Initial assessment. ATLS/ABLS protocol and assess for other injuries/fractures based on mechanism. Inhalational injury. Vascular compromise:
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1 Complex Hand Burns Brent Egeland, MD Assistant Professor Dell Medical School Department of Surgery and Perioperative Care Institute of Reconstructive Plastic Surgery Plastic, Hand, and Reconstructive Microsurgery
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3 Annual Burn Burden Receiving Medical Treatment: 450,000 Hospitalizations: 45,000 Deaths: 3,500 Survival Rate: 94.8% Gender: 70% male, 30% female Cause: 42% fire/flame, 31% scald, 9%
4 ATLS/ABLS protocol and assess for other injuries/fractures based on mechanism Initial assessment Inhalational injury Vascular compromise: Compartment syndrome Circumferential burns
5 Partial thickness burns of >10% TBSA in children <10 years old or adults > 50 Partial thickness burns >20% Hands, face, feet, perineum, genitalia, joints Full thickness burns Electrical or chemical burns Inhalational injury Burns in patients with multiple comorbidities or with extensive rehabilitation needs Transfer Criteria
6 Multidisciplinary Approach Nursing Wound Care Teams Case Worker Dietician ICU staff OT Pharmacist Psychiatrist Physical Therapist RTs Social Worker Surgeon
7 Hand Burns Hand burns: 50-70% of all burns Most commonly in laborers and children Frequently not life-threatening, but have a critical effect on long term HRQOL
8 159 patients with hand burns 75% returned to work 30% required job modification % TBSA is the largest predictor of the ability to return to work Bilateral hand and trunk burns Other: length of hospital stay, age, employment prior to injury, primary wage earners
9 32 patients with dorsal hand burns involving extensor mechanism >50% required amputation; 22% boutonniere deformities 40% TAM <180 degrees JTT scores lower MHQ: ADL scores lower
10 181 children with hand burns Longer hospitalizations, ICU stays, TBSA burns 70% recover ADLs 20% full normal function
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14 Hand Burn: Management ATLS/ABLS ABCs Limit zone of stasis demarcation: preserve viable tissue Resuscitation Escharotomies, Fasciotomies Local wound care: Prevent Infection ROM and splinting: Avoid Resting Posture Excision of burn injury and coverage Rehabilitation Late burn care Contracture / Scar Management resection of HO
15 Hand Burns: Dorsal Dorsal skin: thin, mobile, minimal subcutaneous tissue Unprotected Vital structures in close proximity Extensor tendon Joint capsule
16 Hand Burns: Volar Thick, glabrous palmar skin Privileged Protected Often seen in children as contact burns Conservative management with early motion and splinting to prevent contracture
17 Partial thickness Superficial vs. Deep Epidermis + varying levels of dermis Superficial: re-epithelialize in days: Blistering, painful Minimal scarring because inflammatory phase is cut short by re-epithelialization Minimal loss of function with early therapy and edema control
18 Superficial Partial Thickness
19 Superficial Partial Thickness
20 Superficial Partial Thickness
21 Deep Partial Thickness Greater depth of dermal injury Most epithelial elements are destroyed Destruction of nerve endings: insensate Poor re-epithelialization Scarring likely protracted inflammatory phase excess collagen deposition Usually require surgical intervention 21 Day Rule OT is mandatory
22 Full thickness Depth includes epidermis, dermis, subcutaneous tissue Will not heal spontaneously and scar extensively Require surgical intervention
23 4 th degree Extension of injury into muscle, tendon, bone Usually require debridement, excision, amputation with reconstruction
24 Assessment: Perfusion Escharotomy / Fasciotomy Decrease/absence of Doppler signals Loss of pulse is late Subjective neurosensory disturbance Intrinsic minus position of the hand Temperature change at fingertips or decrease in pulse oximetry Pain with passive stretch Interstitial Pressure >30mmHg
25 Escharotomy Improve perfusion by releasing edema pressure under eschar Bedside Bovie or scalpel Endpoint usually obvious
26 Digital Escharotomy? Possibility of injury to the neurovascular bundles Minimal muscle to create rhabdomyolysis Significant burns likely involve deeper structures
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28 Management: Wound Care Option Application Advantage Disadvantages Silver sulfadiazine 1% QD - BID Painless, gram negative coverage Poor eschar penetration; leukopenia 5-15% Acticoat: silver rayon mesh 3-7 days Few dressing changes, antimicrobial none Aquacel: silver impregnated hydrofiber 1-14 days Painless, excellent antimicrobial coverage Mafenide solution/cream BID Eschar penetration; GP coverage Painful; no coverage against fungus, metabolic acidosis Bacitracin QD - QID Painless, inexpensive, superficial burns Xeroform: 3% bismuth tribromophenate none QD Some bacteriostatic activity dessication Resistance and dermatitis with prolonged use Adaptic: petroleum impregnated dressing Dakins: sodium hypochlorite/oxychlorserin e QD Painless, good moisture No antimicrobial effect QD - QID Excellent antimicrobial coverage painful Collagenase QD Penetrates collagen and eschar Skin irritation
29 Management: Splinting
30 Intrinsic Plus Splint
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32 Surgical Management
33 Excision and grafting Split thickness 0.012in sheet graft Optimal durability Function: Reduced Secondary healing Optimal aesthetics Dorsal: Palmar: Full thickness glabrous if available
34 Split Thickness Graft
35 Full Thickness Skin Graft
36 Local Rotation Flap
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39 Local Pedicled Flap: rrf
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44 Distant Pedicled Flap: Louver Flaps Courtesy Dr Thomas Woloszyn
45 Courtesy Dr Thomas Woloszyn
46 Courtesy Dr Thomas Woloszyn
47 Courtesy Dr Thomas Woloszyn
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49 Amputation
50 Late Effects of Burn Injury Scar contractures Hypertrophic scarring Heterotopic ossification Marjolin s ulcer
51 Hypertrophic scarring Painful, pruritic, exacerbate contractures Can occur in wounds that take longer than 2-3 weeks to heal, or grafted wounds Pressure garments, silicone, steroid injection, surgical revision
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55 Web Space Contracture
56 Z-Plasty
57 Double Z-plasty
58 Multiple Z-plasties
59 Local Pedicled Flap: rpia
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61 Distant Pedicled Flap: Groin Flap
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63 Free Flap
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65 Free ALT
66 Free Flap: Toe Transfer
67 Heterotopic ossification Transformation of primitive mesenchymal tissue to mature lamellar bone Decreased ROM 6-8 weeks 1-3% of all burns Greater incidence with >TBSA injury or Head Injury Elbow most common site, hip, shoulder Bilateral, posteromedial
68 Heterotopic ossification Serum alk phos, calcium, phosphorus, bone scan Surgical intervention if decreased ROM compromising ADLs despite therapy Wait at least 6 months from time of injury Resection, XRT, NSAIDS
69 Summary: Hand burn management Prevent stiffness and contracture with early motion / splinting Prevent dessication and optimize resuscitation to prevent extension of the burn at zone of stasis Low threshold for fasciotomy and escharotomies Early excision of deep and full thickness injuries to minimize edema and inflammatory response Full thickness grafts for palmar/volar coverage Fasciocutaneous flaps for tendon exposure to optimize gliding Observe for late complications Secondary reconstruction often required
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