Primary Operative Management of Hand Burns: An Overview

Introduction:

The hand represents nearly one percent of the total body surface area. The hand is considered one of the most common sites for burns. The quality of life is majorly affected due to decreased functionality of hands. The problem can be prevented by initial management and treatment by the doctor. The treatment for hand burns is usually multidisciplinary, involving general surgeons, physicians, plastic surgeons, and physiotherapists. Different kinds of surgical procedures are available depending on the type of burns. These include skin grafts and splinting-free flaps.

What Are the Different Types of Burn Injuries?

Before evaluating the treatment, the surgeon should assess the type of burn. Depending on the severity of the burn, the treatment and evaluation vary.

• First-Degree Burn - These are usually seen in sunburns associated with redness. These types of burns resolve within three to four days without any scarring.

• Second-Degree Burn - This type of burn involves the epidermis and part of the dermis. These are again divided into superficial and deep.

• Second Degree Superficial - This burn involves the epidermis and superficial layers of the dermis (papillary dermis). It is associated with pain and paresthesia. These types of burns resolve within 10 to 20 days with minimal scarring.

• Second Degree Deep - This type of burn involves the epidermis and deep layers of the dermis (reticular dermis). These burns take three to five weeks to heal and are associated with scarring. There is a greater chance of infection to occur.

• Third-Degree Burn - These types of burns are called full-thickness burns as they involve the epidermis and dermis. Usually, the skin appears dull, dry, and inelastic.

• Fourth-Degree Burn - If the burn involves subcutaneous tissue apart from the epidermis and dermis, it falls under fourth-degree burns.

For practical purposes, the burns are divided into-

• Partial Thickness Burns - Burns that do not require surgery and heal themselves.

• Full Thickness Burns - Burns that require the help of the surgeon for reconstruction to heal as they cannot heal by themselves.

How Is Pre-Surgical Evaluation Done?

• The surgeon takes the complete history of the incident and does a thorough physical examination.

• The surgeon evaluates the severity of the burn, how it happened, depth of injury, perfusion status, and viability of the digits and hand.

• Doppler test is performed when the radial and ulnar pulses are not palpable, and it is usually seen in cases of the full-thickness flap.

• Once the evaluation is done, the surgeon plans the treatment for reconstruction.

What Are the Goals of Surgery?

The main aim of surgery is to:

• Prevention of Further Injury - This is achieved by proper examination and prompt delayed treatment.

• Prevention of Infection - This is achieved by wound closure using adequate dressing.

• Prevention of Loss of Function - This is achieved by recognizing and identifying the perfusion to each digit and restoring it accordingly via a surgical procedure like escharotomy.

• Functional Rehabilitation - This can be achieved by splinting and biobrane skin gloves to help establish the hand's active and passive movement.

• Surgical Management - This is usually preferred in case of full-thickness burns to establish functional and aesthetic rehabilitation.

What Are the Different Kinds of Surgical Treatments for Hand Burns?

One of the most common complications of burns is neurovascular compromise caused by full-thickness burns due to increased pressure on the muscles to compensate for fluid replacement.

These include decompressive therapies such as,

Escharotomy -

• This procedure is performed under local anesthesia or regional anesthesia.

• In this process, the blood supply to the tissues is restored by removing the constricting eschar that is the burn or scar present around the hand, which can shrink and cause hindrance to the blood supply for the underlying tissues.

• In this procedure, an incision is made using a knife or electrocautery, incising the entire thickness of eschar until the subcutaneous tissues.

• Care should be taken to prevent nerves, blood supply, and muscle injury.

• An escharotomy is mainly performed to restore the blood supply to tissue. If the perfusion is not achieved, it is considered a failure, and fasciotomy is performed.

Fasciotomy -

• This procedure is usually done under general anesthesia.

• In this procedure, a small incision is made in the fascia to release the pressure to prevent loss of perfusion and increase the blood supply to a particular area or tissue.

In hand fasciotomy, four incisions are made.

• Radial Side of Thumb - To release the thenar component.

• Dorsal Incision Over the Index Finger - To remove first and second interossei muscles

• Dorsal Incision Over Ring Finger - To release the third and fourth interossei muscles.

• Ulnar Incision Over Little Finger - To release the hypothenar muscles.

Peripheral Nerve Release -

• This is performed whenever there are signs of loss of sensation, motor function, or paresthesia.

• In such situations, the surgeon should identify the nerve and release it to achieve normal motor functions, as sensory functions are difficult to assess.

Grafting -

• In this procedure, skin sections are used to replace the scar tissue caused due to burns.

• Skin grafts taken from the unburnt donor sites are used.

• Split-thickness grafts are held in place using splints and fibrin glue.

• Resorbable sutures are placed to hold the graft.

Skin Substitutes -

• These skin substitutes are used to improve the healing and epithelialization process of the skin.

• They are not used as substitutes for grafts.

Different types of skin grafts include :

• Biobrane Gloves: These are tailor-made to fit a particular individual.

• Integra: This is made of bovine collagen and is placed for two weeks to help regenerate skin.

• Alloderm: This is placed over the burns for two weeks. After the granulation is achieved, split-thickness grafts are placed.

• Matriderm: This is a three-dimensional collagen matrix that helps in excellent regeneration.

Tissue Flaps -

• The exposed bone and tendon should be covered. In such cases, tissue flaps are used.

• Skin grafts cannot serve the purpose of coverage.

• Tissue flaps are commonly used from the radial forearm, dorsal forearm, groin, and abdomen, or free tissue transfer, tissue transferred along with blood supply to a specific area.

What Are the Post-Operative Instructions for Hand Burns?

• Care should be taken to prevent the infection.

• The dressing should be frequently changed every 24 hours.

• Antibiotic cream and medications should be followed as suggested by the surgeon.

• The wound should be inspected to prevent any hematoma or fluid collection.

• As suggested by doctors, physical therapy should be advocated to achieve a free range of motion.

• The hand should always be elevated to prevent edema, and hand exercises also help reduce inflammatory symptoms.

What Are the Complications?

The postoperative complications can be:

• Infection.

• Scarring.

• Contracture of the wounds.

• Edema.

• Failure of the skin grafts.

Conclusion:

Hand burns always pose a challenge. Superficial burns may not require therapy or surgery; deep burns require surgery to rehabilitate function. In some cases, second and third surgery may be required apart from primary surgical correction to achieve the desired results.