Surgical treatment of the deeply burned hand

Surgical treatment of the deeply burned hand

2 14 Burns, 9. 2 14-2 17 Printed in Great Britain Surgical Treatment hand of the deeply burned A. Buhl Nielsen and J. Sommer Department of Orthop...

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2 14

Burns, 9. 2 14-2 17

Printed in Great Britain

Surgical Treatment hand

of the deeply burned

A. Buhl Nielsen and J. Sommer Department of Orthopaedic Surgery, Aarhus County Hospital, Aarhus, Denmark

Summary

An individualized treatment programme has been used in the management of deeply burned hands based on early excision of third-degree bums and delayed excision of mixed deep second-degree and third-degree burns. The function of the hand has been a crucial object both before surgery by means of treatment with gloves and postoperatively by exposure treatment. Six out of 25 hands have needed reconstructive procedures. By the follow-up respectively 86 per cent of the hands treated by early excision and 88 per cent of the hands treated by delayed excision have obtained a good functional and cosmetic result. We recommend both methods, but find that they have to be used separately for each particular burn. INTRODUCTION

Anatomical deformities and functional impairment together with unsatisfactory results after reconstructive procedures are even nowadays a common outcome of burns of the hand (Huang et al. 1975). These burns are frequently in combination with large bums elsewhere on the body (Huang et al. 1975, Habal, 1978). Where disturbances of the body fluid and electrolytes, pulmonary complications and even shock occur, Tab/e /. The treatment

these conditions require immediate treatment and in these patients the treatment of burned hands is often a secondary priority. During recent years a more aggressive system of care has improved the results, but the optimal primary treatment is still controversial. Our report is concerned mainly with the isolated deeply burned hands, as only 15 per cent of the patients had deep burns on other parts of the body, and nobody had burns exceeding 20 per cent of the body surface. PATIENTS

Early excision Delayed excision Amputation of the hand Total

METHODS

in relationship to the depth of the burn Mixed

Treatment

AND

During the period 1973~80,23 patients with 26 deeply thermal burned hands have been treated. At the primary admission the depth ofthe bums was evaluated as either a third-degree bum or a mixed deep second-degree and third-degree burn and the treatment was suited to this evaluation. Two kinds of treatment have been used, either (a) early excision (i.e. excision and transplantation between day 2-5) of 15 hands or (b) delayed excision (i.e. excision and transplantation between day 10-14) of 10 hands (Table I). In the group treated with delayed excision 2

Third-degree

burns

deep second-degree third-degree burns

& Total

13 hands 2 hands 1 hand

2 hands 8 hands -

15 10 1

16 hands

10 hands

26

Nielsen and Sommer:

215

The deeply burned hand

hands with primary third-degree burns were admitted to our department 10 days after the burn, two hands treated with early excision had widespread mixed bums on both the dorsum and the palmar of the hand (Table I) . In an 82-yearold patient with dementia senilis, amputation of the hand was necessary. The injuries were mostly localized to the dorsum of 20 hands. Anterior escharotomy was only preformed in one case. After 1975 all the hands (20 hands) have been treated with occlusive gloves (Frandsen et al. 1977) until the time of surgery. In connection with mixed burns the exact assessment of the depth and extension of the bums were difficult to estimate at the primary admission, and the treatment with glove continued until about day 10. The injuries were then estimated again. About half of the hands with primary mixed burns healed by spontaneous re-epithelialization while they were treated in the occlusive bags, and these patients are not included in this study. Three hands developed wound infection during the management with gloves, and both topical and systematical antibiotic agents were necessary before excision and transplantation could be carried out. The operations were done under general anaesthesia and tourniquet control. All the excisions were performed by means of the tangential excision technique (Janzekovic, 1970). lmmediate graft was obtained with unmeshed split skin, frequently using the thigh as donor site. In order to prevent scars near the joints long sheets ofgrafts were applied to the dorsum ofthe hand and the fingers (Fig. I). Elevation and fixation of 5 hands recently treated, were obtained by means of a transmetacarpal Kirschner wire (Fig. I). Fourteen out of 18 adults’ hands required no postoperative dressing, while the remaining 4 hands and children’s hands received occlusive dressings supplied by plaster-of-Paris. These hands were kept in a functional position with a slight dorsiflexion of the wrist, with MP joints in 80” flexion and the IP joints in full extension. The hands selected for exposure treatment received passive exercise after 5 days and active exercise after IO days, while both passive and active exercise were established on day 10, when the hands had been immobilized in a splint. The average stay in the hospital was I7 days after early excision and 27 days after delayed excision. RESULTS

Superficial

infections

with partial

rejection

of

Fig. 1, Long sheets of unmeshed split skins applied to the dorsum of the hand and the postoperative elevation by means of a Kirschner wire. grafts needing regrafting appeared in 2 hands in the early excision group and in 4 hands in the delayed excision group. The remaining hands obtained graft healing in IO days. After the primary management 10 out of 25 hands developed different kinds of anatomical deformities (Table Ifi, but only 6 of these hands required reconstructions (Table III). Just one hand underwent more than one secondary operation before the functional and cosmetic results were good. Nobody developed the typical claw deformity with hyperextension of the MP joints and flexion contractures of the IP joints. The functional results were recorded by a retrospective examination and then compared with the results described in the records before reconstructions were performed {Table IV). The following functions must be required to obtain a good result: (a) normal motion of the wrist, (b) normal extension of all the fingers, (c) the distance between the finger tip and the distal palmar crease of all the fingers had to be less than 2 cm and (d) no considerable weakness of the hand. There was a good agreement between the cosmetic and functional result. The two methods of treatment used result in a similar outcome.

216

Burns Vol. g/No. 3 Table //, Deformities

before reconstructive

Deformities

procedures

Early excision (hands)

Delayed excision (hands)

2 2 1 1 2 1 8

2 1 0 1 1 0 7

Syndactylism Boutonniere deformity Extension contracture Flexion contracture Loss of fingers Keloid scars No deformities

Table l/L Patients requiring reconstructive to treatment

Boutonniere deformity Syndactyli & flexion contracture Syndactyli & extension contracture & keloid scars Total

Table IV. The functional results before and after reconstructions in relation to the treatment

Results

Early excision before after

%

%

%

%

Good Bad

10 71 4 29

12 86 2 14

5 63 3 37

7 88 1 12

Delayed excision before after

DISCUSSION

The classical conservative treatment consisting of immobilization of the burned hand for more than 2 weeks (Robertson, 1958) produces unsatisfactory results. Immobilization for several days of the burned swollen hand causes overhydration of the collagen fibrils, development of fibrosis and joint stiffness (Peacock et al. 1970). Introduction ofthe tangential excision technique (Janzekovic, 1970, Jackson & Stone, 1972) in treatment of both third-degree and more superficial burns causes fewer scars, permits earlier physiotherapy and therefore improves the function of the hand (Wexler et al. 1974, Levine et al. 1979).

procedures in relationship

Early excision

Delayed excision

2

1

1

1

1 4114

218

There is very little disagreement about the treatment of third-degree burns, and nearly all authors recommend excision and transplantation before day 5. On the other hand the primary care of the mixed deep second-degree ant third-degree burns continuously is also con cerned with quality. The use of topical anti. biotical agents has reduced infection as a cause of conversion of partial-thickness to full-thick. ness skin lost. Together with an early start o intensive physiotherapy, conservative treatmen of the mixed burned hands has yielded gooc results (Labandter et al. 1976, Edstrom et al 1979). The polythene glove counteracts encrus tations while keeping the hand soft and alsc facilitates movement (Frandsen et al. 1979). I gloves are used in connection with a primar: conservative treatment of the mixed burns, it i: possible to avoid many unnecessary excisions o viable tissue. Therefore some authors (Krizek e al. 1973, Habal, 1978) wait for the decision con cerning operative or non-operative treatment 0 these burns until approximately day 14. Earlier reports are marked by the frequen combination between burned hands and large burns elsewhere on the body demanding earl: care, This report almost exclusively consists o the isolated burned hands. We have introducec

Nielsen

and

Sommer:

The

deeply burned hand

217

recently an individualized treatment programme based on early excision of third-degree burns and delayed excision of mixed deep seconddegree and third-degree burns. At the same time we have paid attention to the function of the hand both before surgery by glove management and postoperatively by the exposure treatment related to the adults. The transmetacarpal Kirschner wire has only brought slight discomfort for the patients, it has improved the possi-

bility of exercises and reduced the oedema of the hand by means of the elevation. Both before and

after

the recontructions,

our

results

have

been acceptable. We could not demonstrate any differences at the outcome between the two methods of treatment, and this is surprising compared with other reports (Burke et al. 1976, Huang et al. 1975), where the need for reconstructive procedures is increased in third-degree burns. It is very difficult to compare the two treatment programmes because the depth and extent of the initial tissue destruction is quite different for the two categories of patients. We find that both methods have their advantages, but recommend that they are used separately for each particular case. REFERENCES Burke J. F. et al. (1976)

Primary surgical management

ofthe deeply burned hand. J. Trauma 16, 593. Edstrom L. E. et al. (1979) Prospective randomized treatments for burned hands: nonoperative vs. operative. SUUUII.J. Plast. Reconstr. Surg. 13, 13 1. (‘or~r\ponci~nc,e

thou/d

he a&lrra~/

fo: Dr

A. Buhl

Nielsen,

Frandsen P. A., Overgaard-Nielsen H. and Sommer J. (1977) Treatment of second-degree burns of the hand: a comparison ofocclusive dressing and gloves. Burns 4, 20.. Habal M. B. (1978) The burned hand: a planned treatment program. J. Trauma 18, 587.

Huang T. T., Larsson D. L. and Lewis S. R. (1975) Burned hands. Plast. Reconstr. Surg. 56, 2 1. Jackson D. M. and Stone P. A. (1972) Tangential excision and grafting of burns, the method and report of 50 consecutive cases. Br. J. Phst. Surg. 25, 4 16. Janzekovic Z. (1970) A new concept in the early excision and immediate grafting of burns. J. Trcluma 10, 1103. Krizek T. J. et al. (1973) Delayed primary excision and skin grafting of the burned hand. Burned Hand.\ 51, 524. Labandter H., Kaplan 1. and Shavitt C. (1976) Burns on the dorsum of the hand: Conservative treatment with intensive physiotherapy versus tangential excision and grafting. Br. J. Pk. Surg. 29, 352. Levine B. A. et al. (1979) Efficacy of tangential excision and immediate autografting of deep seconddegree burns of the hand. J.~Trauma 19, 670. Peacock E. E.. Madden J. W. and Trier W. C. (1970) Some stud& on the treatment of burned hands; Ann. Surg. 171, 903. Robertson D. C. (1958) The management of the burned hand. J. Bone Joint Surg. 40A, 625. Wexler M. R., Yeschua R. and Neuman Z. (1974) Early treatment of burns of the dorsum of the hand by tangential excision and skin grafting. Burned Hunch 54,268.

Paper accepted 28 June 1982. Egebjergvej

141. 8220

Braband,

Denmark.