Frequently involved in patient sustaining burn >50% TBSA
Frequently ignored as area seems less compared to total burn area.
Assess burn depth
1st degree – superficial
2nd degree superficial – pink, moist, painful and blanches on pressure and blistering
2nd degree deep – more whitish and dry appearance (waxy), does not blanches on pressure
3rd degree – full thickness – thick leathery skin, thrombosed vein
1st degree – heals within 2-3 days
2nd degree superficial – heals within 7 -10 days
2nd degree deep – heals within 14-21 days
3rd 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.
1st degree and 2nd degree superficial burn – spontaneous healing
2nd degree deep and 3rd 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 1st 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 –
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.
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 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)
Dorsal contracture –
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
- Flexion contracture
- Extension contracture
- Both flexion and extension contracture
Grade I & II – conservative
Grade III & IV – surgical
Webspace contracture –
Depending on the contracture –
Double opposing Z plasty
Jumping man or five flap Z plasty
Intrinsic muscle release
Release and SSG
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 –
[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]
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 –
[PIPJ = MCP +5]
[2nd to 5th + 5][2nd is 20]
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]
Type 1 – skin release and SSG
Type 2 – additional capsulotomy and SSG or flap
Type 3 – joint arthrodesis
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
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
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
Digital amputation is managed as similar to other amputations.
For reconstruction –
Thumb and index are most important
Thumb reconstruction options –
Toe to thumb transfer
Osteoplastic thumb reconstruction
Management of burned hand starts with acute stage of injury –
Elimination of edema
Adequate early resurfacing and
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.