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Postburn Contractures of the Hand Duretti T. Fufa, MD, Shiow-Shuh Chuang, MD, Jui-Yung Yang, MD CME INFORMATION AND DISCLOSURES The Review Section of JHS will contain at least 3 clinically relevant articles selected by the editor to be offered for CME in each issue. For CME credit, the participant must read the articles in print or online and correctly answer all related questions through an online examination. The questions on the test are designed to make the reader think and will occasionally require the reader to go back and scrutinize the article for details. The JHS CME Activity fee of $30.00 includes the exam questions/answers only and does not include access to the JHS articles referenced.
Provider Information can be found at http://www.assh.org/Pages/ContactUs.aspx. Technical Requirements for the Online Examination can be found at http://jhandsurg. org/cme/home. Privacy Policy can be found at http://www.assh.org/pages/ASSHPrivacyPolicy.aspx. ASSH Disclosure Policy: As a provider accredited by the ACCME, the ASSH must ensure balance, independence, objectivity, and scientific rigor in all its activities. Disclosures for this Article
Statement of Need: This CME activity was developed by the JHS review section editors and review article authors as a convenient education tool to help increase or affirm reader’s knowledge. The overall goal of the activity is for participants to evaluate the appropriateness of clinical data and apply it to their practice and the provision of patient care. Accreditation: The ASSH is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. AMA PRA Credit Designation: The American Society for Surgery of the Hand designates this Journal-Based CME activity for a maximum of 2.00 “AMA PRA Category 1 Credits”. Physicians should claim only the credit commensurate with the extent of their participation in the activity. ASSH Disclaimer: The material presented in this CME activity is made available by the ASSH for educational purposes only. This material is not intended to represent the only methods or the best procedures appropriate for the medical situation(s) discussed, but rather it is intended to present an approach, view, statement, or opinion of the authors that may be helpful, or of interest, to other practitioners. Examinees agree to participate in this medical education activity, sponsored by the ASSH, with full knowledge and awareness that they waive any claim they may have against the ASSH for reliance on any information presented. The approval of the US Food and Drug Administration is required for procedures and drugs that are considered experimental. Instrumentation systems discussed or reviewed during this educational activity may not yet have received FDA approval.
Editors Ghazi M. Rayan, MD, has no relevant conflicts of interest to disclose. Authors All authors of this journal-based CME activity have no relevant conflicts of interest to disclose. In the printed or PDF version of this article, author affiliations can be found at the bottom of the first page. Planners Ghazi M. Rayan, MD, has no relevant conflicts of interest to disclose. The editorial and education staff involved with this journal-based CME activity has no relevant conflicts of interest to disclose. Learning Objectives
Discuss the relationship between the degree of burn and contracture development. Observe the different clinical patterns of postburn contracture in the hand. Appraise the methods of preventing postburn contracture. Review the nonsurgical and surgical management of postburn contractures of the hand and wrist. Assess postsurgical rehabilitation after hand burn reconstruction.
Deadline: Each examination purchased in 2014 must be completed by January 31, 2015, to be eligible for CME. A certificate will be issued upon completion of the activity. Estimated time to complete each month’s JHS CME activity is up to 2 hours. Copyright ª 2014 by the American Society for Surgery of the Hand. All rights reserved.
From the Division of Hand and Upper Extremity Surgery, Hospital for Special Surgery, New York, NY; and the Division of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan. Received for publication February 3, 2014; accepted in revised form March 19, 2014.
Corresponding author: Duretti T. Fufa, MD, Hospital for Special Surgery, 535 E. 70th Street, New York, NY 10021.; e-mail: [email protected]. 0363-5023/14/3909-0037$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.03.018
No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.
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Several functionally limiting sequelae can follow deep thermal injury to the hand. Despite appropriate initial management, contractures are common. Whereas acute burn care is often managed by multidisciplinary, specialized burn units, postburn contractures may be referred to hand surgeons, who should be familiar with the patterns of burn contracture and nonsurgical and operative options to improve function and expected outcomes. The most common and functionally limiting sequelae are contractures of the webspace, hand, and digits. Webspace contractures and postburn syndactyly are managed with scar excision and local soft tissue rearrangement or skin grafting. The burn claw hand presents as extension contracture of the metacarpophalangeal joints
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and flexion contractures of the proximal interphalangeal joints. The mainstays of management of these contractures include complete surgical excision of scar tissue and resurfacing of the resultant soft tissue defect, most commonly with full-thickness skin grafts. If scar contracture release results in major exposure of the tendons or joints, distant tissue transfer may be required. Early motion and rehabilitative modalities are essential to prevent initial contracture formation and recontracture after surgical release. (J Hand Surg Am. 2014;39(9):1869e1876. Copyright 2014 by the American Society for Surgery of the Hand. All rights reserved.) Key words Burn, hand, contractures, reconstruction.
A
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Burn Repository’s recent report, flame and scald burns make up more than 75% of burn injuries requiring hospital admission in the United States. Flame burns most commonly result from to nonework-related accidents occurring in the home (61%), followed by recreational events (6%) and industrial accidents (6%), and least from self-inflicted (1.9%) or suspected abuse (1.4%) mechanisms. Children under the age of 5 years make up 19% of burns requiring admission.1 Roughly 39% of burns involve the upper extremity.2 The hands account for less than 5% of total body surface area. Despite this small percentage, burns involving the hand are considered severe injuries meeting criteria for referral to a specialized burn center, as established by the American Burn Association and American College of Surgeons.1e3 Acute and sometimes serial assessment of the depth and extent of the burn determines the need for escharotomy and/or fasciotomy (in cases of circumferential full-thickness burn) for wound healing. The principles of acute hand burn care include elevation and functional orthosis fabrication in the intrinsic-plus or anti-deformity position. When necessary, early definitive wound coverage facilitates early motion, which is essential in hand burns.2,4e6 In the subacute phase, the diligent use of supervised motion, compressive dressings, and scar management techniques (massage and silicone sheet compression) is important. The goal of specialized, multidisciplinary care for acute hand burns is to minimize sequelae of thermal injury. These include nail deformities, hypertrophic scars, boutonniere deformity, contractures, and digit loss.2 Despite appropriate early management, functional limitations can develop. The most complex and functionally limiting sequelae include webspace (first and interdigital), and flexion or extension contractures of the hand and digits, which are the focus of this review. CCORDING TO THE NATIONAL
CLINICAL PICTURE Contracture development First-degree and superficial second-degree burns typically heal satisfactorily within about 2 weeks and have good functional and aesthetic results. Deep secondJ Hand Surg Am.
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degree (partial skin thickness), third-degree (full skin thickness), and fourth-degree (tendon, bone, nerve, or joint involvement) burns take longer than 2 weeks to heal. These injuries predictably heal by scar tissue formation. As a result, at the time of acute management, deep burns can be resurfaced with skin grafts or skin substitutes to hasten wound healing, facilitate early motion, and minimize contracture formation.4 The skin on the palmar and dorsal aspects of the hand has distinct properties that make them variably susceptible to contracture formation. Dorsal skin is more thin and pliable and the extensor mechanism lies just deep to a thin layer of subcutaneous tissue. The glabrous skin of the palmar surface contains thicker skin and subcutaneous tissues. Additional fibrous septa, and the palmar fascia, protect the flexor tendons. For these reasons, the dorsal skin and extensor mechanism are more susceptible to contractures than the palmar skin and flexor tendons. Contracture prevention Even when resurfaced early, deep burns will form contractures without appropriate preventative therapies including orthosis fabrication, pressure garments, and supervised motion. At the time of initial treatment, the hand should be fabricated in an orthosis in an antideformity position with the wrist extended 20 to 30 , metacarpophalangeal (MCP) joints flexed 70 to 90 , proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints fully extended, and the thumb in maximal palmar abduction. The hand should be elevated with the shoulder abducted to decrease edema and prevent contractures of the shoulder web in cases of more extensive proximal burns. A supervised passive motion protocol should be initiated by a hand therapist as soon as possible after injury and within the first 2 weeks of acute surgical management. At this early subacute phase, patients should also be fit for pressure garments. Silicone sheets are particularly useful to apply pressure to the dorsum of the digits and webspaces. These therapies decrease scar formation through a pressure effect and create a state of relative tissue hypoxia.2 Compressive garments should be worn 23 hours Vol. 39, September 2014
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FIGURE 1: Classification of MCP joint extension contracture. Type I contractures are limited to less than 30 with the wrist in maximal flexion, but demonstrate more than 30 passive flexion with the wrist in maximum extension. Type II contractures fail to reach 30 passive flexion even with the wrist in maximal extension. In type III, the MCP joint position is fixed regardless of wrist position. (Adapted with permission from Graham TJ, Stern PJ, True MS. Classification and treatment of postburn metacarpophalangeal joint extension contractures in children. J Hand Surg Am. 1990;15(3)450e456.)
FIGURE 2: A Radiograph and B clinical photograph and radiograph of a severely contracted hand in a pediatric patient, demonstrating malalignment of the thumb ray as a result of contracture.
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FIGURE 3: Burn claw hand deformity demonstrating loss of MCP joint flexion and PIP joint flexion.
daily for the first 6 months to 1 year after a severe hand burn, and should be removed only for bathing and therapeutic activities. Despite adequate early rehabilitation and scar management, debilitating deformity still develops in severe burns.
Current Concepts
Patterns of burn contracture Most deep dermal and full-thickness burns involve the dorsum of the hand. This is the result of the natural response to use the palms of the hands to shield the face and body. Combined with the thin and pliable nature of the skin, this makes the dorsum of the hand particularly prone to contractures. Hand burns in children may follow different patterns. Less common mechanisms, including scald burns from spilling hot liquids and friction burns such as from contact with moving treadmills, have increased prevalence in children.1,7 The mechanism of injury in children often involves the child touching a hot or rotating object or submerging the hand in a hot substance. As a result, postburn flexion contractures are more commonly seen in the young population. Graham et al8 classified extension contractures of the MP joint. Type I contractures are more than 30 passive flexion with the wrist in maximum extension, but are limited to less than 30 with the wrist in maximal flexion. This type of contracture is limited to the skin. Type II contractures fail to reach 30 passive flexion even with the wrist in maximal extension. These contractures involve scarring of both the skin and MCP joint capsule. Type III contractures are the most severe. The MCP joint position is fixed in extension regardless of wrist position (Fig. 1). Contractures of this degree often include bony or articular abnormalities (Fig. 2). Use of these physical findings can aid in surgical planning, to inform the patient whether superficial soft tissue procedures will suffice or whether capsular procedures will also need to be used. The most severe dorsal hand burns result in a claw hand deformity with the MCP joints in rigid hyperextension and PIP joint flexion contracture J Hand Surg Am.
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(Fig. 3). At the MCP joint, contracture leads to hyperextension. In severe cases, this results in dorsal subluxation of the MCP joint. Proximal and DIP joint deformities result from direct thermal injury to or desiccation of the central tendon as a result of prolonged exposure caused by skin loss. Central tendon necrosis leads to PIP flexion and palmar subluxation of the lateral bands. Severe hand burn contractures may also extend to the wrist. Wrist contractures usually only involve the skin without involvement of the deeper capsular or bony structures, except in chronic or severe cases. Postburn contractures also affect the webspaces and can lead to substantial functional and aesthetic deformities. Web contractures may involve the dorsal web, palmar web, or interdigital space, so-called burn syndactyly.9 These contractures affect the normal 45 dorsal slope and palm-to-finger ratio. Thumbeindex web contractures may involve only skin, and in chronic settings may include fibrosis and shortening of the adductor pollicis muscle.10 In severe and chronic cases, soft tissue contractures may have underlying bony abnormalities; radiographic evaluation facilitates treatment decision making. TREATMENT Management of skin loss in acute hand burn Split-thickness skin grafts remain the standard treatment for acute wound resurfacing. Although it is generally believed that graft contracture is inversely proportional to graft thickness, the thickness of split-thickness skin grafts was not shown to affect clinical range of motion after hand burn injury in a prospective, randomized trial.11 The use of skin substitutes such as acellular dermal matrices has gained popularity. Their primary benefit is not using a donor site skin graft. Whereas this may be of particular aesthetic benefit to patients who are known to form hypertrophic scars or keloids, no clinically beneficial effect of skin substitutes on secondary scar contracture has been proven over standard skin grafting. As a result, the cost of skin substitutes should be weighed against the donor site morbidity of skin grafts on a patient-to-patient basis.12,13 Nonsurgical management Once functionally limiting contractures have developed, little nonsurgical treatment can be offered to reverse the scarring process. As a result, efforts to minimize contracture development are of paramount importance. The classic rule of burn surgery is to delay secondary procedures until scars have fully matured, which takes approximately 1 year. Immature scars are Vol. 39, September 2014
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FIGURE 5: A Posteelectric burn contracture of the first webspace. B After release and resurfacing with a free lateral arm flap.
hypervascular and exhibit excessive bleeding that may adversely affect wound healing and skin graft take and cause additional scarring. Before scar maturation, compulsive, multimodal efforts to minimize contracture formation include early passive and active motion, compressive therapies with silicone sheets and pressure garments, antideformity orthosis fabrication, J Hand Surg Am.
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avoidance of direct sunlight, and scar massage. Intralesional steroid injections, light- and laser-based therapies such as pulsed dye laser, and carbon dioxide laser or intense pulsed light therapy, commonly administered by dermatologists, have been used on both maturing and mature scars of the hand, with some clinical and aesthetic improvement.14e16 Vol. 39, September 2014
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FIGURE 4: A Hand burn that was initially treated with skin grafting and went on to develop interdigital webspace contractures. B Clinical outcome following z-plasty of all webspaces.
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FIGURE 6: Severe burn syndactyly.
Indications for surgical release These rehabilitative strategies should be carried out under close supervision of physical and occupational therapists. Plateau in progress with therapy of 2 months with functionally limiting contracture is an indication for surgical management. The definition of functional limitation may be distinct for each patient based on his or her personal and professional requirements, and may even include aesthetic considerations. For excision of a purely hypertrophic scar, without functionally limiting contracture, we delay surgical management until the scar has fully matured. Surgical intervention may be indicated before the scar has fully matured in cases of severe skin contracture with limitation of motion, to prevent secondary tendon and joint contractures. In such cases, delicate handling of the soft tissues, meticulous hemostasis and compressive bandages postoperatively help minimize complications traditionally associated with surgery in an immature scar bed.
Current Concepts
Surgical management of webspace contracture Webspace contractures of the thumb and digits are common after severe hand burns.17 Contractures of the first webspace are of particular functional importance owing to their impact on thumb abduction and opposition. In mild cases, first web contractures can be managed with the standard host of z-plasty and web-deepening procedures (Fig. 4). In more severe or chronic cases, additional consideration should be given to the possibility of muscle contracture or fibrosis, which may require additional releases. In such cases, local soft tissue rearrangement may not be sufficient and may require the addition of soft tissue in the form of skin grafts or local or distant tissue transfer. Our typical surgical management of first web contracture begins with selecting a local tissue rearrangement based on the specific case. If this fails to provide adequate span of the first webspace, we J Hand Surg Am.
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perform additional release of the first dorsal interosseous and adductor pollicis muscles. Small resultant defects may be treated with full-thickness skin grafting (FTSG) from the forearm or groin. In cases in which the surrounding soft tissues are healthy, a first dorsal metacarpal artery flap from the dorsum of the index finger is another option.18 Because of the importance of the thumb web, in the presence of severe contracture in which local soft tissue is obviously insufficient or when there is joint exposure after release, we augment the local environment with free tissue transfer to minimize the chance of subsequent recurrence19e21 (Fig. 5). Our most common donor sites for free tissue transfer to the hand webspaces include the lateral arm, anterolateral thigh, and medial sural artery perforator flaps. Contractures of the second through fourth webs can be categorized as primarily affecting the dorsal web, palmar web, or interdigital space, leading to syndactyly9 (Fig. 6). These deformities are of both functional and cosmetic consequence. Our surgical approach to interdigital webspace contractures differs based on the degree of involvement. The palmar margin of the webspace normally extends to the level of the middle of the proximal phalanx. For contractures in which the distal margin of the web lies between this normal position and 75% of the length of the proximal phalanx, we can typically reconstruct the web using local tissue rearrangement. If the interdigital contracture extends beyond 75% of the length of the proximal phalanx, we use a dorsally based hourglass flap for webspace reconstruction.22 After web reconstruction, particularly when skin grafts have been used, postoperative compression is essential to minimize web creep and recurrence. Surgical management of burn claw hand Surgical management of classic burn claw hand deformity involves wide surgical excision of scar contracture followed by soft tissue coverage for the resultant defect. The pathology involves the MP, PIP, and DIP joints. As a result, surgical release must address each of these levels. First, we identify the depth of involvement (skin, tendons, joint capsule, and/or bone) and then use appropriate techniques to ensure complete release. After excision of scarred tissue, we perform manipulation of the joints to assess for remaining range of motion deficit. Residual contractures involving the deeper structures then can be released using various techniques including tenotomy of the terminal extensor tendon, extensor tenolysis, mobilization of the lateral bands, and intrinsic release. It is important to perform releases through windows of tissue that can subsequently be closed, to preserve a Vol. 39, September 2014
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Postoperative rehabilitation after hand burn reconstruction Rehabilitation after late burn reconstruction is essential and mimics the principles of rehabilitation used after acute injury: orthosis fabrication and positioning, supervised motion, scar massage, and the use of pressure dressings and garments. All of these methods are initiated by 2 to 3 weeks regardless of the reconstructive procedure performed. After FTSG, as soon as the graft shows good take, we initiate full active motion under the guidance of a therapist. OUTCOMES In our experience, complete scar excision and FTSG, in the absence of exposure of the tendons or joints, patients
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can reliably obtain 50 MP flexion by 6 weeks postoperatively. By 6 months, with rigorous therapy, full flexion has been achieved in this cohort in more than 90% of patients. In our limited cases of incomplete improvement in MP flexion, repeat scar excision employing free tissue transfer for soft tissue resurfacing improved range of motion. Undoubtedly, the severity of initial contracture and compliance with intensive therapy and scar tissue management modalities have a crucial role in our success treating burn contractures. Skin substitutes, pedicled random-pattern flaps (groin or abdominal), regional flaps (posterior interosseous), and free flaps may be used as an alternative to FTSG. Whether one resurfacing technique is superior to another with regard to maintenance of operative correction remains unclear in the literature. A study in 9 patients using 2-stage coverage after scar excision with acellular dermal matrix followed by split-thickness skin graft demonstrated maintenance of more than 80% improvement of joint range of motion and webspace correction, but follow-up was only 10 to 25 months.24 Use of random-pattern pedicled flaps from the trunk and free tissue transfer offers more robust soft tissue resurfacing with fewer tendencies toward contracture, but requires more time and advanced reconstructive techniques and risks complications. No current literature has compared recurrence using resurfacing with free tissue transfer versus skin grafting, so it remains unclear whether these more advanced techniques result in superior maintenance of surgical correction.25e27 Deep burns to the hand are severe injuries with high potential for scarring and contracture. Acute hand burns should be managed initially by a multidisciplinary team with experience in assessing burn depth and surgical debridement and resurfacing. Splinting, early range of motion, and compressive therapy are essential at all stages of burn rehabilitation. Despite adequate management of acute burns, functionally limiting contractures may occur. Surgical management of postburn hand and webspace contractures is based on diligent scar excision and replacement with supple tissues (most commonly by FTSG). After surgical management of postburn contractures, rehabilitation by splinting, compressive therapy, and early motion is essential to obtaining optimal outcomes. In our experience, surgical correction of webspace and hand contractures results in meaningful functional enhancement, and functionally limiting recontracture is rare and is best prevented by appropriate therapy.
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soft tissue plane for skin graft take. We prefer to use soft tissue releases to capsulectomy of the MCP joint when possible. Although capsulectomy yields a good intraoperative result in passive motion, additional bleeding from the dissection and associated postoperative pain affect the patient’s ability to participate in early postoperative therapy and increase recurrence. Although temporary wire and even external fixation are described to maintain intraoperative correction, we avoid this when possible, again because of the importance of initiating early range of motion.23 However, in cases of severe or recurrent contracture or incomplete surgical release, temporary wire fixation for 1 to 2 weeks may be employed to help maintain the maximal position of correction. Once adequate release has been achieved, the resultant soft tissue defect can most often be resurfaced using FTSG. The groin provides both a large area for donor tissue and a discrete donor surgical scar. We prefer FTSG to split-thickness grafting because of less secondary contracture postoperatively.24 Free tissue transfer is infrequently necessary, except in cases in which there is severe tendon or bone exposure or the remaining soft tissue bed does not provide adequate blood supply for graft take. When FTSG is used, we deflate the tourniquet before skin graft inset and ensure meticulous hemostasis to allow for graft take and minimize postoperative hematoma and swelling, which can limit motion and promote scar contracture recurrence. Wrist contractures may occur dorsally or palmarly, resulting in either extension or, more commonly, flexion contractures. They are typically limited in depth to the soft tissues, which makes standard scar management possible. This includes scar excision and z-plasty. More severe cases may require tenotomy of the flexor carpi radialis, flexor carpi ulnaris, or palmaris longus.24
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REFERENCES 1. Bessey PQ, Cassavant CW, Edelman LS, et al. National Burn Repository 2012 report. Chicago, IL: American Burn Association, National Burn Repository; 2012. 2. Kreymerman PA, Andres LA, Lucas HD, Silverman AL, Smith AA. Reconstruction of the burned hand. Plast Reconstr Surg. 2011;127(2): 752e759. 3. Tredget EE. Management of the acutely burned upper extremity. Hand Clin. 2000;16(2):187e203. 4. Stern PJ, Yakuboff KP. Burn contractures. In: Chapman MW, ed. Chapman’s Orthopaedic Surgery. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001:1763e1780. 5. Luce EA. The acute and subacute management of the burned hand. Clin Plast Surg. 2000;27(1):49e63. 6. Cartotto R. The burned hand: optimizing long-term outcomes with a standardized approach to acute and subacute care. Clin Plast Surg. 2005;32(4):515e527. 7. Friedrich JB, Muzaffar AR, Hanel DP. Pediatric hand friction burns from treadmill contact. Hand (N Y). 2007;2(4):188e193. 8. Graham TJ, Stern PJ, True MS. Classification and treatment of postburn metacarpophalangeal joint extension contractures in children. J Hand Surg Am. 1990;15(3):450e456. 9. Gulgonen A, Ozer K. Correction of postburn contractures of the second through fourth web spaces. J Hand Surg Am. 2007;32(4):536e564. 10. Smith MA, Munster AM, Spence RJ. Burns of the hand and upper limb—a review. Burns. 1998;24(6):493e505. 11. Mann R, Gibran NS, Engrav LH, et al. Prospective trial of thick vs standard split-thickness skin grafts in burns of the hand. J Burn Care Rehabil. 2001;22(6):390e392. 12. Askari M, Cohen MJ, Grossman PH, Kulber DA. The use of acellular dermal matrix in release of burn contracture scars in the hand. Plast Reconstr Surg. 2011;127(4):1593e1600. 13. Bezuhly M, Fish JS. Acute burn care. Plast Reconstr Surg. 2012;130(2):349ee3359e. 14. Parrett BM, Donelan MB. Pulsed dye laser in burn scars: current concepts and future directions. Burns. 2010;36(4):443e449. 15. Hultman CS, Edkins RE, Lee CN, Calvert CT, Cairns BA. Shine on: review of laser and light-based therapies for treatment of burn scars.
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Dermatol Res Pract. 2012;2012:243651. Available at: http://dx.doi. org/10.1155/2012/243651. Epub 2012 Jun 20. Hultman CS, Edkins RE, Wu C, Calvert CT, Cairns BA. Prospective, before-after cohort study to assess the efficacy of laser therapy on hypertrophic burn scars. Ann Plast Surg. 2013;70(5):521e526. Kamolz LP, Kitzinger HB, Karle B, Frey M. The treatment of hand burns. Burns. 2009;35(3):327e337. Yang JY. The first dorsal metacarpal flap in first web space and thumb reconstruction. Ann Plast Surg. 1991;27(3):258e264. Tsai FC, Yang JY, Mardini S, Chuang SS, Wei FC. Free splitcutaneous perforator flaps procured using a three-dimensional harvest technique for the reconstruction of postburn contracture defects. Plast Reconstr Surg. 2004;113(1):185e193. Ulkur E, Uygur F, Karagoz H, Celikoz B. Flap choices to treat complex severe postburn hand contracture. Ann Plast Surg. 2007;58(5):479e483. Woo SH, Seul JH. Optimizing the correction of severe postburn hand deformities by using aggressive contracture release and fasciocutaneous free-tissue transfers. Plast Reconstr Surg. 2001;107(1): 1e8. Salisbury RE, Bevin AG. Burn syndactyly: the “hourglass” procedure. In: Salisbury RE, Bevin AG, eds. Atlas of Reconstructive Burn Surgery. 1st ed. Philadelphia, PA: Saunders; 2010:180e185. Acarturk TO, Krishnamurthy A, Lee WP. The use of external skeletal fixation to facilitate the surgical release of wrist flexion and thumb web space contractures. J Hand Surg Am. 2006;31(10): 1619e1625. Beasley RW. Secondary repair of burned hands. Hand Clin. 1990;6(2):319e341. Askari M, Cohen MJ, Grossman PH, Kulber DA. The use of acellular dermal matrix in release of burn contracture scars in the hand. Plast Reconstr Surg. 2011;127(4):1593e1599. Yongwei P, Jianin W, Junhi Z, Guanlei T, Chun L. The abdominal flap using scarred skin in the treatment of postburn hand deformities of severe burn patients. J Hand Surg Am. 2004;29(2): 209e215. Woo SH, Seul JH. Optimizing the correction of severe postburn hand deformities using aggressive contracture release and fasciocutaneous free-tissue transfer. Plast Reconstr Surg. 2001;107(1):1e8.
JOURNAL CME QUESTIONS Postburn Contractures of the Hand
Current Concepts
The antideformity position for preventing postburn contracture of the hand includes which of the following? a. Wrist in 25 of flexion, MCP joints in 80 of flexion, and PIP joints in 25 of flexion. b. Wrist in 25 of flexion, MCP joints in 80 of flexion, and PIP joint in 0 (neutral). c. Wrist in 25 of extension, MCP joints in 80 of flexion, and PIP joints in 0 (neutral). d. Wrist in 25 of extension, MCP joints in 25 of flexion, and PIP joints in 0 (neutral). e. Wrist in 0 (neutral), MCP joints in 0 (neutral), and PIP joints in 80 of flexion.
Sequelae of severe thermal injury to the hand include which of the following? a. Flexion deformity of the metacarpophalangeal (MCP) joints and extension deformity of the proximal interphalangeal (PIP) joints. b. Flexion deformity of the wrist, MCP, and PIP joints. c. First web space abduction deformity and digital web space adduction contracture. d. Nail deformities, hypertrophic scars, boutonniere deformity, and digital loss. e. Wrist contractures are common but digital contractures are rare.
To take the online test and receive CME credit, go to http://www.jhandsurg.org/CME/home.
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Postburn Contractures of the Hand Duretti T. Fufa, MD, Shiow-Shuh Chuang, MD, Jui-Yung Yang, MD CME INFORMATION AND DISCLOSURES The Review Section of JHS will contain at least 3 clinically relevant articles selected by the editor to be offered for CME in each issue. For CME credit, the participant must read the articles in print or online and correctly answer all related questions through an online examination. The questions on the test are designed to make the reader think and will occasionally require the reader to go back and scrutinize the article for details. The JHS CME Activity fee of $30.00 includes the exam questions/answers only and does not include access to the JHS articles referenced.
Provider Information can be found at http://www.assh.org/Pages/ContactUs.aspx. Technical Requirements for the Online Examination can be found at http://jhandsurg. org/cme/home. Privacy Policy can be found at http://www.assh.org/pages/ASSHPrivacyPolicy.aspx. ASSH Disclosure Policy: As a provider accredited by the ACCME, the ASSH must ensure balance, independence, objectivity, and scientific rigor in all its activities. Disclosures for this Article
Statement of Need: This CME activity was developed by the JHS review section editors and review article authors as a convenient education tool to help increase or affirm reader’s knowledge. The overall goal of the activity is for participants to evaluate the appropriateness of clinical data and apply it to their practice and the provision of patient care. Accreditation: The ASSH is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. AMA PRA Credit Designation: The American Society for Surgery of the Hand designates this Journal-Based CME activity for a maximum of 2.00 “AMA PRA Category 1 Credits”. Physicians should claim only the credit commensurate with the extent of their participation in the activity. ASSH Disclaimer: The material presented in this CME activity is made available by the ASSH for educational purposes only. This material is not intended to represent the only methods or the best procedures appropriate for the medical situation(s) discussed, but rather it is intended to present an approach, view, statement, or opinion of the authors that may be helpful, or of interest, to other practitioners. Examinees agree to participate in this medical education activity, sponsored by the ASSH, with full knowledge and awareness that they waive any claim they may have against the ASSH for reliance on any information presented. The approval of the US Food and Drug Administration is required for procedures and drugs that are considered experimental. Instrumentation systems discussed or reviewed during this educational activity may not yet have received FDA approval.
Editors Ghazi M. Rayan, MD, has no relevant conflicts of interest to disclose. Authors All authors of this journal-based CME activity have no relevant conflicts of interest to disclose. In the printed or PDF version of this article, author affiliations can be found at the bottom of the first page. Planners Ghazi M. Rayan, MD, has no relevant conflicts of interest to disclose. The editorial and education staff involved with this journal-based CME activity has no relevant conflicts of interest to disclose. Learning Objectives
Discuss the relationship between the degree of burn and contracture development. Observe the different clinical patterns of postburn contracture in the hand. Appraise the methods of preventing postburn contracture. Review the nonsurgical and surgical management of postburn contractures of the hand and wrist. Assess postsurgical rehabilitation after hand burn reconstruction.
Deadline: Each examination purchased in 2014 must be completed by January 31, 2015, to be eligible for CME. A certificate will be issued upon completion of the activity. Estimated time to complete each month’s JHS CME activity is up to 2 hours. Copyright ª 2014 by the American Society for Surgery of the Hand. All rights reserved.
From the Division of Hand and Upper Extremity Surgery, Hospital for Special Surgery, New York, NY; and the Division of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan. Received for publication February 3, 2014; accepted in revised form March 19, 2014.
Corresponding author: Duretti T. Fufa, MD, Hospital for Special Surgery, 535 E. 70th Street, New York, NY 10021.; e-mail: [email protected]. 0363-5023/14/3909-0037$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.03.018
No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.
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Several functionally limiting sequelae can follow deep thermal injury to the hand. Despite appropriate initial management, contractures are common. Whereas acute burn care is often managed by multidisciplinary, specialized burn units, postburn contractures may be referred to hand surgeons, who should be familiar with the patterns of burn contracture and nonsurgical and operative options to improve function and expected outcomes. The most common and functionally limiting sequelae are contractures of the webspace, hand, and digits. Webspace contractures and postburn syndactyly are managed with scar excision and local soft tissue rearrangement or skin grafting. The burn claw hand presents as extension contracture of the metacarpophalangeal joints
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and flexion contractures of the proximal interphalangeal joints. The mainstays of management of these contractures include complete surgical excision of scar tissue and resurfacing of the resultant soft tissue defect, most commonly with full-thickness skin grafts. If scar contracture release results in major exposure of the tendons or joints, distant tissue transfer may be required. Early motion and rehabilitative modalities are essential to prevent initial contracture formation and recontracture after surgical release. (J Hand Surg Am. 2014;39(9):1869e1876. Copyright 2014 by the American Society for Surgery of the Hand. All rights reserved.) Key words Burn, hand, contractures, reconstruction.
A
Current Concepts
Burn Repository’s recent report, flame and scald burns make up more than 75% of burn injuries requiring hospital admission in the United States. Flame burns most commonly result from to nonework-related accidents occurring in the home (61%), followed by recreational events (6%) and industrial accidents (6%), and least from self-inflicted (1.9%) or suspected abuse (1.4%) mechanisms. Children under the age of 5 years make up 19% of burns requiring admission.1 Roughly 39% of burns involve the upper extremity.2 The hands account for less than 5% of total body surface area. Despite this small percentage, burns involving the hand are considered severe injuries meeting criteria for referral to a specialized burn center, as established by the American Burn Association and American College of Surgeons.1e3 Acute and sometimes serial assessment of the depth and extent of the burn determines the need for escharotomy and/or fasciotomy (in cases of circumferential full-thickness burn) for wound healing. The principles of acute hand burn care include elevation and functional orthosis fabrication in the intrinsic-plus or anti-deformity position. When necessary, early definitive wound coverage facilitates early motion, which is essential in hand burns.2,4e6 In the subacute phase, the diligent use of supervised motion, compressive dressings, and scar management techniques (massage and silicone sheet compression) is important. The goal of specialized, multidisciplinary care for acute hand burns is to minimize sequelae of thermal injury. These include nail deformities, hypertrophic scars, boutonniere deformity, contractures, and digit loss.2 Despite appropriate early management, functional limitations can develop. The most complex and functionally limiting sequelae include webspace (first and interdigital), and flexion or extension contractures of the hand and digits, which are the focus of this review. CCORDING TO THE NATIONAL
CLINICAL PICTURE Contracture development First-degree and superficial second-degree burns typically heal satisfactorily within about 2 weeks and have good functional and aesthetic results. Deep secondJ Hand Surg Am.
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degree (partial skin thickness), third-degree (full skin thickness), and fourth-degree (tendon, bone, nerve, or joint involvement) burns take longer than 2 weeks to heal. These injuries predictably heal by scar tissue formation. As a result, at the time of acute management, deep burns can be resurfaced with skin grafts or skin substitutes to hasten wound healing, facilitate early motion, and minimize contracture formation.4 The skin on the palmar and dorsal aspects of the hand has distinct properties that make them variably susceptible to contracture formation. Dorsal skin is more thin and pliable and the extensor mechanism lies just deep to a thin layer of subcutaneous tissue. The glabrous skin of the palmar surface contains thicker skin and subcutaneous tissues. Additional fibrous septa, and the palmar fascia, protect the flexor tendons. For these reasons, the dorsal skin and extensor mechanism are more susceptible to contractures than the palmar skin and flexor tendons. Contracture prevention Even when resurfaced early, deep burns will form contractures without appropriate preventative therapies including orthosis fabrication, pressure garments, and supervised motion. At the time of initial treatment, the hand should be fabricated in an orthosis in an antideformity position with the wrist extended 20 to 30 , metacarpophalangeal (MCP) joints flexed 70 to 90 , proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints fully extended, and the thumb in maximal palmar abduction. The hand should be elevated with the shoulder abducted to decrease edema and prevent contractures of the shoulder web in cases of more extensive proximal burns. A supervised passive motion protocol should be initiated by a hand therapist as soon as possible after injury and within the first 2 weeks of acute surgical management. At this early subacute phase, patients should also be fit for pressure garments. Silicone sheets are particularly useful to apply pressure to the dorsum of the digits and webspaces. These therapies decrease scar formation through a pressure effect and create a state of relative tissue hypoxia.2 Compressive garments should be worn 23 hours Vol. 39, September 2014
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FIGURE 1: Classification of MCP joint extension contracture. Type I contractures are limited to less than 30 with the wrist in maximal flexion, but demonstrate more than 30 passive flexion with the wrist in maximum extension. Type II contractures fail to reach 30 passive flexion even with the wrist in maximal extension. In type III, the MCP joint position is fixed regardless of wrist position. (Adapted with permission from Graham TJ, Stern PJ, True MS. Classification and treatment of postburn metacarpophalangeal joint extension contractures in children. J Hand Surg Am. 1990;15(3)450e456.)
FIGURE 2: A Radiograph and B clinical photograph and radiograph of a severely contracted hand in a pediatric patient, demonstrating malalignment of the thumb ray as a result of contracture.
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FIGURE 3: Burn claw hand deformity demonstrating loss of MCP joint flexion and PIP joint flexion.
daily for the first 6 months to 1 year after a severe hand burn, and should be removed only for bathing and therapeutic activities. Despite adequate early rehabilitation and scar management, debilitating deformity still develops in severe burns.
Current Concepts
Patterns of burn contracture Most deep dermal and full-thickness burns involve the dorsum of the hand. This is the result of the natural response to use the palms of the hands to shield the face and body. Combined with the thin and pliable nature of the skin, this makes the dorsum of the hand particularly prone to contractures. Hand burns in children may follow different patterns. Less common mechanisms, including scald burns from spilling hot liquids and friction burns such as from contact with moving treadmills, have increased prevalence in children.1,7 The mechanism of injury in children often involves the child touching a hot or rotating object or submerging the hand in a hot substance. As a result, postburn flexion contractures are more commonly seen in the young population. Graham et al8 classified extension contractures of the MP joint. Type I contractures are more than 30 passive flexion with the wrist in maximum extension, but are limited to less than 30 with the wrist in maximal flexion. This type of contracture is limited to the skin. Type II contractures fail to reach 30 passive flexion even with the wrist in maximal extension. These contractures involve scarring of both the skin and MCP joint capsule. Type III contractures are the most severe. The MCP joint position is fixed in extension regardless of wrist position (Fig. 1). Contractures of this degree often include bony or articular abnormalities (Fig. 2). Use of these physical findings can aid in surgical planning, to inform the patient whether superficial soft tissue procedures will suffice or whether capsular procedures will also need to be used. The most severe dorsal hand burns result in a claw hand deformity with the MCP joints in rigid hyperextension and PIP joint flexion contracture J Hand Surg Am.
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(Fig. 3). At the MCP joint, contracture leads to hyperextension. In severe cases, this results in dorsal subluxation of the MCP joint. Proximal and DIP joint deformities result from direct thermal injury to or desiccation of the central tendon as a result of prolonged exposure caused by skin loss. Central tendon necrosis leads to PIP flexion and palmar subluxation of the lateral bands. Severe hand burn contractures may also extend to the wrist. Wrist contractures usually only involve the skin without involvement of the deeper capsular or bony structures, except in chronic or severe cases. Postburn contractures also affect the webspaces and can lead to substantial functional and aesthetic deformities. Web contractures may involve the dorsal web, palmar web, or interdigital space, so-called burn syndactyly.9 These contractures affect the normal 45 dorsal slope and palm-to-finger ratio. Thumbeindex web contractures may involve only skin, and in chronic settings may include fibrosis and shortening of the adductor pollicis muscle.10 In severe and chronic cases, soft tissue contractures may have underlying bony abnormalities; radiographic evaluation facilitates treatment decision making. TREATMENT Management of skin loss in acute hand burn Split-thickness skin grafts remain the standard treatment for acute wound resurfacing. Although it is generally believed that graft contracture is inversely proportional to graft thickness, the thickness of split-thickness skin grafts was not shown to affect clinical range of motion after hand burn injury in a prospective, randomized trial.11 The use of skin substitutes such as acellular dermal matrices has gained popularity. Their primary benefit is not using a donor site skin graft. Whereas this may be of particular aesthetic benefit to patients who are known to form hypertrophic scars or keloids, no clinically beneficial effect of skin substitutes on secondary scar contracture has been proven over standard skin grafting. As a result, the cost of skin substitutes should be weighed against the donor site morbidity of skin grafts on a patient-to-patient basis.12,13 Nonsurgical management Once functionally limiting contractures have developed, little nonsurgical treatment can be offered to reverse the scarring process. As a result, efforts to minimize contracture development are of paramount importance. The classic rule of burn surgery is to delay secondary procedures until scars have fully matured, which takes approximately 1 year. Immature scars are Vol. 39, September 2014
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FIGURE 5: A Posteelectric burn contracture of the first webspace. B After release and resurfacing with a free lateral arm flap.
hypervascular and exhibit excessive bleeding that may adversely affect wound healing and skin graft take and cause additional scarring. Before scar maturation, compulsive, multimodal efforts to minimize contracture formation include early passive and active motion, compressive therapies with silicone sheets and pressure garments, antideformity orthosis fabrication, J Hand Surg Am.
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avoidance of direct sunlight, and scar massage. Intralesional steroid injections, light- and laser-based therapies such as pulsed dye laser, and carbon dioxide laser or intense pulsed light therapy, commonly administered by dermatologists, have been used on both maturing and mature scars of the hand, with some clinical and aesthetic improvement.14e16 Vol. 39, September 2014
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FIGURE 4: A Hand burn that was initially treated with skin grafting and went on to develop interdigital webspace contractures. B Clinical outcome following z-plasty of all webspaces.
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FIGURE 6: Severe burn syndactyly.
Indications for surgical release These rehabilitative strategies should be carried out under close supervision of physical and occupational therapists. Plateau in progress with therapy of 2 months with functionally limiting contracture is an indication for surgical management. The definition of functional limitation may be distinct for each patient based on his or her personal and professional requirements, and may even include aesthetic considerations. For excision of a purely hypertrophic scar, without functionally limiting contracture, we delay surgical management until the scar has fully matured. Surgical intervention may be indicated before the scar has fully matured in cases of severe skin contracture with limitation of motion, to prevent secondary tendon and joint contractures. In such cases, delicate handling of the soft tissues, meticulous hemostasis and compressive bandages postoperatively help minimize complications traditionally associated with surgery in an immature scar bed.
Current Concepts
Surgical management of webspace contracture Webspace contractures of the thumb and digits are common after severe hand burns.17 Contractures of the first webspace are of particular functional importance owing to their impact on thumb abduction and opposition. In mild cases, first web contractures can be managed with the standard host of z-plasty and web-deepening procedures (Fig. 4). In more severe or chronic cases, additional consideration should be given to the possibility of muscle contracture or fibrosis, which may require additional releases. In such cases, local soft tissue rearrangement may not be sufficient and may require the addition of soft tissue in the form of skin grafts or local or distant tissue transfer. Our typical surgical management of first web contracture begins with selecting a local tissue rearrangement based on the specific case. If this fails to provide adequate span of the first webspace, we J Hand Surg Am.
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perform additional release of the first dorsal interosseous and adductor pollicis muscles. Small resultant defects may be treated with full-thickness skin grafting (FTSG) from the forearm or groin. In cases in which the surrounding soft tissues are healthy, a first dorsal metacarpal artery flap from the dorsum of the index finger is another option.18 Because of the importance of the thumb web, in the presence of severe contracture in which local soft tissue is obviously insufficient or when there is joint exposure after release, we augment the local environment with free tissue transfer to minimize the chance of subsequent recurrence19e21 (Fig. 5). Our most common donor sites for free tissue transfer to the hand webspaces include the lateral arm, anterolateral thigh, and medial sural artery perforator flaps. Contractures of the second through fourth webs can be categorized as primarily affecting the dorsal web, palmar web, or interdigital space, leading to syndactyly9 (Fig. 6). These deformities are of both functional and cosmetic consequence. Our surgical approach to interdigital webspace contractures differs based on the degree of involvement. The palmar margin of the webspace normally extends to the level of the middle of the proximal phalanx. For contractures in which the distal margin of the web lies between this normal position and 75% of the length of the proximal phalanx, we can typically reconstruct the web using local tissue rearrangement. If the interdigital contracture extends beyond 75% of the length of the proximal phalanx, we use a dorsally based hourglass flap for webspace reconstruction.22 After web reconstruction, particularly when skin grafts have been used, postoperative compression is essential to minimize web creep and recurrence. Surgical management of burn claw hand Surgical management of classic burn claw hand deformity involves wide surgical excision of scar contracture followed by soft tissue coverage for the resultant defect. The pathology involves the MP, PIP, and DIP joints. As a result, surgical release must address each of these levels. First, we identify the depth of involvement (skin, tendons, joint capsule, and/or bone) and then use appropriate techniques to ensure complete release. After excision of scarred tissue, we perform manipulation of the joints to assess for remaining range of motion deficit. Residual contractures involving the deeper structures then can be released using various techniques including tenotomy of the terminal extensor tendon, extensor tenolysis, mobilization of the lateral bands, and intrinsic release. It is important to perform releases through windows of tissue that can subsequently be closed, to preserve a Vol. 39, September 2014
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Postoperative rehabilitation after hand burn reconstruction Rehabilitation after late burn reconstruction is essential and mimics the principles of rehabilitation used after acute injury: orthosis fabrication and positioning, supervised motion, scar massage, and the use of pressure dressings and garments. All of these methods are initiated by 2 to 3 weeks regardless of the reconstructive procedure performed. After FTSG, as soon as the graft shows good take, we initiate full active motion under the guidance of a therapist. OUTCOMES In our experience, complete scar excision and FTSG, in the absence of exposure of the tendons or joints, patients
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can reliably obtain 50 MP flexion by 6 weeks postoperatively. By 6 months, with rigorous therapy, full flexion has been achieved in this cohort in more than 90% of patients. In our limited cases of incomplete improvement in MP flexion, repeat scar excision employing free tissue transfer for soft tissue resurfacing improved range of motion. Undoubtedly, the severity of initial contracture and compliance with intensive therapy and scar tissue management modalities have a crucial role in our success treating burn contractures. Skin substitutes, pedicled random-pattern flaps (groin or abdominal), regional flaps (posterior interosseous), and free flaps may be used as an alternative to FTSG. Whether one resurfacing technique is superior to another with regard to maintenance of operative correction remains unclear in the literature. A study in 9 patients using 2-stage coverage after scar excision with acellular dermal matrix followed by split-thickness skin graft demonstrated maintenance of more than 80% improvement of joint range of motion and webspace correction, but follow-up was only 10 to 25 months.24 Use of random-pattern pedicled flaps from the trunk and free tissue transfer offers more robust soft tissue resurfacing with fewer tendencies toward contracture, but requires more time and advanced reconstructive techniques and risks complications. No current literature has compared recurrence using resurfacing with free tissue transfer versus skin grafting, so it remains unclear whether these more advanced techniques result in superior maintenance of surgical correction.25e27 Deep burns to the hand are severe injuries with high potential for scarring and contracture. Acute hand burns should be managed initially by a multidisciplinary team with experience in assessing burn depth and surgical debridement and resurfacing. Splinting, early range of motion, and compressive therapy are essential at all stages of burn rehabilitation. Despite adequate management of acute burns, functionally limiting contractures may occur. Surgical management of postburn hand and webspace contractures is based on diligent scar excision and replacement with supple tissues (most commonly by FTSG). After surgical management of postburn contractures, rehabilitation by splinting, compressive therapy, and early motion is essential to obtaining optimal outcomes. In our experience, surgical correction of webspace and hand contractures results in meaningful functional enhancement, and functionally limiting recontracture is rare and is best prevented by appropriate therapy.
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soft tissue plane for skin graft take. We prefer to use soft tissue releases to capsulectomy of the MCP joint when possible. Although capsulectomy yields a good intraoperative result in passive motion, additional bleeding from the dissection and associated postoperative pain affect the patient’s ability to participate in early postoperative therapy and increase recurrence. Although temporary wire and even external fixation are described to maintain intraoperative correction, we avoid this when possible, again because of the importance of initiating early range of motion.23 However, in cases of severe or recurrent contracture or incomplete surgical release, temporary wire fixation for 1 to 2 weeks may be employed to help maintain the maximal position of correction. Once adequate release has been achieved, the resultant soft tissue defect can most often be resurfaced using FTSG. The groin provides both a large area for donor tissue and a discrete donor surgical scar. We prefer FTSG to split-thickness grafting because of less secondary contracture postoperatively.24 Free tissue transfer is infrequently necessary, except in cases in which there is severe tendon or bone exposure or the remaining soft tissue bed does not provide adequate blood supply for graft take. When FTSG is used, we deflate the tourniquet before skin graft inset and ensure meticulous hemostasis to allow for graft take and minimize postoperative hematoma and swelling, which can limit motion and promote scar contracture recurrence. Wrist contractures may occur dorsally or palmarly, resulting in either extension or, more commonly, flexion contractures. They are typically limited in depth to the soft tissues, which makes standard scar management possible. This includes scar excision and z-plasty. More severe cases may require tenotomy of the flexor carpi radialis, flexor carpi ulnaris, or palmaris longus.24
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REFERENCES 1. Bessey PQ, Cassavant CW, Edelman LS, et al. National Burn Repository 2012 report. Chicago, IL: American Burn Association, National Burn Repository; 2012. 2. Kreymerman PA, Andres LA, Lucas HD, Silverman AL, Smith AA. Reconstruction of the burned hand. Plast Reconstr Surg. 2011;127(2): 752e759. 3. Tredget EE. Management of the acutely burned upper extremity. Hand Clin. 2000;16(2):187e203. 4. Stern PJ, Yakuboff KP. Burn contractures. In: Chapman MW, ed. Chapman’s Orthopaedic Surgery. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001:1763e1780. 5. Luce EA. The acute and subacute management of the burned hand. Clin Plast Surg. 2000;27(1):49e63. 6. Cartotto R. The burned hand: optimizing long-term outcomes with a standardized approach to acute and subacute care. Clin Plast Surg. 2005;32(4):515e527. 7. Friedrich JB, Muzaffar AR, Hanel DP. Pediatric hand friction burns from treadmill contact. Hand (N Y). 2007;2(4):188e193. 8. Graham TJ, Stern PJ, True MS. Classification and treatment of postburn metacarpophalangeal joint extension contractures in children. J Hand Surg Am. 1990;15(3):450e456. 9. Gulgonen A, Ozer K. Correction of postburn contractures of the second through fourth web spaces. J Hand Surg Am. 2007;32(4):536e564. 10. Smith MA, Munster AM, Spence RJ. Burns of the hand and upper limb—a review. Burns. 1998;24(6):493e505. 11. Mann R, Gibran NS, Engrav LH, et al. Prospective trial of thick vs standard split-thickness skin grafts in burns of the hand. J Burn Care Rehabil. 2001;22(6):390e392. 12. Askari M, Cohen MJ, Grossman PH, Kulber DA. The use of acellular dermal matrix in release of burn contracture scars in the hand. Plast Reconstr Surg. 2011;127(4):1593e1600. 13. Bezuhly M, Fish JS. Acute burn care. Plast Reconstr Surg. 2012;130(2):349ee3359e. 14. Parrett BM, Donelan MB. Pulsed dye laser in burn scars: current concepts and future directions. Burns. 2010;36(4):443e449. 15. Hultman CS, Edkins RE, Lee CN, Calvert CT, Cairns BA. Shine on: review of laser and light-based therapies for treatment of burn scars.
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Dermatol Res Pract. 2012;2012:243651. Available at: http://dx.doi. org/10.1155/2012/243651. Epub 2012 Jun 20. Hultman CS, Edkins RE, Wu C, Calvert CT, Cairns BA. Prospective, before-after cohort study to assess the efficacy of laser therapy on hypertrophic burn scars. Ann Plast Surg. 2013;70(5):521e526. Kamolz LP, Kitzinger HB, Karle B, Frey M. The treatment of hand burns. Burns. 2009;35(3):327e337. Yang JY. The first dorsal metacarpal flap in first web space and thumb reconstruction. Ann Plast Surg. 1991;27(3):258e264. Tsai FC, Yang JY, Mardini S, Chuang SS, Wei FC. Free splitcutaneous perforator flaps procured using a three-dimensional harvest technique for the reconstruction of postburn contracture defects. Plast Reconstr Surg. 2004;113(1):185e193. Ulkur E, Uygur F, Karagoz H, Celikoz B. Flap choices to treat complex severe postburn hand contracture. Ann Plast Surg. 2007;58(5):479e483. Woo SH, Seul JH. Optimizing the correction of severe postburn hand deformities by using aggressive contracture release and fasciocutaneous free-tissue transfers. Plast Reconstr Surg. 2001;107(1): 1e8. Salisbury RE, Bevin AG. Burn syndactyly: the “hourglass” procedure. In: Salisbury RE, Bevin AG, eds. Atlas of Reconstructive Burn Surgery. 1st ed. Philadelphia, PA: Saunders; 2010:180e185. Acarturk TO, Krishnamurthy A, Lee WP. The use of external skeletal fixation to facilitate the surgical release of wrist flexion and thumb web space contractures. J Hand Surg Am. 2006;31(10): 1619e1625. Beasley RW. Secondary repair of burned hands. Hand Clin. 1990;6(2):319e341. Askari M, Cohen MJ, Grossman PH, Kulber DA. The use of acellular dermal matrix in release of burn contracture scars in the hand. Plast Reconstr Surg. 2011;127(4):1593e1599. Yongwei P, Jianin W, Junhi Z, Guanlei T, Chun L. The abdominal flap using scarred skin in the treatment of postburn hand deformities of severe burn patients. J Hand Surg Am. 2004;29(2): 209e215. Woo SH, Seul JH. Optimizing the correction of severe postburn hand deformities using aggressive contracture release and fasciocutaneous free-tissue transfer. Plast Reconstr Surg. 2001;107(1):1e8.
JOURNAL CME QUESTIONS Postburn Contractures of the Hand
Current Concepts
The antideformity position for preventing postburn contracture of the hand includes which of the following? a. Wrist in 25 of flexion, MCP joints in 80 of flexion, and PIP joints in 25 of flexion. b. Wrist in 25 of flexion, MCP joints in 80 of flexion, and PIP joint in 0 (neutral). c. Wrist in 25 of extension, MCP joints in 80 of flexion, and PIP joints in 0 (neutral). d. Wrist in 25 of extension, MCP joints in 25 of flexion, and PIP joints in 0 (neutral). e. Wrist in 0 (neutral), MCP joints in 0 (neutral), and PIP joints in 80 of flexion.
Sequelae of severe thermal injury to the hand include which of the following? a. Flexion deformity of the metacarpophalangeal (MCP) joints and extension deformity of the proximal interphalangeal (PIP) joints. b. Flexion deformity of the wrist, MCP, and PIP joints. c. First web space abduction deformity and digital web space adduction contracture. d. Nail deformities, hypertrophic scars, boutonniere deformity, and digital loss. e. Wrist contractures are common but digital contractures are rare.
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