International Wound Journal ISSN 1742-4801
LETTER TO THE EDITOR
Pressure necrosis of the fingertip during management of hand burn injury: a word of caution Dear Editor, Pressure necrosis is an unwarranted, preventable complication and can be influenced by various internal and external factors. We are presenting an unusual case of fingertip pressure necrosis that occurred during the management of a hand burn injury. A 57-year-old, right-handed dominant male patient presented to the accident and emergency department with a contact burn caused by the coal fireplace at home to the dorsum of his right middle, ring and little finger. The patient is an ex-smoker and is known to have insulin-dependent diabetes causing peripheral diabetic neuropathy. On examination, he had deep dermal burns to the dorsum of the middle finger and a mixed thickness burn to the right ring and little fingers. He had an immediate debridement and excision of burnt skin of the middle and ring fingers and reconstruction with split skin grafts. It was decided to manage the little finger with repeated dressings until the burnt skin fully demarcates. Two weeks later, the grafts failed and the little finger’s burn did not heal. To cover the unhealed wounds, two random abdominal flaps were raised to reconstruct the little and ring fingers and it was decided to preserve the graft of the middle finger. The hand was dressed with jelonet® , packed well with gauze and held in place with adhesive plaster (Figure 1). He was attending the dressing clinic regularly and he was advised to use the right thumb and index fingers to enhance mobilization and to avoid joint stiffness. Twenty days later, he was taken to theatres for the separation of the skin flaps. The flaps were healthy but the graft on the middle finger failed and further grafting was performed. A small area of pressure necrosis on the pulp of his index finger measuring 1 × 1 cm was noticed (Figure 2). The pressure necrosis was treated conservatively. Strict advice was given
Figure 1 Hand in the same position for 20 days.
Figure 2 Pressure necrosis on pulp of index finger.
to enhance mobilization and to keep the fingers dry. Regular follow-up in the dressing clinic until full healing was achieved after 10 days. The history of uncontrolled diabetes was the main influence on us to use thin random abdominal flaps knowing that they are safe and easy to harvest compared to other complex choices of flaps (1). A disadvantage of these flaps is that they can be bulky and also may not match with the skin thickness of the hand. Finally, the immobility of the hand while in the abdominal tissue pocket results in joint stiffness and can predispose to having a pressure necrosis in stationary areas (2). The individual’s potential to develop pressure ulcers maybe influenced by many internal and external risk factors, which therefore should be considered when performing a risk assessment: reduced mobility or immobility, sensory impairment, acute illness, level of consciousness, extreme of ages, vascular disease, severe chronic or terminal illness, previous history of pressure damage, malnutrition and dehydration (3). The patient was given strict advice for hand physiotherapy. Unfortunately, he did not mobilize them during this period. Immobilization of the fingers and the given history of peripheral diabetic neuropathy have resulted in the development of pressure necrosis on the fingertip. Also bulky dressing and improper padding are other factors might have predisposed for this complication. Pressure necrosis can occur in the fingertip predisposed by neuropathy and bulky dressing. Mobilization has always played an important role to prevent pressure necrosis. This role should also be applied to the fingers following a hand surgery. Other measures include proper padding on pressure points, use of loose dressings, patient’s education, mobilization
© 2014 The Authors International Wound Journal © 2014 Medicalhelplines.com Inc and John Wiley & Sons Ltd
291
A. Allouni et al.
Letter to the Editor
of the non-covered fingers and more regular follow-up visits. Also specialist involvement with management of such patients is advised. Ammar Allouni, Obaidullah Zafar, David Wilson, FRCS Burns Centre Birmingham University Hospital Birmingham, UK [email protected]
References 1. Ali A, Farag M, Safe K. Reconstruction of hand and forearm defects by abdominal thin skin flaps. J Plast Reconstr Surg 2007;31:181–185. 2. Yilmaz S, Saydam M, Seven E, Ercocen AR. Paraumbilical perforator-based pedicled abdominal flap for extensive soft-tissue deficiencies of the forearm and hand. Ann Plast Surg 2005;54:565. 3. Rycroft-Malone J. Pressure ulcer risk assessment and prevention. Royal College of Nursing. Clinical Practice Guidelines 2001. URL http://rcn.org.uk
doi: 10.1111/iwj.12253
292
© 2014 The Authors International Wound Journal © 2014 Medicalhelplines.com Inc and John Wiley & Sons Ltd
LETTER TO THE EDITOR
Pressure necrosis of the fingertip during management of hand burn injury: a word of caution Dear Editor, Pressure necrosis is an unwarranted, preventable complication and can be influenced by various internal and external factors. We are presenting an unusual case of fingertip pressure necrosis that occurred during the management of a hand burn injury. A 57-year-old, right-handed dominant male patient presented to the accident and emergency department with a contact burn caused by the coal fireplace at home to the dorsum of his right middle, ring and little finger. The patient is an ex-smoker and is known to have insulin-dependent diabetes causing peripheral diabetic neuropathy. On examination, he had deep dermal burns to the dorsum of the middle finger and a mixed thickness burn to the right ring and little fingers. He had an immediate debridement and excision of burnt skin of the middle and ring fingers and reconstruction with split skin grafts. It was decided to manage the little finger with repeated dressings until the burnt skin fully demarcates. Two weeks later, the grafts failed and the little finger’s burn did not heal. To cover the unhealed wounds, two random abdominal flaps were raised to reconstruct the little and ring fingers and it was decided to preserve the graft of the middle finger. The hand was dressed with jelonet® , packed well with gauze and held in place with adhesive plaster (Figure 1). He was attending the dressing clinic regularly and he was advised to use the right thumb and index fingers to enhance mobilization and to avoid joint stiffness. Twenty days later, he was taken to theatres for the separation of the skin flaps. The flaps were healthy but the graft on the middle finger failed and further grafting was performed. A small area of pressure necrosis on the pulp of his index finger measuring 1 × 1 cm was noticed (Figure 2). The pressure necrosis was treated conservatively. Strict advice was given
Figure 1 Hand in the same position for 20 days.
Figure 2 Pressure necrosis on pulp of index finger.
to enhance mobilization and to keep the fingers dry. Regular follow-up in the dressing clinic until full healing was achieved after 10 days. The history of uncontrolled diabetes was the main influence on us to use thin random abdominal flaps knowing that they are safe and easy to harvest compared to other complex choices of flaps (1). A disadvantage of these flaps is that they can be bulky and also may not match with the skin thickness of the hand. Finally, the immobility of the hand while in the abdominal tissue pocket results in joint stiffness and can predispose to having a pressure necrosis in stationary areas (2). The individual’s potential to develop pressure ulcers maybe influenced by many internal and external risk factors, which therefore should be considered when performing a risk assessment: reduced mobility or immobility, sensory impairment, acute illness, level of consciousness, extreme of ages, vascular disease, severe chronic or terminal illness, previous history of pressure damage, malnutrition and dehydration (3). The patient was given strict advice for hand physiotherapy. Unfortunately, he did not mobilize them during this period. Immobilization of the fingers and the given history of peripheral diabetic neuropathy have resulted in the development of pressure necrosis on the fingertip. Also bulky dressing and improper padding are other factors might have predisposed for this complication. Pressure necrosis can occur in the fingertip predisposed by neuropathy and bulky dressing. Mobilization has always played an important role to prevent pressure necrosis. This role should also be applied to the fingers following a hand surgery. Other measures include proper padding on pressure points, use of loose dressings, patient’s education, mobilization
© 2014 The Authors International Wound Journal © 2014 Medicalhelplines.com Inc and John Wiley & Sons Ltd
291
A. Allouni et al.
Letter to the Editor
of the non-covered fingers and more regular follow-up visits. Also specialist involvement with management of such patients is advised. Ammar Allouni, Obaidullah Zafar, David Wilson, FRCS Burns Centre Birmingham University Hospital Birmingham, UK [email protected]
References 1. Ali A, Farag M, Safe K. Reconstruction of hand and forearm defects by abdominal thin skin flaps. J Plast Reconstr Surg 2007;31:181–185. 2. Yilmaz S, Saydam M, Seven E, Ercocen AR. Paraumbilical perforator-based pedicled abdominal flap for extensive soft-tissue deficiencies of the forearm and hand. Ann Plast Surg 2005;54:565. 3. Rycroft-Malone J. Pressure ulcer risk assessment and prevention. Royal College of Nursing. Clinical Practice Guidelines 2001. URL http://rcn.org.uk
doi: 10.1111/iwj.12253
292
© 2014 The Authors International Wound Journal © 2014 Medicalhelplines.com Inc and John Wiley & Sons Ltd
