- See:
-
Burn Management:
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Chemical Burns:
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Electrical Burns:
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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:
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Surgical correction of postburn flexion contractures of the fingers in children.
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Correction of postburn syndactyly: an analysis of children with introduction of the VM-plasty and postoperative pressure inserts.
- Surgical Considerations:
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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:
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The adequacy of limb escharotomies-fasciotomies after referral to a major burn center.
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Intramuscular pressure in the burned arm: measurement and response to escharotomy.
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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;
- references:
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Polyurethane film (Opsite) vs. impregnated gauze (Jelonet) in the treatment of outpatient burns: a prospective, randomized study.
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The use of Biobrane for coverage of the pediatric donor site.
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Burn wound closure with cultured autologous keratinocytes and fibroblasts attached to a collagen-glycosaminoglycan substrate.
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topical antibiotics: (choices)
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mafenide acetate apply burn cream following early morning daily cleansing;
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silver sulfadiazine burn cream is applied for the nocturnal 12 hours;
-
mafenide acetate alternate w/
silver sulfadiazine topical;
- references:
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Therapeutic efficacy of timentin and augmentin versus silvadene in burn wound infections.
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Failure of topical prostaglandin inhibitors to improve wound healing following deep partial-thickness burns.
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Failure of topical prostaglandin inhibitors to improve wound healing following deep partial-thickness burns.
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Comparison of silver sulphadiazine 1 per cent, silver sulphadiazine 1 per cent plus chlorhexidine digluconate 0.2 per cent and mafenide acetate 8.5 per cent for topical antibacterial effect in infected full skin thickness rat burn wounds.
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Silver sulphadiazine and the healing of partial thickness burns: a prospective clinical trial.
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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:
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A comparison of full-thickness versus split-thickness autografts for the coverage of deep palm burns in the very young pediatric patient.
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Proceedings of the NIH Conference: Advances in Understanding Trauma and Burn Injury: Session IV: Wound Healing: Current Status of Skin Replacements for Coverage of Extensive Burn Wounds.
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Selection of topical antimicrobial agents for cultured skin for burns by combined assessment of cellular cytotoxicity and antimicrobial activity.
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Treatment of severe burns with widely meshed skin autograft and meshed skin allograft overlay.
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Early adipofascial flap coverage of deep electrical burn wounds of upper extremities.
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Early free-flap coverage of electrical and thermal burns.
- Dorsal Hand Wounds:
- these burns 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
Year Book: Thermal-Crush Injuries of the Hands and Forearms: An Analysis of 60 Cases.
Wang-Xue-Wei. et al.
1986 Year Book of Rehabilitation. Article 2-34. Original Article: Burns. 1985 Apr. 11. pp 264-268.
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.
SP Pegg et al.
Burns. Vol 11. p 99-103. 1984.
Tangential excision of eschar for deep burns of the hand: Analysis of 156 patients collected over 10 years.
Wand XW.
Burns. Vol 11. p 92-98. 1984;
A comparison of full-thickness versus split-thickness autografts for the coverage of deep palm burns in the very young pediatric patient.
Burn sydactyly.
EZ Browne et al.
Plastic. Reconstructive Surg.
Vol 62. 1978. p 92.
Acute Hand Burns in Children: Management and Long-Term Outcome Based on a 10-Year Experience With 698 Injured Hands
Robert L. Sheridan MD. Annals of Surgery. Volume 229 Number 4 April 1999
