a major burn center.
- Intramuscular pressure in the burned arm: measurement and response to escharotomy.
- Tangential excision of eschar for deep burns of the hand: Analysis of 156 patients collected over 10 years.
- wound management:
- wounds are washed once daily;
- wound dressings:
- occlusive dressing using bland petrolatum impregnated gauze under dry sterile gauze, will absorb any serous exudaate, yet
provide the patient comfort and protect the wound;
- pressure therapy:
- pressure glove useful for patients with burns and skin grafts;
- maintains edema control with the hand in more dependent positions
- custom and off-the-shelf gloves in various sizes are available;
- pressure needs to be at a level of 24 to 30 mm Hg for 6 to 12 months
- day gloves stop at middle phalanges so as to permit sensory input and allow for activities of daily living;
- (Opsite) vs. impregnated gauze (Jelonet) in the treatment of outpatient burns: a prospective, randomized study.
- The use of Biobrane for coverage of the pediatric donor site.
- Burn closure with cultured autologous keratinocytes and fibroblasts attached to a collagen-glycosaminoglycan substrate.
- topical antibiotics: (choices)
- mafenide acetate apply burn cream following early morning daily cleansing;
- silver sulfadiazine burn cream is applied for the nocturnal 12 hours;
- mafenide acetate alternate w/ silver sulfadiazine topical;
- Therapeutic efficacy of timentin and augmentin versus silvadene in burn wound infections.
- Failure of topical prostaglandin inhibitors to improve wound healing following deep partial-thickness burns.
- Silver sulphadiazine and the healing of partial thickness burns: a prospective clinical trial.
- MP and PIP joints:
- K wires may assist with functional positioning w/ open and unstable MP and IP joints injuries;
- joints require twice daily ROM and otherwise maintained in the functional position with MP joints at 70° to 90°, IP joints in
extension, thumb web space open, and wrist in slight extension;
- the exception to this may include deep palmar burns should be splinted in extension;
- burn of the central slip (boutonniere), Rx w/ PIP fusion
- PIP flexion contracture 2nd to scarred volar skin
- Rx with Z plasty or excise and apply FTSG;
- soft tissue coverage:
- deep partial and full-thickness injuries should undergo layered excision and autografting within 72 hours of injury;
- soft tissue coverage for the hand
- split thickness skin grafts
- full thickness skin grafts
- Full-thickness versus split-thickness autografts for the coverage of deep palm burns in the very young pediatric patient.
- Current Status of Skin Replacements for Coverage of Extensive Burn Wounds.
- Antimicrobial agents for skin for burns by combined assessment of cellular cytotoxicity and antimicrobial activity.
- Treatment of severe burns with widely meshed skin autograft and meshed skin allograft overlay.
- Early adipofascial flap coverage of deep electrical burn wounds of upper extremities.
- Early free-flap coverage of electrical and thermal burns.
- Dorsal Hand Wounds:
- these are complicated by the fact that the skin and subcutaneous tissue is thin which leaves the extensor tendons poorly protected;
- the depth of the injury (partial or full thickness) needs to be determined:
- partial thickness injuries are best treated by allowing spontaneous re-epithelialization;
- full thickness injuries:
- patients should expect some limitation of hand and wrist function;
- proper debridement is required to prevent tendon entrapment in scar;
- zone of injury is debrided down to the subcutaneous tissue (sensate and bleeding tissues are not debrided);
- care is taken to preserve the exetensor tendon paratenon and dorsal veins;
- wound coverage:
- wound dressings are applied until a layer of granulation tissue is present which indicates that the wound is ready to recieve
a skin graft;
- wounds are covered with unexpanded 1.5 to 1 meshed STSG;
- ideally, STSG should be greater than 0.015 inches in thickness (to minimize contracture);
- hand is splinted in the functional position;
- early passive and active motion facilitates an optimal functional outcome;
- skin contracture:
- muscle contracture (fibrosis):
- joint contracture:
- unlike tendon adhesions, joint contracture will limit passive motion;
- tendon adherence to bone:
- tendon adherence to bone is also common following fractures;
- passive motion may be present but active motion is diminished;
- FDS most often will adhere to the proximal phalanx (limiting PIP motion);
- FDP most often will adhere to the middle phalanx (limiting DIP motion);
- FDP adherence to the proximal phalanx will cause limitation of motion in both the DIP and PIP joints;
- Outside Links:
- First Aid Manual - 1
- First Aid Manual - 2
- Iowa Family Practice Handbook
- Merck Manual
Management of the Acutely Burned Hand
Year Book: Thermal-Crush Injuries of the Hands and Forearms: An Analysis of 60 Cases.
Primary surgical management of the deeply burned hand in children.
Early free-flap coverage of electrical and thermal burns.
Surgical correction of postburn flexion contractures of the fingers in children.
Results of early excision and grafting in hand burns.
A comparison of full-thickness versus split-thickness autografts for the coverage of deep palm burns in the very young pediatric patient.
Acute Hand Burns in Children: Management and Long-Term Outcome Based on a 10-Year Experience With 698 Injured Hands
Original Text by Clifford R. Wheeless, III, MD.
Last updated by Data Trace Staff on Saturday, June 25, 2016 7:40 am