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Biosynthetic compound dressings—management of hand burns
Burns (1988) 14, (5). 405408
Biosynthetic management
compound dressingsof hand burns
D. J. Smith, T. P. McHugh, Division of Plastic Medicine, Detroit,
405
Prinred in Great Britain
Linda G. Phillips, M. C. Robson and J. P. Heggers
and Reconstructive Michigan, USA
Surgery,
Summary
To achieve optimal hand function, wound closure becomes the most important ingredient in hand burns. This study documents the use of a biosynthetic compound dressing (Biobrane) which has been fabricated as a glove for management of hand burns. The glove allowed rapid active motion and minimized the pain of open wounds. Forty-two Biobrane glove applications were evaluated with 50 per cent applied over superficial hand burns and 50 per cent over deep partial thickness or full thickness injuries. In the superficial hand burns, the patients were discharged home after a mean time of2.8 days. With the deep burns the dressing provided a closed wound after early excision of eschar without the use of an autograft or biological dressing. Based on these studies, WC conclude that the biosynthetic compound dressing glove is a useful adjunct to be added to the armamentarium for treatment of the burned hand.
INTRODUCTION BURNS of the hands are special. Although they comprise less than 4 per cent of the total body surface area, they are classified as major burns by the American Burn Association (American Burn Association, 1984). The goal of management of the burned hand is to obtain optimal function by preventing infection, closing the wound, and preserving or regaining motion. This optimal function will simultaneously incorporate both fine pinch and power grip. Six principles have been reformulated for the care of the burned hand to achieve optimal functional return (Robson and Smith, in the press). These include: (I) to do no harm, (2) to maintain vascularity, (3) to prevent infection, (4) to obtain wound closure, (5) to preserve and regain motion, (6) to obtain optimal functional rehabilitation. To achieve optimal hand function following these six f(~”1988 Butterworth & Co (Publishers) 03054179/88/050405-04 $03.00
Ltd
Wayne State University
School
of
principles, wound closure becomes the most important ingredient in hand burns. This wound closure can be accomplished in five ways: (I) spontaneous healing within 14 days of superficial wounds; (2) early excision and grafting of deep wounds; (3) delayed excision and grafting of spontaneously healing wounds; (4) spontaneous healing in burns requiring more than 14 days; (5) late grafting of the delayed spontaneously healing wound (Krizek et al., 1973). In modern burn care, only the first three are routinely considered practical managements and with the increasing emphasis on earlier hospital discharge, really only the first two are practical ways of managing the burned hand. This work documents the use of a new biosynthetic compound dressing (Biobrane) which has been fabricated as a glove for management of hand burns. It will allow either uninterrupted epithelialization of superficial wounds or provide temporary wound closure of deep wounds following surgical or enzymic debridement. MATERIALS AND METHODS Two hundred and eighteen applications of Biobrane were studied, of which 42 (19.25 per cent) examined the utilization of the Biobrane glove (Fig. 1). In 50 per cent of these cases, the Biobrane gloves were used bilaterally. When the glove was used on patients with superficial hand burns, the patients were placed in the Hubbard tank, and the burn wound was cleansed and debrided of obviously devitalized epithelium. The burned hand was then covered with the Biobrane glove which in turn was covered with an elastic gauze to maintain the glove against the
406
Fig. 1. Biobrane
has been fabricated into various sized gloves for easier application in the management of hand burns.
wound. The Biobrane glove was inspected for adherence and fluid collection below the dressing 24 h after placement and then daily. Patients were not returned to the Hubbard tank once adherence of the Biobrane was achieved. The dressing was left on the hand burn until epithelialization was achieved, then removed. If the patient was not in need of hospitalization, the individual was discharged with the Biobrane glove in place and followed in the burn outpatient clinic. While the patient was in the hospital, daily total active motion (TAM) measurements were recorded. Similarly, these objective measurements were made on each outpatient visit. Time of healing and pain relief were also recorded. If the hand burns were initially considered to be deep partial thickness or full thickness, Biobrane gloves were not initially applied, and the patient was treated with topical antibacterial agents and scheduled for early excision. The Biobrane glove was applied after excision if adequate donor sites were not available for autografting or if the surgeon felt the excision revealed a sufficient dermal base to allow healing of the tangentially excised wound. Patients in this deep wound category also underwent daily objective motion measurements, and the time of removal of the glove was recorded. If, during the time the Biobrane glove was in place, subdressing fluid collected beneath the glove, it was aseptically aspirated, stained, and cultured.
Burns (1988) Vol. 14/No. 5
Fig. 2. Four days postexcision, oedema
the hand shows decreased with almost full active motion.
less extensive total body surface injuries; 14 adhered well, with the patients discharged home in a mean time of 2.8 days; and three gloves were removed due to aseptic subdressing fluid collections or non-adherence. Four (9.5 per cent) of the gloves placed on patients with superficial hand bums had extensive total body surface injuries and those patients had re-epithelialization of their hands in a mean time of 9.6 days while in the burn centre. None of these inpatients required removal of all or part of the gloves. In these superficial hand burns, the Biobrane glove provided immediate pain relief, decreased oedema, and allowed more complete motion (Table I). Twenty-one (50 per cent) applications were placed on deep partial thickness or full thickness wounds. The biosynthetic compound dressing glove provided a closed wound without the use of autograft or a biological dressing. In these patients, oedema was decreased and motion was increased (Fig. 2). Desiccation appeared to be prevented, and epithelialization proceeded rapidly. However, in seven (16.6 per cent) of the applications used on deeper burns, the gloves were removed and replaced by autograft. In these wounds, the excised Tab/e 1. Bilateral superficial hand burns treated with Biobrane gloves Left
Right IF
MF
RF
LF
IF
MF
RF
LF
Day 4 265” 270” 270” 270” 145” 265” 270” 265
RESULTS
Twenty-one (50 per cent) of the Biobrane glove applications were placed on superficial hand burns. Seventeen (40.4 per cent) were on patients that had
Day 1 l-Totally
healed
IF. index finger; MF, middle finger; RF, ring finger; LF, little finger. “=degrees of total active mot w.
407
Smith et al.: Biosynthetic compound dressings
Table II. Cost of therapy per hand for 10 days (US $) Topical antibacterial cream AgSD Burn dressing NaCl Flexnet
Biobrane
$37.50 10.00 8.00 20.00 $55.00 - $95.00
$75.50 Nursing care lOminx3x10=5 5 h x $12.00 TOTAL
glove
Nursing care 2Ominx1=2Omin $60.00
20 min x $12.00
$135.50
area was maintained in bacterial balance, and motion was allowed until donor sites were available for autograft closure. Five (12 per cent) applications of the gloves had all or a portion of the glove removed due to subdressing collection (i.e. haematoma, seroma, aseptic purulent drainage). None of the fluid collections grew bacteria. In evaluating costs of nursing and other medicalprovider time, materials, and gloves, it was shown that the biosynthetic compound dressing glove was actually more cost effective over a IO-day period than the standard topical antibacterial cream dressings (Table II).
DISCUSSION In a recent series of 2 I8 cases of burns managed with the biosynthetic compound dressing Biobrane, the authors found this dressing to be useful in the management of superficial burn wounds while awaiting epithelialization, in deep wounds following excision of eschar, as coverage for widely meshed autografts while awaiting closure of interstices, and in the coverage of massive donor sites (McHugh et al.. 1986). Biobrane is a biosynthetic skin substitute consisting of custom-knit nylon Lbric mechanically bonded to an ultrathin silicone rubber membrane to which collagenous peptides of porcine skin origin are covalently bonded (Travis ef ul., 1980; Woodroff, 1985). This material has most of the characteristics of an ideal synthetic wound dressing. Therefore, it was thought to be of possible benefit in applying the principles of burned hand management to achieve optimal function. The biosynthetic dressing has been formed into a prefitted glove with gauntlet which comes in several sizes. This study demonstrated that the Biobrane glove
$4.00 $59.00 - $99.00
is effective in the management of hand burns. It allowed rapid active motion and minimized the pain of open wounds. Just as with the use of Biobrane elsewhere on the body, adequate adherence of the glove required 48-72 h of monitoring. Fluid or air pockets should be removed immediately because they ultimately lead to premature separation of the dressing from the wound. All subdressing collections should be aspirated, stained and cultured. In this particular study, subdressing fluid was always sterile. However, in burns elsewhere on the body, the subdressing fluid was sterile in only 68 per cent of cases (Krizek et al., 1973). For excised hand burns, it is absolutely necessary that ail necrotic tissue be removed prior to the application of the glove. If any non-viable tissue is left, the glove will not adhere. Early discharge from hospital is being increasingly encouraged. If the burns are limited only to the hand, patients can be routinely discharged once adherence occurs if grafting is not contemplated. The cost of the Biobrane glove compared to standard antimicrobial dressing changes was somewhat the surprising, but certainly Table II demonstrates cost effectiveness of the glove. iveness of the glove. Based on this study, we conclude that the biosynthetic compound dressing glove is a useful adjunct to be added to the armamentarium for treatment of the burned hand.
REFERENCES American Burn Association (1984) Guidelines for service standards and severity classifications in the treatment of burn injury. An,. Cdl. Surx. Bull. 69. 24. Krizek T. J.. Flagg S. V., Wolfort F. G. et al. (1973)
408
Delayed primary excision and skin grafting of the burned hand. Plast. Reconstr. Surg. 51, 524. McHugh T. P., Robson M. C., Heggers J. P. et al. (1986) Therapeutic efficacy of Biobrane in partial-thickness and full-thickness injury. Surgery 100, 661. Robson M. C. and Smith Jr D. J. (198?) In: Jurkiewicz M. J., Krizek T., Mathes S. et al. (eds), Plastic Surgery: Principles and Practice. St Louis: C. V. Mosby, (in the press).
Burns (1988)
Vol. 1 ~/NO. 5
Travis M. N., Thornton N. W., Bartlett R. H. et al. (1980) A new composite skin prosthesis. Burns 7, 123. Woodroff, E. A. (1985) In: Wise D. L. (ed.) Burn Wound Coverings. Boca Raton: CRC Press, pp. l-27.
Paper accepted
17 March
Correspondenceshouldbe addressedto: Dr D. J. Smith, Section of Plastic Surgery, University Medical Center Drive, Ann Arbor, MI 48109, USA.
1988.
of Michigan
Medical Center, 1500 East
Biosynthetic management
compound dressingsof hand burns
D. J. Smith, T. P. McHugh, Division of Plastic Medicine, Detroit,
405
Prinred in Great Britain
Linda G. Phillips, M. C. Robson and J. P. Heggers
and Reconstructive Michigan, USA
Surgery,
Summary
To achieve optimal hand function, wound closure becomes the most important ingredient in hand burns. This study documents the use of a biosynthetic compound dressing (Biobrane) which has been fabricated as a glove for management of hand burns. The glove allowed rapid active motion and minimized the pain of open wounds. Forty-two Biobrane glove applications were evaluated with 50 per cent applied over superficial hand burns and 50 per cent over deep partial thickness or full thickness injuries. In the superficial hand burns, the patients were discharged home after a mean time of2.8 days. With the deep burns the dressing provided a closed wound after early excision of eschar without the use of an autograft or biological dressing. Based on these studies, WC conclude that the biosynthetic compound dressing glove is a useful adjunct to be added to the armamentarium for treatment of the burned hand.
INTRODUCTION BURNS of the hands are special. Although they comprise less than 4 per cent of the total body surface area, they are classified as major burns by the American Burn Association (American Burn Association, 1984). The goal of management of the burned hand is to obtain optimal function by preventing infection, closing the wound, and preserving or regaining motion. This optimal function will simultaneously incorporate both fine pinch and power grip. Six principles have been reformulated for the care of the burned hand to achieve optimal functional return (Robson and Smith, in the press). These include: (I) to do no harm, (2) to maintain vascularity, (3) to prevent infection, (4) to obtain wound closure, (5) to preserve and regain motion, (6) to obtain optimal functional rehabilitation. To achieve optimal hand function following these six f(~”1988 Butterworth & Co (Publishers) 03054179/88/050405-04 $03.00
Ltd
Wayne State University
School
of
principles, wound closure becomes the most important ingredient in hand burns. This wound closure can be accomplished in five ways: (I) spontaneous healing within 14 days of superficial wounds; (2) early excision and grafting of deep wounds; (3) delayed excision and grafting of spontaneously healing wounds; (4) spontaneous healing in burns requiring more than 14 days; (5) late grafting of the delayed spontaneously healing wound (Krizek et al., 1973). In modern burn care, only the first three are routinely considered practical managements and with the increasing emphasis on earlier hospital discharge, really only the first two are practical ways of managing the burned hand. This work documents the use of a new biosynthetic compound dressing (Biobrane) which has been fabricated as a glove for management of hand burns. It will allow either uninterrupted epithelialization of superficial wounds or provide temporary wound closure of deep wounds following surgical or enzymic debridement. MATERIALS AND METHODS Two hundred and eighteen applications of Biobrane were studied, of which 42 (19.25 per cent) examined the utilization of the Biobrane glove (Fig. 1). In 50 per cent of these cases, the Biobrane gloves were used bilaterally. When the glove was used on patients with superficial hand burns, the patients were placed in the Hubbard tank, and the burn wound was cleansed and debrided of obviously devitalized epithelium. The burned hand was then covered with the Biobrane glove which in turn was covered with an elastic gauze to maintain the glove against the
406
Fig. 1. Biobrane
has been fabricated into various sized gloves for easier application in the management of hand burns.
wound. The Biobrane glove was inspected for adherence and fluid collection below the dressing 24 h after placement and then daily. Patients were not returned to the Hubbard tank once adherence of the Biobrane was achieved. The dressing was left on the hand burn until epithelialization was achieved, then removed. If the patient was not in need of hospitalization, the individual was discharged with the Biobrane glove in place and followed in the burn outpatient clinic. While the patient was in the hospital, daily total active motion (TAM) measurements were recorded. Similarly, these objective measurements were made on each outpatient visit. Time of healing and pain relief were also recorded. If the hand burns were initially considered to be deep partial thickness or full thickness, Biobrane gloves were not initially applied, and the patient was treated with topical antibacterial agents and scheduled for early excision. The Biobrane glove was applied after excision if adequate donor sites were not available for autografting or if the surgeon felt the excision revealed a sufficient dermal base to allow healing of the tangentially excised wound. Patients in this deep wound category also underwent daily objective motion measurements, and the time of removal of the glove was recorded. If, during the time the Biobrane glove was in place, subdressing fluid collected beneath the glove, it was aseptically aspirated, stained, and cultured.
Burns (1988) Vol. 14/No. 5
Fig. 2. Four days postexcision, oedema
the hand shows decreased with almost full active motion.
less extensive total body surface injuries; 14 adhered well, with the patients discharged home in a mean time of 2.8 days; and three gloves were removed due to aseptic subdressing fluid collections or non-adherence. Four (9.5 per cent) of the gloves placed on patients with superficial hand bums had extensive total body surface injuries and those patients had re-epithelialization of their hands in a mean time of 9.6 days while in the burn centre. None of these inpatients required removal of all or part of the gloves. In these superficial hand burns, the Biobrane glove provided immediate pain relief, decreased oedema, and allowed more complete motion (Table I). Twenty-one (50 per cent) applications were placed on deep partial thickness or full thickness wounds. The biosynthetic compound dressing glove provided a closed wound without the use of autograft or a biological dressing. In these patients, oedema was decreased and motion was increased (Fig. 2). Desiccation appeared to be prevented, and epithelialization proceeded rapidly. However, in seven (16.6 per cent) of the applications used on deeper burns, the gloves were removed and replaced by autograft. In these wounds, the excised Tab/e 1. Bilateral superficial hand burns treated with Biobrane gloves Left
Right IF
MF
RF
LF
IF
MF
RF
LF
Day 4 265” 270” 270” 270” 145” 265” 270” 265
RESULTS
Twenty-one (50 per cent) of the Biobrane glove applications were placed on superficial hand burns. Seventeen (40.4 per cent) were on patients that had
Day 1 l-Totally
healed
IF. index finger; MF, middle finger; RF, ring finger; LF, little finger. “=degrees of total active mot w.
407
Smith et al.: Biosynthetic compound dressings
Table II. Cost of therapy per hand for 10 days (US $) Topical antibacterial cream AgSD Burn dressing NaCl Flexnet
Biobrane
$37.50 10.00 8.00 20.00 $55.00 - $95.00
$75.50 Nursing care lOminx3x10=5 5 h x $12.00 TOTAL
glove
Nursing care 2Ominx1=2Omin $60.00
20 min x $12.00
$135.50
area was maintained in bacterial balance, and motion was allowed until donor sites were available for autograft closure. Five (12 per cent) applications of the gloves had all or a portion of the glove removed due to subdressing collection (i.e. haematoma, seroma, aseptic purulent drainage). None of the fluid collections grew bacteria. In evaluating costs of nursing and other medicalprovider time, materials, and gloves, it was shown that the biosynthetic compound dressing glove was actually more cost effective over a IO-day period than the standard topical antibacterial cream dressings (Table II).
DISCUSSION In a recent series of 2 I8 cases of burns managed with the biosynthetic compound dressing Biobrane, the authors found this dressing to be useful in the management of superficial burn wounds while awaiting epithelialization, in deep wounds following excision of eschar, as coverage for widely meshed autografts while awaiting closure of interstices, and in the coverage of massive donor sites (McHugh et al.. 1986). Biobrane is a biosynthetic skin substitute consisting of custom-knit nylon Lbric mechanically bonded to an ultrathin silicone rubber membrane to which collagenous peptides of porcine skin origin are covalently bonded (Travis ef ul., 1980; Woodroff, 1985). This material has most of the characteristics of an ideal synthetic wound dressing. Therefore, it was thought to be of possible benefit in applying the principles of burned hand management to achieve optimal function. The biosynthetic dressing has been formed into a prefitted glove with gauntlet which comes in several sizes. This study demonstrated that the Biobrane glove
$4.00 $59.00 - $99.00
is effective in the management of hand burns. It allowed rapid active motion and minimized the pain of open wounds. Just as with the use of Biobrane elsewhere on the body, adequate adherence of the glove required 48-72 h of monitoring. Fluid or air pockets should be removed immediately because they ultimately lead to premature separation of the dressing from the wound. All subdressing collections should be aspirated, stained and cultured. In this particular study, subdressing fluid was always sterile. However, in burns elsewhere on the body, the subdressing fluid was sterile in only 68 per cent of cases (Krizek et al., 1973). For excised hand burns, it is absolutely necessary that ail necrotic tissue be removed prior to the application of the glove. If any non-viable tissue is left, the glove will not adhere. Early discharge from hospital is being increasingly encouraged. If the burns are limited only to the hand, patients can be routinely discharged once adherence occurs if grafting is not contemplated. The cost of the Biobrane glove compared to standard antimicrobial dressing changes was somewhat the surprising, but certainly Table II demonstrates cost effectiveness of the glove. iveness of the glove. Based on this study, we conclude that the biosynthetic compound dressing glove is a useful adjunct to be added to the armamentarium for treatment of the burned hand.
REFERENCES American Burn Association (1984) Guidelines for service standards and severity classifications in the treatment of burn injury. An,. Cdl. Surx. Bull. 69. 24. Krizek T. J.. Flagg S. V., Wolfort F. G. et al. (1973)
408
Delayed primary excision and skin grafting of the burned hand. Plast. Reconstr. Surg. 51, 524. McHugh T. P., Robson M. C., Heggers J. P. et al. (1986) Therapeutic efficacy of Biobrane in partial-thickness and full-thickness injury. Surgery 100, 661. Robson M. C. and Smith Jr D. J. (198?) In: Jurkiewicz M. J., Krizek T., Mathes S. et al. (eds), Plastic Surgery: Principles and Practice. St Louis: C. V. Mosby, (in the press).
Burns (1988)
Vol. 1 ~/NO. 5
Travis M. N., Thornton N. W., Bartlett R. H. et al. (1980) A new composite skin prosthesis. Burns 7, 123. Woodroff, E. A. (1985) In: Wise D. L. (ed.) Burn Wound Coverings. Boca Raton: CRC Press, pp. l-27.
Paper accepted
17 March
Correspondenceshouldbe addressedto: Dr D. J. Smith, Section of Plastic Surgery, University Medical Center Drive, Ann Arbor, MI 48109, USA.
1988.
of Michigan
Medical Center, 1500 East