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Primary operative management of hand burns

Primary operative management of hand burns
Literature review current through: Sep 2023.
This topic last updated: Aug 26, 2022.

INTRODUCTION — Over 80 percent of severe burn injuries involve the hand and thus have a tremendous impact on daily function and quality of life [1]. Effective treatment of hand burns requires a multifaceted and interdisciplinary approach that includes burn surgeons, plastic surgeons, rehabilitation physicians, and physical therapists.

The initial surgical approach to the patient with a burned hand, including the primary and secondary assessment and primary operative management, are reviewed. Surgical techniques used for primary coverage of burns (eg, skin grafts, free flaps) are also used for reconstruction of burns. The principles of reconstruction and operative procedures for secondary or delayed reconstruction of burns to the hands are reviewed elsewhere. (See "Principles of burn reconstruction: Extremities and regional nodal basins", section on 'Hand'.)

EVALUATION AND INITIAL CARE — The evaluation of the patient with a hand burn begins with a thorough history and physical examination. Information about the mechanism of injury and the circumstances surrounding the injury may provide insight into the potential depth of the burn and healing capacity. The patient's hand dominance, occupation, and prior hand injuries should also be ascertained.

The focus of the physical examination is to estimate the severity and depth of injury as well as the viability of the hand and digits. Adequate hand perfusion is present if the radial and ulnar pulses are palpable; Doppler assessment should be done if pulses are not palpable. Each digit should be evaluated separately for perfusion by Doppler [2]. Patients at greatest risk for loss of perfusion are those who have full-thickness burns, circumferential burns, or associated crush injuries and lacerations.

Signs of poor perfusion include [2-6]:

Capillary refill time >2 seconds

Cold hand to touch

Absence of Doppler signal

Central core-to-extremity temperature difference greater than 7 degrees Celsius

Muscle compartment pressures of >30 mmHg

Oxygen saturation <90 percent or a 6 percent difference between a healthy site and the injured site, with caution as low readings may be due to vasoconstriction rather than compression

Dressings should be applied to fingers individually. The thickness of the dressings should not interfere with range of motion and use of the hand. Splinting is reserved for patients who have deep burns and a clawed deformity or those who have a progressively diminished range of motion. (See 'Postoperative care' below.)

Patients are encouraged to use their injured hands to minimize swelling and loss of function and to elevate the hand when not engaging in activities. All patients are started early on an aggressive range of motion physical therapy program. A passive range of motion exercise program is started for sedated or otherwise unresponsive patients.

The primary treatment goals include [7]:

Prevention of additional or deeper injuries

Rapid wound closure

Preservation of active and passive motion

Prevention of infection

Prevention of loss of function

Early functional rehabilitation

These goals are achieved by applying the following principles:

Determination of dimension and depth of the burn

Escharotomy where indicated

Application of adequate wound dressings

Decision upon nonoperative or surgical treatment

Surgical management (eg, excision, skin grafts, skin substitutes, flaps)

Early hand therapy with splinting

Functional rehabilitation and physical therapy by early active and passive motion

Secondary and tertiary corrections as required

Because of unresolved controversy regarding the optimal treatment of hand burns, the following research priorities were developed [8]:

Optimal management of the exposed tendon, nerves, bone, and joint space

Benefit of and indications for skin substitutes

Optimal surgical approach to prevent and treat web space contractures

Optimal timing and components of physical therapy (eg, exercises and modalities)

Identify risk factors that influence the outcome of skin graft coverage of partial-thickness burns

MANAGEMENT — The decision to operate on hand burns and which procedure to choose depends on the type of injury, injury severity, and availability of tissue for coverage. Given the complex nature of the hand, referral to a designated burn center should be made for surgical management. (See "Overview of the management of the severely burned patient", section on 'Triage and transfer' and "Treatment of superficial burns requiring hospital admission" and "Treatment of deep burns".)

Neurovascular compromise — Neurovascular compromise is one of the major complications of burns to the hand. It can result from formation of a circumferential eschar or from increased pressure in a muscle compartment due to large volumes of resuscitation fluid. Decompressive therapies include escharotomy, fasciotomy, and peripheral nerve release. There is insufficient evidence to support a single standard approach [2,9].

Escharotomy — Escharotomy restores perfusion to the hand by releasing the constricting eschar. In patients with signs of poor perfusion, immediate escharotomy should be performed to salvage the hand [2,10]. By the time radial and ulnar pulses disappear, tissue ischemia is well advanced [10]. For compartment pressures between 25 and 30 mmHg, either escharotomy or close and continued monitoring for signs of vascular compromise is a reasonable approach.

Expert opinion and experience guide decision making in these difficult situations. Continued monitoring, reassessment, and transfer to a burn center if possible will minimize the risk of serious complications [11].

Additional indications for escharotomies resulting from a full-thickness burn include:

Pain

Resistance to passive straightening of fingers

Hand tense to palpation

Circumferential burn [10]

An escharotomy can be performed laterally at the forearm or wrist (conventional) when proximal injury is influencing the blood supply to the hand alone, or with digital escharotomy. The incision is made with a knife or coagulation electrocautery, incising the full thickness of the eschar into the subcutaneous tissue but leaving the fascia intact. A randomized trial comparing the two approaches in 26 circumferentially burned hands found that conventional escharotomy was associated with a threefold higher risk of developing necrotic phalanges than conventional therapy plus digital escharotomy (20.8 versus 7.1 percent, respectively) [12]. Although the digital escharotomy incisions healed without complications in this study, recognized complications of this procedure include nerve damage, tendon injury, and blood loss.

It is not our practice to perform digital escharotomies, as damage to key superficial structures likely outweighs the potential benefit. If a digital escharotomy is performed, the incision should be performed on the ulnar side of the digit. An escharotomy performed on the radial side of the digit may result in damage to the vascular nerve bundle leading to impaired sensitivity and function.

After escharotomy, the hand is clinically evaluated for restoration or failure of perfusion. If perfusion is not restored, then fasciotomy is indicated [10].

Fasciotomy — A fasciotomy releases the tension or pressure in a muscle compartment by incising the fascia [11]. Expert opinion and experience guide the decision to perform the procedure. (See "Acute compartment syndrome of the extremities".)

Indications for fasciotomy in patients with hand burns include [4,10,13]:

Failure of escharotomies to restore perfusion

Compartment pressure exceeds 30 mmHg

Compartment pressure within 10 to 20 mmHg of diastolic pressure

Decrease in peripheral pulse oximetry to <90 percent

High voltage (>1000 volts) electrical injury with signs and symptoms of compartment syndrome

There continues to be controversy over the timing of surgical debridement in electrical burn wounds. We favor initial resuscitation and wound care, reserving fasciotomies and debridement for patients with clinical signs of a compartment syndrome [4,14]. When performed, fasciotomies should be optimally placed to preserve tissue that may needed for later wound coverage. (See 'Fasciotomy' below.)

Peripheral nerve release — Decompressive therapies are performed for signs and symptoms of median, ulnar, and/or radial nerve compression. Symptoms include a loss of sensation, loss of motor function, and paresthesias. Carpal tunnel release may be required if median nerve symptoms, characterized by decreased sensation and/or diminished grip or pinch, develop in a previously normally functioning hand [9]. (See "Carpal tunnel syndrome: Clinical manifestations and diagnosis" and "Surgery for carpal tunnel syndrome".)

Symptoms of ulnar nerve compression, characterized by decreased sensation in the ulnar nerve sensory distribution and diminished flexion of the wrist and digits, can be alleviated with a release of Guyon's canal. Symptoms of radial nerve compression include diminished extension and abduction of the wrist and digits, and paresthesias. Incising the deep interosseous fascia on the dorsal hand releases the entrapped nerve. Sensory symptoms may be difficult to assess in the burn victim, and the focus should be on the motor function.

Amputation — In cases of severe vascular, tendon, bone, or joint damage, it may not be possible to salvage the hand. If there is a question regarding viability, amputation may be delayed or tissue flap coverage attempted. If a flap is performed and fails, delayed amputation is an option. (See "Upper extremity amputation".)

Tissue loss — The extent of the tissue loss depends on the depth and type of the burn (see "Assessment and classification of burn injury"). Wound coverage with either skin grafts, tissue flaps, or skin substitutes is an important component of the process of regaining function of the hand. Skin grafts or tissue flap coverage are generally used in deep second-degree or full-thickness burns approximately 14 to 21 days after burn injury. In comparison, superficial burns are most likely to heal with local nonoperative wound care.

The general approach to burns capable of healing within two to three weeks, such as superficial and superficial partial-thickness burns, is to manage the burn with nonoperative local wound care including debridement and dressing changes, and aggressive range of motion exercises. A prospective study of 164 burned hands found that hands with superficial burns responded equally well to operative or nonoperative management when evaluated for preservation of hand function [15].

Excision and skin grafting — Deep partial thickness, full-thickness, or deeper burns are not likely to heal with nonoperative treatment. These burns are managed with excision of the necrotic tissue and grafting for coverage of the burn [15-19].

A retrospective review of 116 burned hands showed that early excision and grafting within the first four to six days post-burn significantly reduced the risk of functionally debilitating scars compared with delayed grafting (7.7 versus 36.8 percent, respectively) [16].

A prospective trial of patients with deep second- and third-degree burns of the hands treated by early (2 to 12 days post-burn) excision and grafting (n = 25) demonstrated no significant difference in hand function, deformities, scarring, and patient satisfaction compared with burned hands treated with initial conservative management of topical antibiotics and dressings and delayed excision and grafting (four to eight weeks post-burn, n = 25) [20].

A caveat to comparing these studies is that there is no consensus on the definition of what constitutes early versus late surgical excision and grafting of deep hand burns. In the absence of high-quality prospective data, early excision and skin grafting within the first four to six days appears to be the treatment of choice if it is clear that the burn will not heal within two to three weeks.

Burns must be reevaluated frequently as the burn process is dynamic and it is difficult to distinguish partial from full-thickness burns. (See 'Surgical procedures' below and "Hypermetabolic response to moderate-to-severe burn injury and management".)

Burns of the palms warrant special consideration. The skin of the palm is very thick, with excellent healing potential. Hence, palm burns will generally heal without grafting, and early excision should be avoided [7,21]. Aggressive physical therapy must be undertaken to prevent palmar contractures [8].

Tissue flaps — The dorsal skin of the hand is relatively thin, and, therefore, deep burns often injure or expose underlying structures such as tendons, joints, and bone. Debridement of deep burns may also result in exposure of these structures. These wounds, in the absence of periosteum or paratenon, are not amenable to coverage with skin grafts, and tissue flaps are required [22].

The forearm fascial flap, with radial artery preservation or modifications of the blood supply, provides an excellent option for vascularized coverage and is the procedure of choice [23,24]. These versatile and reliable flaps include skin, subcutaneous tissue, the underlying fascia, and septocutaneous perforating branches of the radial or ulnar artery [24]. The success rate for overall viability is excellent. Small series of case reports identify partial or superficial flap loss requiring a skin graft in approximately 15 to 20 percent [25,26]. Long-term results reveal good flap durability and elasticity [27].

With extensive burns, the forearm tissue may not be available, and distant flaps, either pedicled or free flaps, may be required for tissue coverage [22,28]. In a retrospective review of 1339 burn injuries over five years, only six patients (0.4 percent) required a distant pedicle flap for coverage of the burned hand [22]. Five of these six patients had complete healing of the wound, and one had partial loss of the flap. (See 'Surgical procedures' below.)

SURGICAL ANATOMY — The hand has 10 osteofascial compartments: four dorsal interossei, three volar interossei, the thenar muscles, the hypothenar muscles, and the adductor pollicis (figure 1) [6]. The radial and ulnar arteries and the superficial and deep palmar arches provide the blood supply to the hand. In many patients, the hand is viable with only one artery intact (figure 1). The median, radial, and ulnar nerves provide innervation to the hand. These nerves give rise to the digital nerves that run laterally in each digit along with the digital artery (figure 2). The hand also has unique properties in terms of skin structure. The dorsal hand has thin, pliable skin that allows for flexion. The palmar surface, however, is thick and tightly held to underlying structures.

OPERATIVE MANAGEMENT — With the exception of escharotomy, all of the following procedures should be performed in the operating room under a general or regional anesthetic. Emergency hand escharotomy may be performed at the bedside in the intensive care unit (ICU) with appropriate pain and anxiolytic medication.

Intraoperative monitoring is guided by the overall extent of the burn injury. While no specific monitoring is required for hand burns, patients may have extensive and severe burns that require aggressive resuscitation and management [29,30]. (See "Hypermetabolic response to moderate-to-severe burn injury and management".)

SURGICAL PROCEDURES — Decompressive therapies include an escharotomy, fasciotomy, and release of peripheral nerve entrapment. (See 'Management' above.)

Escharotomy — Escharotomy incisions are made in a longitudinal fashion with either a scalpel or electrocautery through the full thickness of the eschar (picture 1). The subcutaneous tissue should not be incised. The procedure is not painful when performed correctly. The eschar itself is insensate, so severe pain during an escharotomy should prompt immediate reevaluation of the appropriateness of the procedure or the technique.

Axial incisions are made at both the radial and the ulnar aspects of the wrist. Longitudinal escharotomies of the digits are performed on the midlateral side of the digit; however, as discussed above, their use is controversial because of potential injury to digital nerves and arteries; thus, clinical judgment is warranted (figure 3) [12]. Perfusion to the digits and hand should be reassessed immediately after escharotomy. If circulation remains compromised, additional escharotomies are performed over the intermetacarpal spaces, without exposing the tendons. (See 'Management' above.)

Fasciotomy — A fasciotomy is performed if an escharotomy fails to restore perfusion. As the constricting fascia is released, viability of muscle is assessed and debridement of necrotic tissue is performed. (See 'Management' above.)

A complete hand fasciotomy consists of four incisions (figure 4): (See "Upper extremity fasciotomy techniques", section on 'Hand fasciotomy'.)

Radial side of the thumb, which releases the thenar compartment.

Dorsal incision over the index finger metacarpal, which releases the first and second dorsal interossei, volar interossei, and adductor pollicis.

Dorsal incision over the fourth (ring) finger metacarpal, which releases the third and fourth interossei and volar interossei.

Ulnar side of the small finger, which releases the hypothenar muscles.

Excision and grafting — Because excision proceeds tangentially across blood vessels, bleeding can be significant, and a tourniquet should be used to minimize blood loss. Excision may be performed with a Goulian knife, though this is difficult in certain areas such as web spaces. A hydrosurgery system (eg, Versajet) is useful in these areas (picture 2) [31,32]. Underlying structures such as tendons, joints, or bones should not be exposed. If small areas are exposed, surrounding periosteum should be sutured in place for coverage.

Adequate hemostasis is essential to preventing hematoma formation and graft loss. Once the excision is complete, epinephrine (1:10,000)-soaked nonadhesive dressings and epinephrine-soaked laparotomy pads are applied prior to deflating the tourniquet and left in place for 10 minutes to achieve hemostasis. Tissue viability is confirmed by releasing the tourniquet to observe bleeding.

Skin grafting of the hand is performed using split-thickness skin grafts from unburned donor sites [10]. As hand function and aesthetic outcome are critical in hand burn management, sheet grafts are preferable to meshed grafts and can be harvested from the back, scalp, or thigh. Skin is harvested at a thickness of 0.012 inches for the dorsal hand and digits for adults and 0.008 inches for children. For the palm, we use full-thickness grafts (particularly in children) when a donor site is available [33], and if not, we use thick split-thickness grafts of 0.016 to 0.018 inches [21,34,35]. Management of the donor site is described separately. (See "Skin autografting", section on 'Donor site dressings and care'.)

To prevent shearing of the grafts, the hand is grafted and the position maintained in the splint (see 'Positioning' below). Grafts are affixed with absorbable suture or specialized fixation tape, using fibrin glue to minimize the number of sutures required. Following placement, the grafted hand is dressed first with a nonadherent dressing and then with a thick gauze wrap, followed by a custom fabricated splint. (See 'Postoperative care' below.)

Following excision of the burn, the wound bed is evaluated to determine if it is suitable for a skin graft. The wound bed should be assessed for thoroughness of the debridement; vascularity; and exposure of bone, joint, or tendon. A cadaver allograft can be used as temporary wound cover as a test of the viability of the wound bed. Adherence of the allograft to the wound bed within five days of coverage indicates that the wound is ready for a skin graft. If the allograft is not adherent to the base, then the wound will not heal with a skin graft.

Skin substitutes — Several skin substitutes are available to use as an adjunct. These substitutes will not create a viable wound bed and should not be used if viability is questioned. Skin substitutes are not replacements for flap coverage in instances of extensive tendon or bone exposure. Use of skin substitutes also allows for coverage by thinner skin grafts. Skin substitutes are discussed in more detail separately. (See "Skin substitutes".)

Biobrane glove — Biobrane is a bilaminate, semipermeable silicone membrane bound to a layer of nylon with porcine collagen. It is an alternative to conventional dressing changes for superficial partial-thickness burns but cannot be used to treat deeper burns [36,37]. Biobrane is available as a glove for burned hands and is applied to clean wounds that present within 24 hours of injury.

Successful use of this modality requires a clean wound bed that is obtained often with use of a regional or general anesthetic [37]. The glove is applied to the wound bed and secured with adhesive tape. For children, sheets of Biobrane can be tailored to fit smaller hands [38]. The glove can be removed once epithelialization occurs. Biobrane has been shown to reduce pain levels, healing times, and hospital stays [39].

Others — The characteristics of other skin substitutes used in our practice include the following:

Integra is a bilayer of bovine tendon collagen and glycosaminoglycan with silicon "epidermis." After burn wound excision, Integra is placed over the wound bed and allowed to incorporate for approximately two weeks. In a second procedure, the outer silicone layer is removed, and a thin (0.006") split-thickness skin graft is placed over the "neo-dermis." In one study, Integra was applied to 216 clean and surgically excised burn wounds in 13 centers in the United States [40]. Two to three weeks later, the dermal layer regenerated and was subsequently covered with a thin epidermal skin graft. The median take rate of the Integra was 95 percent, and the median take rate of the skin graft was 98 percent. The hand is mobilized in the interim between surgical procedures.

AlloDerm is lyophilized human dermis with the cellular components removed. AlloDerm is placed over excised wounds, and the wound is allowed to granulate for approximately two weeks. The AlloDerm is then removed and split-thickness skin grafts are placed. There are small case series describing the use of AlloDerm for burn wound management [41-43].

Matriderm is a three-dimensional collagen and elastin matrix derived from bovine tendon and ligament. A small case series using Matriderm as a one-stage dermal replacement in severe hand burns revealed an overall take rate of 97 percent, excellent pliability of the grafted area, and full range of motion [44].

Tissue flaps — Exposed tendon or bone is best treated by coverage with a tissue flap [7]. Skin grafts should not be used as coverage of these structures. An overview of tissue flaps for soft tissue reconstruction including nomenclature is provided separately. (See "Overview of flaps for soft tissue reconstruction".)

Flaps commonly used in patients with burns to the hand include the following:

Radial forearm fasciocutaneous flap or fascial flap – Radial forearm fasciocutaneous flaps or fascial flaps are used as coverage of exposed tendons, bones, or joints (picture 3). A Doppler ultrasound, rather than the Allen test [45], is performed to ensure adequate blood flow to the hand through the palmar arch as these flaps are based on the radial artery [45]. A skin graft is required either for the donor site if a fasciocutaneous flap is used or for the flap if fascia only is used.

Distally based posterior interosseous flap (DBPIF) – The posterior interosseous flap is a fasciocutaneous flap harvested from the dorsal aspect of the forearm [46]. The principle advantage of this flap is that neither of the major vessels perfusing the hand is disrupted. This is especially important if either the radial or the ulnar artery has already been injured. In such cases, DBPIF remains an option for skin coverage. The most common variation in the anatomy of these vessels is absence or hypoplasia; therefore, a small incision should be made to explore the vessels prior to flap elevation.

Abdominal and groin flaps (distant pedicled flaps) – A pedicled flap is tissue that is transposed to a recipient site while still attached at the base to the donor site. The pedicle serves as a conduit for blood supply. The abdomen or groin pedicled flaps are options for skin coverage when local flaps are not feasible due to the extent of injury to the extremity (picture 4) [10]. The transfer of tissue as a pedicled flap is a two-step procedure that includes creating the flap and covering the burn, then allowing time for vascularization of the wound and subsequent division from the base of the pedicled flap.

As the first stage of the procedure, the skin, subcutaneous tissue, and fascia are raised on a pedicle from the groin or abdomen and secured to the burned hand. The hand is retained in the in-situ position on the abdomen or groin for two to three weeks prior to flap division. Indocyanine-green near-infrared fluorescence angiography is used to assess flap viability, if needed [47].

At the second stage of the procedure, the flap is either divided completely from the donor site or a Crane procedure is performed in which only the fascia is transferred and the skin and subcutaneous tissue are resutured to the donor site [48]. This approach requires grafting of the fascia on the hand but provides a viable thin and supple coverage as a base for an autograft.

Free tissue transfer – Free tissue transfer, or free flaps, is the transfer of tissue from one location to another, along with its blood supply, and detached from the primary location. Free flaps provide a single-step approach to hand coverage in cases where there are no local tissue coverage options. Fascial flaps from the contralateral radial forearm fascia, temporoparietal fascia, dorsalis pedis fascia, anterolateral thigh, and muscle flaps from the serratus anterior, rectus abdominis, and gracilis are used as donor sites [28,49].

Negative pressure wound therapy — Negative pressure wound therapy (NPWT), also referred to as vacuum-assisted closure devices, are topical negative pressure systems used to promote healing in acute and chronic wounds [50-57] (see "Negative pressure wound therapy"). NPWT can also can serve as a bolster for grafts.

Data on the efficacy of this NPWT devices for the care of burns of the hand are promising but limited:

A prospective trial compared use of the NPWT with a standard bolster dressing over two weeks in 22 adult patients with skin-grafted burn wounds [54]. Compared with the standard bolster group, 75 percent of wounds treated with VAC had a greater than or equivalent degree of reepithelialization, and 85 percent had a better than or equivalent graft quality.

A prospective multicenter trial evaluated NPWT with conventional conservative management in 11 patients with bilateral hand burns [58]. The patients served as their own controls. The hand treated with the NPWT had less connective tissue edema, improved microcirculation by dynamic laser-fluorescence videography, and faster wound healing for both superficial and deep burns.

POSTOPERATIVE CARE — Following placement of the grafts, the operative site is dressed with a nonadherent dressing, thick gauze wrap, and a custom fabricated splint. Dressings are removed on postoperative day 1 for inspection of the wound for a hematoma or seroma. If present, a small incision is used to incise the graft over the fluid collection. Daily inspection continues until there are no further fluid collections. The hand remains in dressings and immobilized until day 5, at which time range of motion exercises are started [10].

Physical therapy — It is our practice to begin physical therapy within 24 hours after injury regardless of the extent of the burn. Initially, the focus is on range of motion (ROM) and reduction of edema. Pain medications are provided but should not impede efforts at physical therapy. If the patient cannot actively participate in therapy, passive ROM should be performed. Throughout hospitalization, the patient is educated and directed toward independence with physical therapy [59].

Edema management — Elevation of the hand is one primary method of edema prevention. Hand exercises can activate muscle pumping within the hand and help reduce edema. In some cases, external pressure through self-adhesive wraps or bandages may be useful [60].

Positioning — Splinting is used when ROM is limited and contracture of the hand is likely to occur. The hand should be immobilized with wrist extension, metacarpophalangeal joint (MCP) flexion, proximal interphalangeal joint (PIP) and distal interphalangeal joint (DIP) extension, and thumb palmar abduction [59]. The first web space must be maintained. In cases of palmar burns, a pan-extension splint is used. Patients are instructed to continue ROM exercises, even with a splinting program.

FOLLOW-UP CARE — Patients are not discharged until they are self-sufficient with wound care and physical therapy routines, including application of splints, if needed. Outpatient regimens may vary but remain multidisciplinary.

COMPLICATIONS — Scarring and contracture with loss of hand function remain serious problems, even with aggressive acute burn care. Split-thickness skin grafts contract from 30 to 50 percent [61]. Even with early grafting, debilitating contractures occur in 7.7 percent of burned hands [16]. In a review of 562 patients with hand burns, 15 percent required reconstructive surgery during a 10-year follow-up period [62].

Scarring — Pressure application is the mainstay of early scar management. In the early phase when shear forces from gloves cannot be tolerated on fragile skin grafts, self-adhesive bandages are used. As healing progresses, prefabricated pressure gloves are used, followed by custom-made pressure garments if needed. Inserts are used to ensure pressure is applied to appropriate areas [63]. The time for scar tissue to mature is 12 to 24 months. Therefore, surgical correction should generally be deferred until 12 months post-injury.

Contracture — Four main types of hand contracture can occur following burn injury (picture 5) [7]:

Contracture of the digits

Palmar contracture

Dorsal hand contracture

Web space contractures

Contractures affecting the deep structures are surgically released, and grafts or flaps cover the defects. Prior to considering procedures for contracture release, patient compliance with a physical therapy regimen is essential. If patients do not participate, the endeavor is doomed to failure. Secondary surgery, in the form of contracture release, is not a substitute for an aggressive physical therapy regimen [10,59].

Prior to the reconstruction operation, the functional deficit, the structure causing the problem, and available options for tissue coverage of the defect are addressed. The discussion with the patient focuses on reasonable expectations and outcome. The final portion of the operative planning includes timing of procedures. If both hands require reconstruction, it is more practical for the patient to operate on one hand at a time. In addition, if one correction will require aggressive use of the digits, it should not be performed at the same time as a procedure requiring prolonged immobilization.

Operative procedures for specific complications of burns to the hands and secondary reconstruction techniques are described in detail elsewhere (see "Principles of burn reconstruction: Extremities and regional nodal basins", section on 'Hand').

Common techniques used in the management of burn hand deformities include:

Z-Plasty – Z-plasty provides a method of scar lengthening and is particularly well suited for isolated scar bands and web space contractures where there is not a significant skin deficit. For large areas, multiple Z-plasty can be performed to lengthen the scar. (See "Z-plasty".)

V-Y plasty – This technique can be used to lengthen a scar or close a small defect. It is designed in line with the contracture in the shape of a "V." The "V" is then advanced and closed to form a "Y."

Y-V plasty – Y-V plasties also provide a method of scar lengthening and are particularly useful for long linear scars. Y-V plasties do not require wide flap undermining as in the case of Z-plasties, since the flaps are advancement flaps and not transposition flaps. This is of particular importance when the flaps include scar tissue, since undermining of the Z-limbs in these situations may result in flap tip necrosis.

Full-thickness skin grafts – In cases of skin deficiency, Z-, V-Y, and Y-V plasties insufficiently address the scar defect. Skin grafts or flaps are needed in these cases. Digit and palm flexion contracture releases should be performed sharply under tourniquet control. Templates of the resulting defects should be obtained, and full-thickness skin grafts should be used to close these defects. In the case of digit contractures, temporary fixation of the digits (three to four weeks) with Kirschner wires can be used to maintain adequate digit positioning.

OUTCOMES — Loss of a hand results in an overall 57 percent loss of independent function; hence, aggressive measures to preserve function are a key component of burn management [64,65]. A retrospective review of 1047 acutely burned hands (659 patients) described a return to normal function in 97 percent of patients with superficial burns and 81 percent with deep dermal or full-thickness burns [66]. Only 9 percent of patients with burns involving bone or joint capsules regained normal function, but 90 percent were able to perform activities of daily living independently.

The best measures to assess hand function and outcomes have not been established [67]. While it is possible to take many objective measures of hand movement, it can be difficult to correlate these with function, patient impairment, or quality of life. Future work in this area may help to improve outcome for the relatively small number of patients that have significant impairment following injury.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Care of the patient with burn injury".)

SUMMARY AND RECOMMENDATIONS

Evaluation – The mechanism of burn injury and the circumstances surrounding the injury may provide insight into the potential depth of injury. Adequate perfusion of the burned hand is determined by detecting radial and ulnar pulses by palpation or Doppler; determining capillary refill time; and monitoring oxygen saturation, compartment pressures, and temperature. (See 'Evaluation and initial care' above.)

Management – Effective treatment of hand burns requires a multifaceted and interdisciplinary approach.

Escharotomies are indicated when clinical signs indicate poor perfusion or nerve entrapment. (See 'Management' above.)

Fasciotomies are indicated when escharotomies fail to restore normal perfusion or release neural pressure. (See 'Management' above.)

Tissue flaps are used as coverage for exposed bones, joints, and tendons. Skin grafts or tissue flap coverage are generally used within 14 to 21 days following injury to reduce the risk of functionally debilitating scars. (See 'Tissue loss' above and 'Management' above.)

Physical therapy is started within 24 hours of the burn injury. Scarring and contractures are managed by physical therapy and operative correction to restore hand function. (See 'Postoperative care' above and 'Complications' above.)

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