Management of hand burn

Introduction

Frequently involved in patient sustaining burn >50% TBSA

Frequently ignored as area seems less compared to total burn area.

Management –

Assess burn depth

1^st degree – superficial

2^nd degree superficial – pink, moist, painful and blanches on pressure and blistering

2^nd degree deep – more whitish and dry appearance (waxy), does not blanches on pressure

3^rd degree – full thickness – thick leathery skin, thrombosed vein

1^st degree – heals within 2-3 days

2^nd degree superficial – heals within 7 -10 days

2^nd degree deep – heals within 14-21 days

3^rd degree burn – does not heal by its own

Wounds that are unlikely to heal within 14 days should be managed by early excision and grafting.

1^st degree and 2^nd degree superficial burn – spontaneous healing

2^nd degree deep and 3^rd degree burn – excision and grafting

Initial management –

Gentle cleaning of the wound – of foreign material and loose skin.

Blisters are deflated with sterile needle.

Burn wound depth is assessed.

Wound is dressed with moist non-adherent dressing and topical antimicrobial.

Hand is immobilized with splint with –

Wrist in – mid dorsiflexion

MCPJ in 90° flexion

IPJ in full extension

Full range of movement is done between two dressings or splint be removed and fingers moved both actively and passively.

Alternatively, hand can be covered with antibiotic cream and placed in surgical gloves to allow continuous movements of hand.

Hand is kept in elevated position.

Acute hand burn – pathophysiology

Palmer skin – is thick, glaborous and attached to bone by fibrous septa

Dorsal skin – is thin and loosely attached to underlying structure.

Post burn edema cause –

Significant swelling on dorsum, leading to unphysiological joint positions.

Significant pressure on vessels on palmer side and median nerve in carpal tunnel.

Pressure in palm can cause arterial insufficiency and swelling in dorsum can compromise venous return – this combination causes compartment syndrome of intrinsic muscle.

In the stage of edema if hand is unsupported the wrist gets flexed, MCPJ hyperextended and PIPJ flexed.

Collateral ligaments are lax when MCPJ is hyperextended and if stiffness occurs in this position, then contracted ligaments resists correction.

Boutonneire deformity –

When the PIPJ is flexed and if central slip gets attenuated or if skin over PIPJ dorsum gets thin – boutonneire deformity occurs.

Swan-neck deformity –

If intrinsic muscle suffer compartment syndrome – swan-neck deformity and 1^st web space contracture develops.

Early surgery for burn

Intermediate and full thickness burn require excision and grafting – it is done as early as possible.

Technique of “tangential excision” is useful. (Janzekovic, 1970)

Thin layers of tissue are excised sequentially until the all non-viable tissue is removed and underlying viable tissue is reached, evidenced by punctate bleeding.

This is done under tourniquet control using Humby knife.

Bleeding is confirmed after tourniquet release.

Hemostasis is achieved by cautery or wrapping the area.

The area is then skin grafted.

Palm – full thickness skin graft

Dorsum – split thickness skin graft (unmeshed)

Excision and grafting is done in PBD 4 (when patient has recovered from post burn shock)

Grafting is delayed in case of infected burn.

STSG is managed post operatively with closed dressing. (Open dressing is also efficacious in managing STSG in hand)

Hand is placed in splint.

Dressing is usually done within 48 hours – any subgraft collection is removed by rolling to the edge or by releasing the fluid using 18G needle.

Motion of hand can be started after 2-3 weeks when graft uptake is good.

Till then hand is kept in “functional position” – wrist in mid-extension, MCPJ in flexion, IPJ in extension.

Splint is continued even when movement is started and during period of inactivity and during night.

Excision of burn and flap cover –

Limited area can be covered

Definitely full thickness burn

Overlying critical areas, such as bone, joint, tendon etc.

Escharatomy in hand –

In full thickness circumferential burn or deep partial thickness burn causing circulatory compromise.

Significant increase in survival of finger have been found after escharatomy.

Escharatomy is started proximally in arm depending upon involvement.

If proximal escharatomy does not make the fingers warm then the escharatomy is continued to the hand and digits.

In the digits, escharatomy is done –

On ulnar side of index, middle, ring and little finger and

On radial side of thumb.

Escharatomy is extended proximally on dorsum of hand.

Aftercare of burned hand –

Hand physiotherapy

Daily supervised – aim to decrease edema, increase range of movement and prevent scar hypertrophy

Pressure garments –

Advocated by Park and Larson

Continuous controlled pressure of 25mm Hg above the capillary pressure

Custom made pressure garments are to be used

Pressure garments must be worn all the time except exercise

They must be worn for at least 6 months

Pressure garments are most effective in the early stage and hypertrophic scar is responsive to pressure in the first 3 – 6 month

Compliance for pressure garments is poor with active (even small) wound – so stable wound healing should be quickly achieved.

Silicon –

Perkins initiated its use

Mode of action is unclear, but it is effective in controlling HTS

Probably acts by decreasing evaporation from skin and maintaining optimum hydration

It is applied for few months

Silicon gel application allows early pain free movement of stiff joint

When applied over healed skin graft it prevents contraction of graft.

When applied over HTS, it softens it and makes them more amenable to pressure therapy

Post burn hand deformities

Hypopigmentation – treated by excision and skin grafting

Hypertrophic scar – pressure garments use. If a/w contracture, release of contracture relieves pressure in the scar and scar settle down.

Contracture –

Contracture release is done when the scar has reached equilibrium – evidenced by absence of scar tenderness and redness

This usually occurs by 3-6 months

Release and SSG of immature scar often leads to recurrence.

Matured scars are managed with incision release and grafting.

Incision release – eliminates tension in the scar and favourably influences the maturity of residual scar.

HTS – focal and linear – incisional release and SSG

HTS – large and diffuse – excision and SSG

Positions of hand

Position of comfort –

Wrist – volar flexion

MCPJ – hyperextended

IPJ – variable degree of flexion

Thumb – adducted and extended

Anticlaw or “safe” position –

Wrist – 35° extension

MCPJ – 40-70° flexion

IPJ – extension

Thumb – abducted and internally rotated (towards palm)

Contractures –

Dorsal

Volar

Websapce

Dorsal contracture –

Most common

Due to scant tissue burn is usually deep

McCauley classification of burn contracture –

Grade I – symptomatic tightness. ROM – normal. Underlying architecture – normal

Grade II – ROM – mildly decreased. Architecture – normal. ADL – normal

Grade III – functional deficit present. Architecture early changes.

Grade IV – loss of hand function. Significant distortion of normal architecture.

[Tightness-Decreased ROM-function Deficit –function Loss]

Subset of grade III & IV

1. Flexion contracture
2. Extension contracture
3. Both flexion and extension contracture

Treatment –

Grade I & II – conservative

Grade III & IV – surgical

Webspace contracture –

Depending on the contracture –

Z plasty

Double opposing Z plasty

Jumping man or five flap Z plasty

Intrinsic muscle release

Release and SSG

Joint deformities 

MCP joint –

Classification (Graham et al) –

Type 1 –

MCP flexion <30° with wrist flexion

MCP flexion >30° with wrist extension

Type 2 –

MCPJ flexion very limited with wrist flexion

MCPJ flexion <30° with wrist extension

Type 3 –

Fixed deformity

[Type I – >30 with WE; type II – <30 with WE; type III – Fixed]

Structures involved –

Type 1 – scarring limited to skin (also called dermodesis effect)

Type 2 – scarring involves – skin, dorsal capsule, dorsal apparatus, collateral ligament

Type 3 – extensive skin scarring, atrophy of intrinsic muscles, joint incongruity, dorsally subluxated or dislocated MCPJ

[SCJ – Skin – Capsule – Joint]

Surgery –

Type 1 – release and SSG

Type 2 – release of skin and deeper tissue capsulotomies with coverage with SSG or flap. Aims to achieve MCPJ flexion of 90° and maintained with K-wire or splint

Type 3 – arthrodesis of MCPJ with 10-45° of flexion

Recommended angle of arthrodesis –

Digit	MCPJ	PIPJ	DIPJ
1st	10-20	10-20	–
2nd	20-30	25-35	5-15
3rd	25-35	30-40	5-15
4th	30-40	35-45	5-15
5th	35-45	40-50	5-15

Angle of arthrodesis at different joints

[PIPJ = MCP +5]

[2^nd to 5^th   + 5][2^nd is 20]

PIP joint

PIPJ is the most frequent affected deep structure in burn hand

MC is flexion deformity

Classification (Stern et al) –

Type I – limited to skin

Type II – additional capsule contracture

Type III – joint involvement (decreased joint space, articular incongruity)

               [SCJ – Skin – Capsule – Joint]

Treatment –

Type 1 – skin release and SSG

Type 2 – additional capsulotomy and SSG or flap

Type 3 – joint arthrodesis

Boutoniere deformity

Thin overlying skin and scanty subcutaneous tissue over PIP joint – gives little protection to the structure of joint

Destruction of skin and extensor apparatus can result in Boutoneire deformity

Methods of correction of boutoneire deformity –

I – splinting

II – lateral band transposition

III – tendon graft

IV – arthrodesis

DIP joint

Rupture of weakening of the extensor tendon – results in Mallet finger.

If this a/w PIPJ hyper extension – Swan-neck deformity occurs.

Managed by wedge excision, arthrodesis or digital amputation

Amputation –

Vascular status of the digit should be assessed early in acute burn

Certain maneuvers can improve circulation in the early acute phase –

Elimination of edema

Escharatomy

Fasciotomy

Digital amputation is managed as similar to other amputations.

For reconstruction –

Thumb and index are most important

Thumb reconstruction options –

Phalangization

Pollicization

Distraction lengthening

Toe to thumb transfer

Osteoplastic thumb reconstruction

Summary –

Management of burned hand starts with acute stage of injury –

Elimination of edema

Adequate positioning

Adequate early resurfacing and

Prompt physiotherapy

These are crucial in maintaining hand function

Post burn deformities require multidisciplinary approach and treatment based on functional assessment and the formulation of realistic goals.