- Email: [email protected]
Care of the burned hand
Care o/ the Burned H a n d - - W . H. Reid
CARE OF THE BURNED
HAND
W. H. REID, Glasgow It is a distressing fact that in spite of progressively stricter legislation we have an increasing number of burns each year especially involving the hands. THE PROBLEM
Our experience is similar to other units in that there has been a 15 per cent increase in the proportion of burns in the working population, that is between the ages of fifteen and sixty-five years. Many of these burns involve the hands. The full thickness burns of hands, for example those caused by electric fires, are a very difficult problem whose solution seems far off. The place of immediate excision and tangential excision of burns of the hand has not been finally decided. The type of burn on which I want to concentrate is the more frequent partial thickness burn, which should almost always have a functionally good result, but this is unfortunately often not achieved. The aim in these burns is to prevent infection and allow healing to take place. This aim is best achieved by dressings. CONVENTIONAL DRESSINGS
The type of dressing which is required is one which is easily changed, without pain, by relatively unskilled staff. The type of dressing frequently used is to apply Tulle gras or cream to the raw surface. The dressing is then built up with layers of gauze being finished with Tubegauze (Figs. 1 and 2). This method requires skill to apply safely and properly. Circulation of the digits can be at risk if the Tubegauze is twisted too tightly at the proximal part of the digit. Dressing changes can be painful and usually take twenty minutes or longer. Frequently the effect of such a dressing is to inhibit movements of the digits.
Figs. 1 & 2. Standard dressing of bitumen burn of hand. The H a n d - - V o l . 6
No. 2
1974
163
Care of the Burned H a n d - - W . H. Reid
RECENT DEVELOPMENTS
Slater and Hughes (1971) introduced a method of using polythene bags, which was easy to use, but several disadvantages were found. Patients did not have individual use of the fingers and some became upset by the exudate which accumulated in the dependant part of the bag. To overcome these disadvantages the normal disposable plastic dressing gloves are used. These are available in several sizes and can be bought sterile or unsterile. Using the unsterile gloves, we were unable to isolate any bacteria from either inner or outer surfaces. Dressing changes are easily performed by relatively unskilled staff. Such changes are almost painless and take only a few minutes which allows the dressing to be changed several times a day if desired, even with the frequently existing shortage of nursing staff. The raw surfaces are covered with Silver Sulphadiazine (Flamazine) cream which is easy to apply and has a good range of antibacterial activity. Two gloves are applied to the affected hand and are secured at the wrist by a crepe bandage. OTHER FACTORS
There are three further important factors in the successful treatment of burns of the hand. Elevation of the hand and upper limb is helpful in the early stages. The swelling of the hand is minimised. Physiotherapy, especially the inclusion of a c t i v e a n d passive movements of all joints, wrist, metacarpophalangeal and interphatangeal, to achieve as full a range of joint movement as possible. The physiotherapy shculd be given several times a day if this can be arranged. With the glove dressing technique described, the patient can perform the usual tasks of feeding and toilet requirements and can with benefit be involved in occupational therapy using the digits as fully as possible. Splintage is helpful. The joint which is fundamental to the function of the hand and fingers is the wrist joint. If there is the slightest tendency for flexion to occur and persist, splintage of the wrist in 45 ° of dorsiflexion should be applied using any convenient material, often plastic. Such a splint can be readily incorporated with the dressing. A C L I N I C A L CASE
The accompanying series of photographs (Figs. 3-7) shows a typical industrial burn in a seventeen-year-old male from the day of the burn to complete healing. The patient undertook all toilet and feeding requirements himself from 48 hours after the burning accident, and made several models.
REFERENCES H U M M E L , R. P., M a c M I L L A N , B. G. and A L T E M E I E R , W. A. (1970) Topical and Systemic Antibacterial Agents in the Treatment of Burns. Annals of Surgery, 172: 370-384. SLATER, R. M. and H U G H E S , N. C. (1971). A Simplified Method Of Treating Burns Of The Hands. British Journal of Plastic Surgery, 24: 296-300. 164
The H a n d - - V o l . 6
No. 2
1974
Care of the Burned H a n d - - W . H. Reid
Fig. 3. Fig. 4.
Industrial burn of both hands after blisters have been deroofed. Dressed in plastic gloves with Silver Sulphadiazine cream.
Fig. 5. Healing progressing well at six days. Figs. 6 & 7. Both hands completely healed at sixteen days. Full function. The Hand--Vol. 6
No. 2
1974
165
CARE OF THE BURNED
HAND
W. H. REID, Glasgow It is a distressing fact that in spite of progressively stricter legislation we have an increasing number of burns each year especially involving the hands. THE PROBLEM
Our experience is similar to other units in that there has been a 15 per cent increase in the proportion of burns in the working population, that is between the ages of fifteen and sixty-five years. Many of these burns involve the hands. The full thickness burns of hands, for example those caused by electric fires, are a very difficult problem whose solution seems far off. The place of immediate excision and tangential excision of burns of the hand has not been finally decided. The type of burn on which I want to concentrate is the more frequent partial thickness burn, which should almost always have a functionally good result, but this is unfortunately often not achieved. The aim in these burns is to prevent infection and allow healing to take place. This aim is best achieved by dressings. CONVENTIONAL DRESSINGS
The type of dressing which is required is one which is easily changed, without pain, by relatively unskilled staff. The type of dressing frequently used is to apply Tulle gras or cream to the raw surface. The dressing is then built up with layers of gauze being finished with Tubegauze (Figs. 1 and 2). This method requires skill to apply safely and properly. Circulation of the digits can be at risk if the Tubegauze is twisted too tightly at the proximal part of the digit. Dressing changes can be painful and usually take twenty minutes or longer. Frequently the effect of such a dressing is to inhibit movements of the digits.
Figs. 1 & 2. Standard dressing of bitumen burn of hand. The H a n d - - V o l . 6
No. 2
1974
163
Care of the Burned H a n d - - W . H. Reid
RECENT DEVELOPMENTS
Slater and Hughes (1971) introduced a method of using polythene bags, which was easy to use, but several disadvantages were found. Patients did not have individual use of the fingers and some became upset by the exudate which accumulated in the dependant part of the bag. To overcome these disadvantages the normal disposable plastic dressing gloves are used. These are available in several sizes and can be bought sterile or unsterile. Using the unsterile gloves, we were unable to isolate any bacteria from either inner or outer surfaces. Dressing changes are easily performed by relatively unskilled staff. Such changes are almost painless and take only a few minutes which allows the dressing to be changed several times a day if desired, even with the frequently existing shortage of nursing staff. The raw surfaces are covered with Silver Sulphadiazine (Flamazine) cream which is easy to apply and has a good range of antibacterial activity. Two gloves are applied to the affected hand and are secured at the wrist by a crepe bandage. OTHER FACTORS
There are three further important factors in the successful treatment of burns of the hand. Elevation of the hand and upper limb is helpful in the early stages. The swelling of the hand is minimised. Physiotherapy, especially the inclusion of a c t i v e a n d passive movements of all joints, wrist, metacarpophalangeal and interphatangeal, to achieve as full a range of joint movement as possible. The physiotherapy shculd be given several times a day if this can be arranged. With the glove dressing technique described, the patient can perform the usual tasks of feeding and toilet requirements and can with benefit be involved in occupational therapy using the digits as fully as possible. Splintage is helpful. The joint which is fundamental to the function of the hand and fingers is the wrist joint. If there is the slightest tendency for flexion to occur and persist, splintage of the wrist in 45 ° of dorsiflexion should be applied using any convenient material, often plastic. Such a splint can be readily incorporated with the dressing. A C L I N I C A L CASE
The accompanying series of photographs (Figs. 3-7) shows a typical industrial burn in a seventeen-year-old male from the day of the burn to complete healing. The patient undertook all toilet and feeding requirements himself from 48 hours after the burning accident, and made several models.
REFERENCES H U M M E L , R. P., M a c M I L L A N , B. G. and A L T E M E I E R , W. A. (1970) Topical and Systemic Antibacterial Agents in the Treatment of Burns. Annals of Surgery, 172: 370-384. SLATER, R. M. and H U G H E S , N. C. (1971). A Simplified Method Of Treating Burns Of The Hands. British Journal of Plastic Surgery, 24: 296-300. 164
The H a n d - - V o l . 6
No. 2
1974
Care of the Burned H a n d - - W . H. Reid
Fig. 3. Fig. 4.
Industrial burn of both hands after blisters have been deroofed. Dressed in plastic gloves with Silver Sulphadiazine cream.
Fig. 5. Healing progressing well at six days. Figs. 6 & 7. Both hands completely healed at sixteen days. Full function. The Hand--Vol. 6
No. 2
1974
165