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Burns of the Hand

- See:
      - 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;
        - references:
                - 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;
         - escharotomy:
              - indicated for circumferential burns with objective evidence of inadequate perfusion;
                    - look for decreased skin temperature, increased tissue firmness, and decreased capillary refill;
              - technique:
                    - 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;
              - references:
                    - 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;
         - references:
                      - (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;
              - references:
                      - 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
              - references:
                      - 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;
          - debridement:
                  - 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;

- Complications:
    - Contracture:
          - 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.

Burn sydactyly.

Acute Hand Burns in Children: Management and Long-Term Outcome Based on a 10-Year Experience With 698 Injured Hands