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Burns of the dorsum of the hand treated by tangential excision
British Journal of Plastic Surgery (I976), 29, 78-8I
BURNS OF THE D O R S U M OF THE HAND TREATED BY TANGENTIAL EXCISION By G. A. M. MALFEYT,MD.. Department of Plastic Surgery, St Luke's Hospital, Bradford and the Regional Burns Unit, Pinderfields Hospital, VdakefieM THE treatment of deep dermal burns by tangential excision and skin grafting is now widely accepted (Janzekovic, 197o; Jackson and Stone, 1972; Lawrence and Carney, 1973; Stone and Lawrence, 1973; Wexler and Yeschua, 1974). When these burns are shaved down to the deepest layer of the dermis, they will accept autografts, despite the fact that this layer of dermis may be damaged by the heat, and will slough if ungrafted (Stone and Lawrence, 1973; Lawrence and Carney, 1973). Burns of the hands are particularly suitable for tangential excision because the early replacement of the burned skin allows early mobilisation. The aim of this investigation was to compare the results of 34 deep dermal burns of the dorsum of the hand treated by tangential excision with those of I I similar hand burns which were treated conservatively and allowed to granulate before grafting. Tangential excision technique. The time between the burn and the excision varied from I to 5 days. The first ~ patients were operated under a tourniquet and grafted without releasing it during the operation. After 24 hours the hands were checked for haematomas under general anaesthesia as recommended by Janzekovic. However, it was found that this was not strictly necessary and a second anaesthetic can be avoided by elevating the limb without a tourniquet during operation. Tangential excision is then carried out until punctate bleeding occurs. Pressure dressings are applied immediately until bleeding stops when the raw area is covered with split skin autografts. It is important to cut the grafts as broad as possible so that the complete dorsum of the hand including all the fingers can be covered by one single sheet. This saves time and avoids scar formation at the junction of separate grafts. The dressings are removed between the 7th and Ioth postoperative days (Fig. I). Physiotherapy is started between the 7th and I4th day even in the case of poor graft take. RESULTS The take of skin grafts was very satisfactory in most of the tangentially excised cases; two-thirds had a take of over 9o per cent. The time for complete healing varied from 7 days to 5 weeks; half of the hands were healed within a fortnight. In the conservatively treated group none of the hands healed in less than 4 weeks. When graft take was good full function was rapidly regained in the tangentially excised hands (Fig. 2) at a time when the conservatively treated cases were still unready for grafting. The most serious complication was failure of the graft to take over ' finger joints whether from inadequate excision, haematoma or infection. Such cases had little better function in the affected fingers than the conservatively treated cases. At first the appearance of some of the grafts was marred by many small cysts (Fig. 3) but these disappeared within 6 months. Overhanging graft edges were also complained of but these also improved with time and may be removed by dermabrasion. They 78
BURNS OF DORSUM OF THE HAND TREATED BY TANGENTIAL EXCISION
79
FIG. I. A~ Analgesic deep dermal burn. B~ Tangential excision until punctate bleeding appears. C~ Split skin graft applied. A sheet broad enough to cover the whole dorsum is preferred. D, Full take of grafts at 8 days.
may be partly avoided by cutting the graft thinner marginal scars were hypertrophic in the early months The final appearance of the excised hands with the deepest layer of the dermis had been preserved, was retained (Fig. 4).
at the edges. Occasionally the but flattened out later. good take was normal and since the natural mobility of the skin
CONCLUSIONS
Early tangential excision and grafting is the treatment of choice for deep dermal burns of the dorsum of the hand. The operation must be carried out with care, making sure that all dead tissue is excised, that there is no residual bleeding when the grafts are applied, and that the whole area is grafted. Grafts over the finger joints are especially important. Graft loss from infection is more likely to occur in patients with other burns elsewhere. Full recovery of function may be achieved within z weeks, whereas the conservative treatment of burns of comparable depth takes about 3 weeks for desloughing alone, so that the shortest possible time for full healing is about 5 weeks. Tangential excision not only reduces hospital stay but virtually abolishes pain and morbidity.
80
B R I T I S H JOURNAL OF P L A S T I C SURGERY
BURNS OF DORSUM OF THE HAND TREATED BY TANGENTIAL EXCISION FIG. 2.
81
A and B, Same patient as in Figure I. Full range of movements 12 days after excision and grafting.
FIG. 3- Cyst formation 23 days after tangential excision; all disappeared within 6 months. FIG. 4. A and B, Tangential excision of the dorsum of both hands was carried out 3½ years previously. Note completely normal appearance, and C, Normal skin mobility.
Special thanks are due to M r T. L. Barclay who helped and encouraged me during this study and also to M r D. J. Crockett, Dr J. Settle and M r K . Paton who allowed me to study their cases. REFERENCES JACKSON, D. M. and STONE, P. A. (1972). Tangential excision and grafting of burns. British Journal of Plastic Surgery, 25, 416. JANZEKOVlC, Z. (197o). A new conception in the early excision and immediate grafting of bums. Journal of Trauma, IO, 11o 3. LAWRENCE, J. C. and CARNEY, S. A. (1973). Tangential excision of burns: Studies on the metabolic activity of the recipient areas for skin grafts. British Journal of Plastic Surgery, 26, 93STONE, P. A. and LAWRENCE, J. C. (1973)- Healing of tangentially excised and grafted burns in man. British Journal of Plastic Surgery~ 26, 20. WEXLER, M. R. and YESCttUA, R. (1974). Early treatment of burns of the dorsum of the hand by tangential excision and grafting. Plastic and Reconstructive Surgery, 54, 268.
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BURNS OF THE D O R S U M OF THE HAND TREATED BY TANGENTIAL EXCISION By G. A. M. MALFEYT,MD.. Department of Plastic Surgery, St Luke's Hospital, Bradford and the Regional Burns Unit, Pinderfields Hospital, VdakefieM THE treatment of deep dermal burns by tangential excision and skin grafting is now widely accepted (Janzekovic, 197o; Jackson and Stone, 1972; Lawrence and Carney, 1973; Stone and Lawrence, 1973; Wexler and Yeschua, 1974). When these burns are shaved down to the deepest layer of the dermis, they will accept autografts, despite the fact that this layer of dermis may be damaged by the heat, and will slough if ungrafted (Stone and Lawrence, 1973; Lawrence and Carney, 1973). Burns of the hands are particularly suitable for tangential excision because the early replacement of the burned skin allows early mobilisation. The aim of this investigation was to compare the results of 34 deep dermal burns of the dorsum of the hand treated by tangential excision with those of I I similar hand burns which were treated conservatively and allowed to granulate before grafting. Tangential excision technique. The time between the burn and the excision varied from I to 5 days. The first ~ patients were operated under a tourniquet and grafted without releasing it during the operation. After 24 hours the hands were checked for haematomas under general anaesthesia as recommended by Janzekovic. However, it was found that this was not strictly necessary and a second anaesthetic can be avoided by elevating the limb without a tourniquet during operation. Tangential excision is then carried out until punctate bleeding occurs. Pressure dressings are applied immediately until bleeding stops when the raw area is covered with split skin autografts. It is important to cut the grafts as broad as possible so that the complete dorsum of the hand including all the fingers can be covered by one single sheet. This saves time and avoids scar formation at the junction of separate grafts. The dressings are removed between the 7th and Ioth postoperative days (Fig. I). Physiotherapy is started between the 7th and I4th day even in the case of poor graft take. RESULTS The take of skin grafts was very satisfactory in most of the tangentially excised cases; two-thirds had a take of over 9o per cent. The time for complete healing varied from 7 days to 5 weeks; half of the hands were healed within a fortnight. In the conservatively treated group none of the hands healed in less than 4 weeks. When graft take was good full function was rapidly regained in the tangentially excised hands (Fig. 2) at a time when the conservatively treated cases were still unready for grafting. The most serious complication was failure of the graft to take over ' finger joints whether from inadequate excision, haematoma or infection. Such cases had little better function in the affected fingers than the conservatively treated cases. At first the appearance of some of the grafts was marred by many small cysts (Fig. 3) but these disappeared within 6 months. Overhanging graft edges were also complained of but these also improved with time and may be removed by dermabrasion. They 78
BURNS OF DORSUM OF THE HAND TREATED BY TANGENTIAL EXCISION
79
FIG. I. A~ Analgesic deep dermal burn. B~ Tangential excision until punctate bleeding appears. C~ Split skin graft applied. A sheet broad enough to cover the whole dorsum is preferred. D, Full take of grafts at 8 days.
may be partly avoided by cutting the graft thinner marginal scars were hypertrophic in the early months The final appearance of the excised hands with the deepest layer of the dermis had been preserved, was retained (Fig. 4).
at the edges. Occasionally the but flattened out later. good take was normal and since the natural mobility of the skin
CONCLUSIONS
Early tangential excision and grafting is the treatment of choice for deep dermal burns of the dorsum of the hand. The operation must be carried out with care, making sure that all dead tissue is excised, that there is no residual bleeding when the grafts are applied, and that the whole area is grafted. Grafts over the finger joints are especially important. Graft loss from infection is more likely to occur in patients with other burns elsewhere. Full recovery of function may be achieved within z weeks, whereas the conservative treatment of burns of comparable depth takes about 3 weeks for desloughing alone, so that the shortest possible time for full healing is about 5 weeks. Tangential excision not only reduces hospital stay but virtually abolishes pain and morbidity.
80
B R I T I S H JOURNAL OF P L A S T I C SURGERY
BURNS OF DORSUM OF THE HAND TREATED BY TANGENTIAL EXCISION FIG. 2.
81
A and B, Same patient as in Figure I. Full range of movements 12 days after excision and grafting.
FIG. 3- Cyst formation 23 days after tangential excision; all disappeared within 6 months. FIG. 4. A and B, Tangential excision of the dorsum of both hands was carried out 3½ years previously. Note completely normal appearance, and C, Normal skin mobility.
Special thanks are due to M r T. L. Barclay who helped and encouraged me during this study and also to M r D. J. Crockett, Dr J. Settle and M r K . Paton who allowed me to study their cases. REFERENCES JACKSON, D. M. and STONE, P. A. (1972). Tangential excision and grafting of burns. British Journal of Plastic Surgery, 25, 416. JANZEKOVlC, Z. (197o). A new conception in the early excision and immediate grafting of bums. Journal of Trauma, IO, 11o 3. LAWRENCE, J. C. and CARNEY, S. A. (1973). Tangential excision of burns: Studies on the metabolic activity of the recipient areas for skin grafts. British Journal of Plastic Surgery, 26, 93STONE, P. A. and LAWRENCE, J. C. (1973)- Healing of tangentially excised and grafted burns in man. British Journal of Plastic Surgery~ 26, 20. WEXLER, M. R. and YESCttUA, R. (1974). Early treatment of burns of the dorsum of the hand by tangential excision and grafting. Plastic and Reconstructive Surgery, 54, 268.
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