By FENTON BRAITHWAITE~ O.B.E.~ F.R.C.S., M.Sc., and J. WATSON, F.R.C.S.E. From the Queen Victoria Hospital, East Grinstead

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SOME OBSERVATIONS ON THE TREATMENT OF THE DORSAL BURN OF THE HAND By FENTON BRAITHWAITE~ O.B.E.~ F.R.C.S., M.Sc., and J. WATSON, F.R.C.S.E. From the Queen Victoria Hospital, East Grinstead

1 SOME OBSERVATIONS ON THE TREATMENT OF THE DORSAL BURN OF THE HAND By FENTON BRAITHWAITE~ O.B.E.~ F.R.C.S., M.Sc., and J. WATSON, F.R.C.S.E. From the Queen Victoria Hospital, East Grinstead INTRODUCTION SEVERE dorsal burns of the hand may cause any or all of the following deformities : hyperextension of the metacarpophalangeal joints ; hyperflexion of the proximal interphalangeal joip.ts ; reversal of the palmar arch of metacarpals. The hyperextension deformity develops at two separate periods during the treatment of the dorsal burn of the hand. In the first instance it is postural and affords some relief from pain. It is transient and splinting will prevent it. The deformity in the second instance is not transient and splinting will not prevent it. It is bound up with the fibrosis and scarring that is so common after severe burns of the hands. The first appearance is immediately after burning and is due to the patient adopting a manual posture designed to afford maximum relief from pain. In normal hands, when the fingers are fully flexed the zone of maximum skin stretch is over and just proximal to the metacarpo-phalangeal joints. Maximum relaxation of skin is produced in this area by hyperextending the proximal phalanx. The hyperextension similarly affords maximum relief from pain if that area is involved in burns. This spastic posture may, if untreated, pass insensibly into the permanent fixed deformity. There are two different schools of thought with regard to the treatment of burned hands. The first school, following the age-old principle of rest, suggest splinting (Trueta, I946). This may prevent the spastic deformity but does not prevent the final deformity. This final deformity is bound up with granulation tissue, oedema, fibrosis, and the natural processes of healing. The second school (McIndoe, I943) advise exercise to maintain mobility. This view will be discussed later. The skin, the fascial layers, the extensor and lumbrico-interosseous muscle complex, the ligaments, and the joints all take part in the deformity. The skin, fasciae, and muscles are primary factors in this; the ligaments are probably of secondary importance. The final deformity can be analysed in terms of the changes which occur in the previously mentioned structures. The Skin.--The healing processes which occur in the skin cause contracture. This contracture pulls centrally from the periphery of the dorsum. Proximal displacement of the skin of the dorsum causes the proximal phalanx to hyperextend at the metacarpo-phalangeal joint. If this deformity is already present, then the contracture will serve either to maintain or increase it. Contracture, from side to side, of the dorsal skin at first compresses the metacarpals together. Continued contracture finally, by virtue of their anteroposterior mobility, displaces the heads of the metacarpals of the ring, little, and index fingers in a dorsal direction. This alters the normal concavity of the palm into a convexity. The palmar arch of the metacarpals is flattened or even reversed, 2I

opposition. Across the base of each interdigital space the scarred skin forms false dorsal webs which bind the fingers close together and prevent the movements of digital abduction. FIG. I FIG.

2 22 BRITISH JOURNAL OF PLASTIC SURGERY and the contracted skin acts as a taut bow-string across this reversed arch (Figs. I and 2). Contracture of the skin of the dorsum of the first interosseous space similarly pulls the metacarpal of the thumb into the plane of the hand and effectively prevents the movements of abduction and opposition. Across the base of each interdigital space the scarred skin forms false dorsal webs which bind the fingers close together and prevent the movements of digital abduction. FIG. I FIG. 2 The skin, by its generalised contraction, interferes with the vascular supply of the hand and renders ischmmic many tissues primarily unharmed by the burn. The Faseial Layers.--Between the deep fascia of the dorsum and the extensor tendons is a potential space. This is the superficial dorsal space of Kanavel. The extensor tendons are separated from this space by a fascia which encloses them. There is a similar fascia on the deep surface of the tendons. This deep layer is separated from the fascia covering the interosseous muscles by another potential space, which is filled with areolar tissue and corresponds with the deep space of Kanavel (Anson et al., I945). The two layers of fascia enclose the extensor tendons and distally are prolonged along them ; they are also attached along each side of the tendon to the periosteum of the metacarpal. Following burns, the two spaces of Kanavel and the space containing the tendons may become obliterated, first by exudate and later by adhesions. The whole tendon complex becomes anchored superficially to the deep fascia of the skin and deeply to the fascia covering the interossei. As a result the whole extensor complex becomes immobile. The fascia contracts, and in so doing plays its part in the maintenance of the hyperextension deformity. The Extensor Museles.--The digital extensor expansion is displaced proximally. This displacement is, in severe deformities, well beyond the limit of normal proximal excursion. The displacement of the extensor complex may be such that the proximal portion of the digital expansion becomes adherent to the metacarpal. In many cases the tendon and its digital expansion appear as a bowstring across the dorsum of the metacarpo-phalangeal joint. This displacement interferes greatly with the mechanics of the interosseous muscles. Normally the interosseous tendons, which are inserted into the ventral portions of the extensor expansion, pass to their insertion along a line ventral to the axis of flexion of the

THE TREATMENT OF THE DORSAL BURN OF THE HAND 2 3 metacarpo-phalangeal joint (Fig. 3). In the hyperextension deformity the line of action of the tendon passes dorsal to the axis.

There is thus no muscle, save the lumbrical, which can initiate flexion, and this muscle is far too weak to do so. Ligaments.--The Deep Ligament of the Metacarpal Heads.

3 THE TREATMENT OF THE DORSAL BURN OF THE HAND 2 3 metacarpo-phalangeal joint (Fig. 3). In the hyperextension deformity the line of action of the tendon passes dorsal to the axis. Any contraction of the interosseous will now increase the hypertension deformity rather than initiate flexion of the FIG. 3 proximal phalanx. There is thus no muscle, save the lumbrical, which can initiate flexion, and this muscle is far too weak to do so. Ligaments.--The Deep Ligament of the Metacarpal Heads.--This ligament is thickened and contracted, and by its contracture crowds the heads of the metacarpals together. The Collateral Ligaments of the Metacarpo-phalangeal Joints.--Normally these collateral ligaments are taut when the joint is flexed and slack when the joint is extended. When the joint is constantly maintained in the hyperextended position the ligaments contract and effectively prevent flexion of the joint (Bunnell, 1944 ; Penn, 1946). The Metaearpo-phalangeal Joint.--The synovium and perisynovial structures contract and maintain the hyperextended position. The joint surface may, in places, be eroded. The ventral pocket of synovium is usually obliterated and adherent to the ventral cartilage of the metacarpal head. The Proximal Interphalangeal Joint.--Loss of the insertion of the extensor tendon into the base of the middle phalanx may be a prominent factor in the production and maintenance of the hyperextension deformity of the metacarpophalangeal joint. Full flexion of the proximal interphalangeal joint follows the loss of this insertion. The delicate balance between the flexors and extensors is lost. The extensors can extend the proximal phalanx, the flexors can flex the middle phalanx, but they can no longer join in those movements which depend upon the simultaneous isotonic contraction of them both (Whillis, Channell, Braithwaite, and Moore, 1948). This co-ordination between the flexors and extensors can, in part measure, be restored by arthrodesis of the proximal interphalangeal joint. This should be arthrodesed in the functional position of semiflexion. The purchase of the flexor muscles on the metacarpo-phalangeal joint can, by this manoeuvre, be restored (Fig. 4, A and B). The hyperextension deformity can be improved in most cases and cured in some. The cure in severe cases is a lengthy process which must be tedious to the patient. The deformity should be prevented if possible. Neither splinting nor exercise will do this. It can, in a large measure, be prevented by early excision of the slough, together with underlying damaged tissue and immediate grafting.

24 BRITISH JOURNAL OF PLASTIC SURGERY Excision of the slough granulation tissue and dermal remnants cuts short the processes of infection and suppuration which are inevitable.

There is no tight constricting skin to contract and encase the hand in a rigid and unyielding grip. A FIG. 4 B The hand can breathe and nerves and arteries are not strangled.

4 24 BRITISH JOURNAL OF PLASTIC SURGERY Excision of the slough granulation tissue and dermal remnants cuts short the processes of infection and suppuration which are inevitable. Grafting prevents fibrosis due to granulation. By this means the hand rapidly regains its function, because the extensor and interosseous muscles and metacarpo-phalangeal joints regain their freedom. There is no tight constricting skin to contract and encase the hand in a rigid and unyielding grip. A FIG. 4 B The hand can breathe and nerves and arteries are not strangled. The source of oedema and fibrosis is removed, pain is prevented, and function rapidly regained. The freedom of the metacarpo-phalangeal joints is the crux of good function, and this must be maintained. Another aspect may be mentioned in this connection. After prolonged immobility of a hand the motor cortex appears to lose its conception of a patterned integrated movement, and prolonged re-education is necessary. If the period of immobility is shortened this psychological barrier is minimised. CASE REPORTS This series of patients is reported as illustrative of the procedures employed and the results obtained. Cases I to 6 sustained burns as the result of an explosion at sea. Because of delay in reaching this centre, and owing to the necessity for urgent surgical treatment of other parts (eyelids, etc.), some of the hands had passed the optimum time for excision and grafting. The dorsal slough had, in some cases, already separated, leaving an abundantly granulating bed. In these hands deformity was already becoming established, nevertheless radical excision of the granulating area and damaged underlying fascia1 planes was carried out. The times at which the hands were grafted varied between twelve days and six weeks after burning. The authors believe that the optimum time for excision and grafting is in the region of twelve to eighteen days after burning, but are carrying out further work to determine whether grafting at an earlier date will produce improved results. Case I.--This patient sustained severe third-degree dorsal burns of his left hand in September I947 as a result of an explosion in the engine-room of a ship. Treatment was undertaken at this centre six weeks later, by which time the whole of the dorsum

There was destruction of the extensor mechanism over the proximal interphalangeal joints of the fingers. The graft took satisfactorily. Fig. 7 shows the graft in situ ten days later, and Fig.

5 THE TREATMENT OF THE DORSAL BURN OF THE HAND 2 5 of the hand, fingers, and thumb were granulating freely (Figs. 5 and 6). The granulations and underlying damaged and 0edematous tissues were excised as described above, and a split skin graft applied to the whole area. There was destruction of the extensor mechanism over the proximal interphalangeal joints of the fingers. The graft took satisfactorily. Fig. 7 shows the graft in situ ten days later, and Fig. 8 the flexion gained FIG. 5 FIG. 6 FIG. 7 FIG. 8 FIG. 9 FIG. IO at the metacarpo-phalangeal joints a year later. Note the fixed flexion contractures of the proximal interphalangeal joints, with consequent reduction in long flexor purchase at the metacarpo-phalangeal joints : it is possible that an improved result could have been attained by early arthrodesis of these interphalangeal joints. This degree of limitation of flexion at the metacarpo-phalangeal joints cannot be accepted, and will necessitate tendolysis, division of collateral ligaments, and interphalangeal arthrodesis.

26 BRITISH JOURNAL OF PLASTIC SURGERY Case 2.--This patient sustained third-degree dorsal burns of the left hand in the same circumstances as Case I.

interphalangeal joints, which showed commencing flexion contractures. The granulations and dermal remnants were freely excised and a split skin graft applied.

6 26 BRITISH JOURNAL OF PLASTIC SURGERY Case 2.--This patient sustained third-degree dorsal burns of the left hand in the same circumstances as Case I. Operative treatment was carried out at this centre six weeks later, at which time the burned area was granulating freely, with destruction of extensor tendons over all the proximal finger interphalangeal joints, which showed commencing flexion contractures. The granulations and dermal remnants were freely excised and a split skin graft applied. Areas of loss occurred over the infected interphalangeal joints, otherwise the graft took well. Fig. 9 shows the graft at the time of the first dressing. Acrylic finger splints were applied to prevent the development of further flexion deformity at the interphalangeal joints, and active flexion at the metacarpo-phalangeal joints encouraged: in a month a range of flexion of 2o at the metacarpo-phalangeal joints was attained. Fig. io shows the maximum flexion attained at the metacarpo-phalangeal joints a year later. The flexion deformity shown, involving the proximal interphalangeal joints of the index, middle, and ring fingers is fixed, and has reduced long flexor purchase on the metacarpo-phalangeal joints. Arthrodesis of these joints has since been carried out, and could no doubt have been performed with advantage earlier., ~,,,~'~i~ii~i i ~i i!i i!! i!~ FIG. II FIG. I2 Case 3.--History as in previous cases. Third-degree dorsal burns of right hand and fingers. In this case the extensor mechanism of the fingers was undamaged. Excision of the slough and underlying damaged tissue was carried out a month after the accident. Fig. I x shows the condition of the hand a month after operation, and Fig. I2 the maximum flexion attained at this time. Fig. 13 shows the flexion attained one year later. Case 4.--History as in previous cases. Figs. I4 and 15 show the condition of the right hand on admission, with patchy dorsal granulations between healing areas of scarring epithelium from small grafts applied previously elsewhere. Operation was carried out five weeks after burning, with application of a split skin graft to the entire dorsum of the hand and fingers. Fig. I6 shows the satisfactory flexion attained a year later. Case 5.--History as in previous cases. Third-degree dorsal burns of right hand, index, and middle fingers, with exposure of extensor tendons to these fingers over the metacarpo-phalangeal joints (Fig. I7). Operation performed five weeks after injury. Fig. 18 shows the hand three weeks after grafting, and Fig. I9 the degree of flexion attained at the metacarpo-phalangeal joints at this time. Final photographs are, unfortunately, not available. Case 6.--History as in previous cases. Deep third-degree dorsal burns of right hand (Fig. 2o), but more superficial over the fingers. Excision and grafting carried out eight weeks after injury. Figs. 2I and 22 show the degree of flexion attained at the metacarpo-phalangeal joints two weeks after operation, and Figs. 23 and 24 the same nine months later. Case 7.--This patient sustained severe dorsal burns of the right hand, fingers, and thumb in September I948 from the power jet of a crashed aircraft. Excision of slough

14 FIG. 13 FIG. 16 FIG. 15 FIG. 18 FIG. [7 FIG. 19 FIG. 2o Case 8.--History as in Case 7.

7 THE TREATMENT OF THE DORSAL BURN OF THE HAND 27 and underlying damaged and oedernatous tissue was carried out twelve days after the accident. Figs. 25, 26, and 27 show the immediate result four weeks after grafting. FIG. 14 FIG. 13 FIG. 16 FIG. 15 FIG. 18 FIG. [7 FIG. 19 FIG. 2o Case 8.--History as in Case 7. Severe third-degree dorsal burns of both hands, fingers, and thumb. Figs. 28 and 29 show the condition on admission. Operation on

Portions of the slough had been excised from time to time during treatment in the saline bath. The FIG. 2I FIG. 22 state of the hand at the eighteenth day is shown in Fig.

8 28 BRITISH JOURNAL OF PLASTIC SURGERY the left hand was carried out at twelve days and on the right four weeks after injury. Figs. 3% A, B, and 31, A, B, show the early appearance of the hands six weeks after the accident. Case 9.--This patient sustained a dorsal burn of the right hand. Portions of the slough had been excised from time to time during treatment in the saline bath. The FIG. 2I FIG. 22 state of the hand at the eighteenth day is shown in Fig. 32. Fig. 33 shows the condition about One month after excision and grafting. Figs. 34 and 35 show the condition six months later. DISCUSSION The preceding cases show that good function can be obtained by excision of the slough, granulation tissue, and dermal remnants followed by immediate grafting. The deformity often is prevented by this early operation; the graft does not become a fibrous unyielding encasement, but a supple yielding cover under which the tendons easily glide. To ensure this result, excision of the slough itself is not sufficient. All the tissues of the dorsum, down to and including the deep fascia, must be excised. The bed of the graft should be the fascia which forms the floor of the superficial dorsal space of Kanavel (Fig. 36). If this fascia is burned it should be excised, and good function is still obtained. Tendons, even if damaged, should not be excised. A graft placed over the damaged tendon can be replaced if it fails. Often tendons which appear of doubtful viability when the slough is being excised survive after grafting. If the damage to the tendon is localised, full movement is often regained. The method of splinting adopted by Trueta forces the hand into immobility. If splinting is maintained, the small muscles lose their power and the hand becomes immobile. Trueta (I946) states that after being immobilised in the functional position for three weeks the fingers regain their full mobility within a few minutes. The authors have not found this so. Furthermore, the contractive element has not ceased in three weeks, and the hand may subsequently become hyperextended. Trueta also states that the hand should preferably not be immobilised for longer than four weeks, and that apart from severe burns of the hand there are few cases in which the burned area has not healed in a month. Healing is not the sole feature in the prevention of this deformity. Removal of the slough, with its attendant ills, is the real crux. McIndoe (I94O) advocated exercises as a method of diminishing oedema. In this method the hands are always elevated during the period of exercise except during treatment in the saline bath. Trueta (I946) says that he

9 THE TREATMENT OF THE DORSAL BURN OF THE HAND 29 FIG. 2 3 FIG. 2 4 FIG. 2 5 FIG. 26 FIG. 27 FIG. 28 FIG. 2 9

10 30 BRITISH JOURNAL OF A PLASTIC SURGERY B FIG. 30 A B FIG. 31 FIG. 32 FIG. 33 FIG. 34 FIG. 35

THE TREATMENT OF THE DORSAL BURN OF THE HAND 3I believes immediate exercise of the fingers to be a great mistake, and even the actual cause of many deformed hands.

Whilst agreeing that exercise does not prevent the deformity, they deny that it may be the actual cause, and reiterate that the real crux is the infected slough and the oedema and granulation tissue

11 THE TREATMENT OF THE DORSAL BURN OF THE HAND 3I believes immediate exercise of the fingers to be a great mistake, and even the actual cause of many deformed hands. The authors do not believe this to be so. Whilst agreeing that exercise does not prevent the deformity, they deny that it may be the actual cause, and reiterate that the real crux is the infected slough and the oedema and granulation tissue provoked by it. Early excision of the slough and dermal remnants obviates the necessity for splinting unless the proximal interphalangeal joints are involved. If the proximal interphalangeal joints are involved they should be splinted. These splints must not interfere with the movements of the metacarpo-phalangeal joints. They should be applied to the volar surface of the finger and should hold the joint in the functional position These splints must be worn continuously until arthrodesis can be performed. Arthrodesis of the joints should be performed as early as possible. It can usually be done within two to three months after the burn. Early Fro. 36 grafting allows early exercise. The two opposing schools of thought can thus be reconciled. Early exercise is important. It ensures that the pattern of normal movement is not forgotten. SUMMARY OF CONCLUSIONS I. The cause of the deformity in dorsal burns of the hand is the infection, suppuration, oedema, and fibrosis due to persistence of the slough. 2. The granulation tissue, which is inevitable in natural separation of the slough, forms the focus of fibrosis and oedema. 3. Even early skin grafting upon this base of granulation tissue is insufficient to prevent deformity. 4. The whole thickness of damaged skin, down to and including the deep fascia, must be excised. 5. The best base for the graft is the fascia enclosing the tendons. 6. Tendon damage is minimised by excision of the infected slough. 7. By the above method function is never completely lost and the process of restitution is not unnecessarily prolonged. The authors wish to thank Sir ArchibaM Mclndoe and their surgical colleagues at East Grinstead for helpful criticisms, and Mr Gordon Clemetson for his photographs. BIBLIOGRAPHY ANSON, B. J., ~TRIGHT, R. R., ASHLEY~ F. L., and DYKES, J. (I945). Surg. Gynec. Obstet., 8:, 327. MCIIqDOE, Sir A. H. (I944). Medical Press and Circular, ccxi, TgUETA (I946). " The Principles and Practice of War Surgery." WHILLIS, J., CHANNELL, G., BRAITHWAITE, F., and MOORE, F. T. (I949)- Guy's Hosp. Rep. Mag.

Physical therapy of the wrist and hand

Physical therapy of the wrist and hand Functional anatomy wrist and hand The wrist includes distal radius, scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate, and hamate. The hand includes