Burned Hand Care and Reconstruction

Care and Reconstruction of the Burned Hand

The hands are important to use as human tools and for expression.  They are frequent sites of burns, accounting for up to 80 percent of burn care even though they only account for 2-3 percent of the total body surface area.  Both flame, electrical, and scald burns are common types of hand burns.  Flame and electrical burns occur primarily in the workplace, while scald burns are commonly occurring in home-related burns and usually occur in small children.

The hand is especially vulnerable because the back of the hand has very thin skin so the burns tend to involve deeper structures.  Loss of fingers and the thumb can easily occur in severe burns.   Loss of just the thumb diminishes the function of the hand by 50 percent.  The goal of treating the burned hand is to restore function of the hand.
 
The Initial Stages

The affected hand should be cooled as soon as possible after the burn occurs.  If the burn is chemical, cool water should flush the burned areas until it is of a normal pH.  Often the circulation of severe burns is compromised in the hands so the surgeon must perform escharotomies—cutting through full-thickness burned areas in order to restore the hand circulation.  Sometimes releases need to be done in the wrist areas if these are involved in burns cutting off the circulation to the hand.  After the releases are completed, the open areas can be covered with nonstick dressings that have antimicrobial ointment or cream on them.  Skin grafting can also be done after opening up the circulation to the hand.  The hands should be elevated to keep swelling to a minimum.
 
Surgery to the Hand

As soon as it becomes clear that the burn is full-thickness or doesn’t heal within a couple of weeks, surgery should be done to reconstruct the hand and cover the burned areas.  Partial-thickness sheets of donor skin are applied to the back of the hand for better, more flexible coverage.  A slightly meshed skin graft will also work to protect the open areas of the hand.  The hand should be placed with finger joints extended and the metacarpal joints flexed with the wrist at thirty degrees extension.  This type of splinting allows for best function of the hand after it heals.  The skin over the back of the finger joints is very thin and sometimes wires are used from bone to bone to keep the joints straight.  The hand is placed in a premade or custom-made splint and elevated for about 5 days after surgery.
 
Managing Deformities

Deformities of the hand are all too common, particularly those caused by contraction of the palm of the hand.  Repair of hand deformities may take as long as two years to be undertaken as the hand needs to heal completely before reconstruction can take place.  There are several reconstructive techniques to consider such as:
  • Cutting out scar tissue and reconnecting the free edges
  • Wound grafting after excising a scar when there is not enough local tissue to cover the exposed area
  • Skin flaps which are rotated onto the hand to cover open areas
  • Z-plasty techniques
  • Using musculocutaneous or fasciocutaneous flaps
There are techniques surgeons can use on the fingers that can become contracted due to scar tissue on the fingers themselves or due to contraction of the tendons of the palm of the hand.  Flaps or skin grafts are used once the finger has been released and is not contracted anymore.  There can be extensor contractions of the joints of the finger, depending on where the scar tissue is the thickest and most contracted.  Wires can be used to keep the fingers in a flexed position while the surgery heals.   Surgery can be done on the web spaces, which sometimes are burned in such a way
that two fingers are partially fused together or the web space between the thumb and the rest of the hand is too narrow.
 
Electrical Burns of the Hand and Arm

Electrical burns are common in the workplace and often affect the hand and arms.  Circulation damage secondarily happens in up to 60 percent of cases.  Doctors can assess the degree of circulatory damage by looking for cyanosis and coolness of the hand and forearm, by seeing deep vascular thromboses, by using Doppler flowmetry, arteriography, MRI scans or circular exploration of the wound.

Deep structures are often damaged in electrical burns and there is an imminent need to decompress areas where swelling has cut off the circulation to the hand. In one to two days, the wounds can be debrided of dead tissue and covered in skin grafts.  Unfortunately, high voltage electrical injuries to the hand and arm are often so severe that parts of the arm and the entire hand need to be amputated in order to save the patient’s life.

The biggest problem with electrical injuries of the hand and forearm is that the circulation is lost.  This means that even if a graft is attempted, the graft will not take.  Flap repairs of the arm and hand tend to do better when they come from body areas that still have intact circulation.
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