Review Article
SEVERE
BURNS
OF THE HAND: A PRACTICAL THEIR MANAGEMENT
GUIDE
TO
P. J. SYKES Consultant Plastic Surgeon, WelshRegional Burns and Plastic Surgery Unit, St. Lawrence Hospital, Chepstow
Those who work regularly in burns units will be familiar with most of the contents of this paper, but it may be helpful for surgeons who treat hand burns less frequently outside this environment. Several reviews have appeared in recent years and this practical guide is intended to complement these (Salisbury, 1979; Leung and Chow, 1982; Madden and Enna, 1983; Groenevelt and Kreis, 1985; Levine and Buchanan, 1986; Silver, 1987; Grossman, 1990).
Assessment of the patient The general treatment of the patient who is likely to have suffered extensive burns takes priority in the acute stage (Settle, 1986; Muir et al., 1987), but thereafter the hands become increasingly important, especially when grafting is necessary.
Local assessment of the burn wound
The treatment of all burns depends on an accurate diagnosis of the depth of the burn. The history of the accident is helpful : for example, flash burns are superficial whereas electrical or molten metal injuries are deep and scalds cause intermediate damage. A superjicial partial-thickness burn is red, painful, wet and shiny. Capillary blanching and return of colour occurs with local pressure and sensation to pin-prick is preserved. It will heal spontaneously in 10 to 14 days. At the other end of the scale, there is usually no difficulty in diagnosing afull-thickness burn, whose dry surface eschar is hard and coagulated with a variable colour from pale white to carbonised black. Pain is not a major feature and the area is insensitive to pin-prick. Healing is by slow marginal epithelial ingrowth. Between these extremes lie the deep partial-thickness or deep dermal burns, which are frequently caused by scalds, have a pale pink or white surface, do not blanch and have reduced sensation to pin-prick. Mis-diagnosis is common even for the experienced. They will heal in three to four weeks from viable cells in deep skin adnexae if infection is controlled, but cause significant scarring. These three depths of burn require different treatment. 6
Emergency measures Circumferential deep burns, which are of full or deep dermal thickness can produce a tourniquet effect so that circulation to the limb and hand is restricted, With the development of burn oedema, rising extra-vascular tissue pressure (Kingsley et al., 1979) threatens capillary perfusion in the limb even before pulses are lost. Emergency escharotomy is essential and can be performed at the bedside, using intravenous analgesia if a deep dermal burn retains some sensation. Monitoring of the distal circulation using ultrasound recordings (Moylan et al., 1971), pulse oximetry (Bardakjian et al., 1988) or photoelectric plethysmography (Smith et al., 1984) has been described but escharotomy should be performed on clinical grounds, especially if the patient is to be transferred a long distance to a burns unit. The skin incision must extend the full length of the area and in deep burns, especially those caused by high-voltage injuries where there is significant muscle swelling, the deep fascia should also be divided (Wang et al., 1985). The technique in the arm, hand and fingers is described by Salisbury and Dingeldein (1988). There is a significant increase in survival of fingers following lateral digital escharotomy compared with those not decompressed (Salisbury and Levine, 1976) and when there is marked swelling of the hand with limitation of finger flexion, the dorsal interosseous compartments must also be released as there is risk of ischaemic necrosis in the intrinsic muscles (Salisbury et al., 1974). The bleeding that results is controlled by dressings and elevation and the escharotomy wound will eventually be covered by the skin grafts used to treat the burn, although in the fingers linear wounds close once swelling subsides.
Large superficial bums These patients require hospitalisation. In young children and some adults, a simple bulky dressing of Vaseline tulle with an antibacterial agent covered with absorbent gauze is used so that the hand is supported and bandaged in a bulky dressing in the safe Edinburgh position. A splint should be used to hold the wrist in moderate extension and the limb elevated. The dressings may be left undisturbed for the healing period and can be patched THE
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with additional absorbent gauze in areas where a little exudate soaks through. More extensive soiling requires repeat dressings but these are not routine. Unnecessary interference causes pain, risks cross-infection and may damage fragile new skin. When the hand has healed at ten to 14 days physiotherapy rapidly restores movement. In co-operative patients these exercises can be started at the onset and continued throughout the healing phase while the wound is observed by placing the hand in a plastic bag bandaged around the wrist (Sykes and Bailey, 1976; Frandsen et al., 1977). An anti-bacterial cream such as silver sulphadiazine is used and the bag can be incorporated into an arm dressing. A cock-up wrist splint is worn to prevent flexion which may lead to clawing of the fingers. The bags are changed when they become full of exudate, which may be once or twice a day in the early period. A full range of active movement can be expected by the time the wound has healed. This technique was originally used to treat deep dermal burns during their lengthy healing phase but can be applied to superficial burns and mixed depth injuries.
Localised full-thickness burns Well-demarcated full-thickness burns should be excised under tourniquet onto viable tissue and grafted. The burns of children who grasp the bars of electric fires (Merrell et al., 1986) and palmar burns in all age-groups are best treated in this way. Pink fat caused by capillary stasis is dead and should be removed. A full-thickness graft cut to the exact pattern of the resulting raw area is then sewn accurately into place and secured with tie-over dressings. The hand is splinted in the functional position until the graft has taken at seven to ten days and is then re-mobilised. Full-thickness grafts do not shrink to produce secondary contractures on the flexor surfaces and are superior in this respect to more superficial skin grafts. When large areas are involved, making full-thickness grafting impractical, an alternative is to use mediumthickness skin grafts taken with the graft knife or dermatome (Burkhardt, 1972). All split-skin grafts will contract to a variable degree and the use of this technique requires a period of prolonged splintage to counteract flexion deformities. The small supple hands of children will tolerate such treatment for many weeks until the phase of contracture is over, but the robust hand of a manual worker will become irreversibly stiff even after a short period of immobilisation and dynamic splintage and exercises are necessary. The choice of either splitskin or full-thickness grafts is much debated. Large fullthickness grafts cause donor site problems but flexion contractures are a risk with split-grafts which take more reliably. There is little difference in the long-term VOL.
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BURNS
OF THE
HAND
functional outcome when either is used to resurface palmar burns (Pensler et al., 1988). Deep partial thickness or deep dermal burns These commonly affect the dorsum of the hand and their management is controversial. The literature is extensive and confusing. Supporters of early excision around four days (Wexler et al., 1974; Burke et al., 1976; Pegg et al., 1984; Mahler et al., 1987) show that this approach speeds healing and reduces the length of stay in hospital. It may also produce a better scar and allows early mobilisation. However this method requires expertise, theatre time and resources compared to a conservative regime. Several comparative studies have been made. In these reports some surgeons (Labandter et al., 1976; Salisbury and Wright, 1982) operated early, whereas others operated at two weeks (Krizek et al., 1973; Edstrom et al., 1979). Both conservative and surgical methods gave good results. The depth of these burns is also difficult to diagnose, so that the inexperienced surgeon may operate on superficial burns that would have healed in two weeks. A “test shave” may overcome this problem. The technique of tangential excision, employed at around four days, involves the successive shaving of the burnt surface with the graft knife set to cut a thin slice until fine punctate bleeding is encountered as the tips of the vertical dermal capillaries are shaved off (Janzekovic, 1970; Jackson and Stone, 1972). With experience, this can be done under tourniquet and confirmed with this deflated. Between the sites of punctate bleeding, dermal collagen is exposed and some epithelium remains viable in the deep skin adnexae. This surface will support a skin graft applied immediately so that it does not dry out, but delayed exposed grafting can be used and the surface kept moist with saline soaks until the grafts are applied within one or two hours. This reduces the risk of graft failure from haematoma. The grafts survive by picking up a blood supply from the capillary loops which have been transected. The intervening dermis becomes incorporated beneath the graft. Remnants of epithelium which grow for some months after graft take may produce small inclusion cysts on the surface (Tandon and Sutherland, 1977). The conservative approach is safer for those who are not experienced in the diagnosis of deep dermal burns or in the technique of tangential excision. The burnt hand is enclosed in a plastic bag with a suitable antibacterial agent and physiotherapy started immediately, as described previously. The burn often takes more than three weeks to heal and some degree of scar hypertrophy is inevitable. Dorsal scars over the M.P. joints are initially tight, limiting full flexion, and some cracking and excoriation may persist in the scars for several months after healing. The use of pressure (Ketchum et al., 1974) 7
P. J. SYKES
particularly by elasticated gloves (Leung and Ng, 1980), is beneficial for hypertrophic scars and may also be used in cases where skin grafts have been necessary. They need to be worn for around six months. These two methods are both effective for treating deep dermal burns. Each has advantages and drawbacks and these should be considered when selecting the best option for individual patients. The systemic effect of the burn must be taken into account (Salisbury and Wright, 1982) and with life-threatening burns there should be some caution before operating (Levine et al., 1979). Extensive full-thickness burns These are harder to treat and the outcome less satisfactory, particularly when both surfaces of the hand are involved. They are frequently associated with large body burns which limit the available donor sites for skin grafts. Some initial caution is worthwhile and delay may make a decision about treatment easier. Palmar burns are not always as deep as originally thought. Thick keratin is resistant to heat and clasping the hand in response to pain protects the palm. The thin exposed skin on the dorsum is more vulnerable and these burns are common. Rather than allow granulation, large deep burns are better treated by early surgery. Excision with the scalpel, under tourniquet, down to viable tissue followed by the application of partial-thickness grafts is the method of choice. A plane of oedema beneath the dead skin makes this easier at this stage. On the dorsum, this leaves behind a thin layer of viable tissue containing patent veins over the intact extensor tendons. Physiotherapy and splintage are necessary to prevent contractures, particularly in the palm. When burns are very deep and excision exposes avascular structures which will not support skin grafts, flap coverage is necessary. On surfaces where flexion contractures can be expected even if grafts survive, then primary flap coverage may be chosen. When bone, joint or tendon are exposed this is essential and, if later reconstructive surgery is anticipated, the primary use of flaps usually makes this easier. Small defects may be covered by local flaps but these are often unavailable or unreliable in burnt hands and, when large areas are involved, distant flap cover will be needed. The choice is again affected by the extent of the burn. The groin flap is valuable, especially for the dorsum of the hand (Hanumadas et al., 1987), and in some circumstances pedicle random flaps from the abdomen may still be useful (Antia and Pandey, 1976). A reversedpedicle radial forearm flap is extremely versatile (Dent and Fattah, 1985 ; Groenevelt and Schoorl, 1985 ; McLean and Clark, 1985; Hallock, 1986) and can be used for all surfaces of the hand. It can also be used as a fascial flap and covered with a graft (Jin et al., 1985). Some caution 8
is necessary if vessels may not be patent (Jones and O’Brien, 1985; Hannock, 1986) and when burns are caused by high-voltage injuries but, as long as the circulation to the hand through the ulnar artery is not compromised, this technique is very useful, especially to provide thin flap cover for exposed tendons. The operation confines the damage to one limb and does not immobilise the hand by attaching it to the trunk in a dependent position for three weeks. Other forearm flaps on reversed vascular pedicles (Costa and Soutar, 1988; Glasson and Lovie, 1988; Zancolli and Angrigiani, 1988) have similar benefits but are more difficult to raise and have not gained as much popularity. Cross-arm fasciocutaneous flaps can also be used (Dickinson and Roberts, 1986) and, if combined with a nerve suture, may provide sensation (Dolich et al., 1978). Free flaps are also useful for localised areas of deep burn where adjacent undamaged vessels are available for microvascular anastomosis (Shen et al., 1988). There are many possible donor sites (Hing et al., 1985). In larger burns, the requirements of the palm and dorsal skin are different. A thin durable adherent sensitive flap is needed for the palm, whereas the dorsum will tolerate a thicker insensitive layer of flap skin which may be thinned later. Although the appearance may not be particularly pleasing, this will serve the functional requirements of the area. Groin flaps tend to be thick, whereas forearm skin is thinner and more suitable for the palm. These pedicle flaps are insensitive but several free flaps may be planned to allow the microneural link-up of sensory nerves in an attempt to provide some useful sensation (Webster and Soutar, 1986). Where extensive skin grafting is required and donor sites are limited, early coverage of hand burns carries a high priority. Consequently the techniques employed to cover large but functionally less important sites, such as the trunk and lower limbs, are rarely necessary. In these circumstances the surgeon may use homografts or cultured skin with or without a variety of biological dressings. Expanded mesh grafting (Tanner et al., 1964) is another valuable technique but is less acceptable in the hand as the inevitable secondary epithelialisation between the mesh is unsightly and produces hypertrophic scar. A 1 to 1.5 meshed but unexpanded graft does have the advantage of allowing escape of haematoma and is useful. Electrical burns of the hand Much has been written about these burns (Salisbury et al., 1973; Bingham, 1980). Small full-thickness lowvoltage injuries, which frequently have entry and exit sites, are common and are treated by early excision and grafting. High-voltage injuries produce more extensive damage but are fortunately rare. The local and generalised effect of the current is dependent on many physical THE
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factors such as voltage, tissue resistance and length of exposure and much is known about the mechanism causing the tissue damage (Lee and Kolodney, 1987; Daniel et al., 1988; Zachary et al., 1990), which proves more complex than was once thought. Immediate treatment of extensive electrical injuries, which frequently involve the hand and arm, must take into account the risk of compartment syndromes and also renal and cardiac involvement. Muscle damage, with systematic release of dangerous intracellular components, is often more extensive than the surface skin wound indicates and dead tissue must be excised. An overaggressive policy of debridement may remove the risk of leaving dead muscle but can sacrifice tissue which may survive, so repeated removal of what is obviously dead may pay dividends. Skin cover using combinations of flaps and grafts is necessary to preserve function of the limb. Nerves are frequently involved, sometimes only temporarily. Blood vessels are also damaged and distal ischaemia may result. Aggressive early arterial grafting has proved valuable in preserving hand function in these circumstances (Wang et al., 1985). Long-term complex reconstructive procedures are usually necessary.
Chemical bums of the hands Specific reviews of this topic are useful (Curreri and Asch, 1970; Bentivegna and Deane, 1990). The longterm management of these burns, which are frequently full-thickness in depth, varies little from that already discussed but emergency measures are vital and different. Water lavage remains the mainstay of early treatment Bromberg et al., 1965; Leonard et al., 1982) and should be prolonged when exposure to caustic chemicals has been extensive. Phenol, which is insoluble in water, is best removed with glycerol (Pardoe et al., 1976) and lime powder should be removed physically before lavage. Phosphorous particles are identified and neutralised with weak solutions of copper sulphate (Ben-Hur et al., 1972). Hydrofluoric acid burns frequently involve the hands, cause considerable pain and have stimulated many papers (Dibbell et al., 1970; Inverson et al., 1971). They cause extensive damage by absorption into the tissues (Anderson and Anderson, 1988). Active fluoride ions can be neutralised by binding to calcium and the topical application of calcium carbonate gel is most useful for small burns (Chick and Borah, 1989). The local injection of calcium gluconate (Blunt, 1964) or its intra-arterial infusion (Vance et al., 1986) has also been recommended, but early excision of the affected area will prevent continued extensive damage and relieve pain (Buckingham, 1988). It is beyond the scope of this paper to list the numerous other antidotes which, in any case, are not always available at short notice (Jelenko, 1974). VOL.
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BURNS
OF THE
Rehabilitation
HAND
and reconstruction
When severe hand burns have healed, long-term complications are common and require treatment by an experienced team. Secondary surgery (Beasley, 1981; Groenevelt et al., 1985) is frequently required and may need repeating to release flexion contractures in growing children. Complex soft-tissue and bony reconstructive procedures designed to restore pinch and power grip are necessary following disabling burns. Thumb reconstruction is difficult because of scars and several methods are described (Pohl et al., 1976; Stern and MacMillan, 1983; May et al., 1984; Ward et al., 1985). When the hand is badly deformed, a detailed treatment plan is essential and several operations are often necessary. Common problems caused by secondary skin graft or scar contractures following inadequate primary care or post-operative physiotherapy and splintage are worth a brief mention. They occur most often in children. Various patterns of flexion contracture involving the fingers and thumb are described (Stern et al., 1985 and 1987). The mainstay of treatment remains the use of skin grafts, followed by splintage, after these tight scars have been released by transverse incisions on the volar surface of the hand. This may be at one or multiple joint levels and the use of temporary Kirschner wire immobilisation is controversial (Jackson and Brown, 1970; Alexander et al., 1981; Thind et al., 1988). Capsulotomy of the P.I.P. joint with check-rein release may be necessary (Watson et al., 1979). Care must be taken to avoid division of the neurovascular bundles which may also go into spasm if an attempt is made to extend the finger fully. A compromise correction may be necessary to avoid this complication. Fortunately the severe and often bizarre contractures seen in children burnt and treated in underdeveloped countries are rarely seen here as primary care is better. Skin flaps may be necessary to relieve extensive contractures where incision exposes tendons, nerves and bone. Local flaps may be used in preference to grafts and to avoid post-operative splintage (Groenevelt and Schoorl, 1985 ; Matthews and Morgan, 1987). Secondary contractures on the extensor surface are difficult to treat (Adamson, 1968; Salisbury and Dingeldein, 1988). They are caused by scar tightness limiting flexion of the M.P. joints and, if severe, cancause hyperextension deformities with dislocation of the joint and inability to flex the fingers. Extensor tendons are often involved and may need tenolysis or lengthening. Capsulotomy of the M.P. joint may also be necessary. In less severe cases, scar release and skin grafting may be sufficient but frequently a large skin flap is necessary. Adduction contractures of the thumb are very disabling. They are frequently the result of both scar and secondary fibrotic contracture of the adductor muscle and are sometimes associated with hyperextension of the 9
P. J. SYKES
M.P. joint which needs release and capsulotomy. In less severe cases, Z-plasties alone may be sufficient (Furnas, 1965; Woolf and Broadbent, 1972; Hirshowitz et al., 1975) but otherwise full release by division of the adductor insertion is necessary. The first and second metacarpals should be held apart temporarily with Kirschner wires. It is then usually best to cover the resulting defect by using either local (Spinner, 1969 ; Flatt and Wood, 1970; Brown, 1972) or distant flaps. Boutonniere deformity is common and harder to treat than that which follows clean traumatic division of the central slip, because skin cover is poor in healed burns. It may result from direct thermal injury to the extensor apparatus but is often seen as a secondary phenomenon produced by oedema and stretching of this structure beneath burnt skin. It can be prevented by early prophylactic splintage and this method may be successful in treating mobile cases of the deformity, although the splint can cause undue pressure on the scarred skin. Attempts may be made to reconstruct the central slip using a number of techniques, but arthrodesis may be the best option where there is significant functional deficit (Larson et al., 1970; Groenevelt and Schoorl, 1986). Burns syndactyly and dorsal hooding of the webs of the fingers is common and is treated by a combination of local flaps, Z-plasties and grafts. Many techniques have been devised over the years (Shaw et al., 1973; Krizek et al., 1974; MacDougal et al., 1976; Browne et al., 1978; Chapman et al., 1987). Recurrence may be prevented by using pressure gloves or web inserts (Alexander et al., 1982). Nail and nail-fold contractures are frequently encountered and, although not functionally debilitating, can be very annoying so that treatment is required (Ngim and Soin, 1986; Alsbjorn et al., 1985; Spanwen et al., 1987). Ulnar and median nerve compression can occur following wrist burns (Fissette, 198 1). Conclusion
Burns commonly involve the hands and severe functional problems will follow if the basic principles of treatment are ignored. Skin grafting and flap coverage are frequently necessary and physiotherapy and splintage play a major role. Long-term functional problems can be avoided with expert primary care, but secondary reconstruction is inevitable when the burns are deep and extensive. The expertise of a hand surgical team familiar with the treatment of burns is required throughout. References ADAMSON, J. E., CRAWFORD, H. H., HORTON, C. E. and BROWN, L. H. (1968). Treatment of dorsal bum adduction contracture of the hand. Plastic and Reconstructive Surgery, 42: 4: 355-359. ALEXANDER, J. W., MacMILLAN, B. G., MARTEL, L. and KRUMMEL, R. (1981). Surgical Correction of Postburn Flexion Contractures of the Fingers in Children, Plastic and Reconstructive Surgery, 68: 2: 218-224. ALEXANDER, J. W.,MacMILLAN,B. G.andMARTEL,L.(1982).Correction 10
of Postburn Syndactyly: An Analysis of Children with Introduction of the VM-Plasty and Postoperative Pressure Inserts. Plastic and Reconstructive Swgery, 70: 3: 345-352. ALSBJORN, B. F., METZ, P. and EBBEHBJ, J. (1985). Nailfold retraction due to burn wound contracture. A surgical procedure. Burns including Thermal Injury, 11: 3: 166167. ANDERSON, W. J. and ANDERSON, J. R. (1988). Hydrofluoric acid burns of the hand: Mechanism of iniurv and treatment. Journal of Hand Sureerv. - . 13A: 1: 52-57. ANTIA, N. H. and PANDEY, S. D. (1976). Semilunar abdominal bipedicled flap for cover of dorsal defects of the hand. British Journal of Plastic Surgery, 29:2: 1299131. BARDAKJIAN, V. B., KENNEY, J. G., EDGERTON, M. T. and MORGAN, R. F. (1988). Pulse oximetry for vascular monitoring in burned upper extremities. Journal of Burn Care and Rehabilitation, 9: 1: 63365. BEASLEY, R. W. (1981). Secondary Repair of Burned Hands. Clinics in Plastic Surgery, 8: 1: 141-162. BEN-HUR, N., GILADI, A., APPLEBAUM, J. and NEUMAN, Z. (1972). Phosphorus burns: The antidote: A new approach. British Journal of Plastic Surgery, 25 : 2455249. BENTIVEGNA, P. E. and DEANE, L. M. (1990). Chemical Burns of the Upper Extremity. Hand Clinics, 6: 2: 2533259. BINGHAM, H. G. (1980). Electrical injuries to the upper extremity-a review. Bums including Thermal Injury, 7 : 3 : 155-l 57. BLUNT, C. P. (1964). Treatment of hydrofluoric acid skin burns by injection with calcium gluconate. Industrial Medicine and Surgery, 33: 869-871. BROMBERG, B. E., SONG, I. C. and WALDEN, R. H. (1965). Hydrotherapy of chemical burns. Plastic and Reconstructive Surgery, 35: 1: 85-95. BROWN, P. W. (1972). Adduction-flexioncontractures ofthe thumb. Correction with dorsal rotation flap and release of contracture. Clinical Orthopaedics and Related Research, 88: 161-168. BROWNE, E. Z., TEAGUE, M. A. and SNYDER, C. C. (1978). Bum syndactyly. Plastic and Reconstructive Surgery, 62: 1: 92-95. BUCKINGHAM, F. M. (1988). Surgery: A Radical Approach to Severe Hydrofluoric Acid Burns. A Case Report. Journal of Occupational Medicine, 30: 11: 873-874. BURKE, J. F., BONDOC, C. C., QUINBY, W. C. and REMENSNYDER, J. P. (1976). Primary surgical management of the deeply burned hand. Journal ofTrauma, 16: 8: 593-598. BURKHARDT, B. R. (1972). Immediate or early excision and skin grafting of full-thickness bums of the palm. Report of two cases. Plastic and Reconstructive Surgery, 49 : 5 : 573-575. CHAPMAN, P., BANERJEE, A. and CAMPBELL, R. C. (1987). Extended use of the Mustard& dancing man procedure. British Journal of Plastic Surgery, 40: 432435. CHICK, L. and BORAH, G. (1989). Topical calciumcarbonategel for treatment of hydrofluoric acid bums to the hand. Proceedings of the American Bum Association, 21: 159. COSTA, H. and SOUTAR, D. S. (1988). The distally based island posterior interosseous flap. British Journal of Plastic Surgery, 41: 221-227. CURRERI, P. W., ASCH, M. J. and PRUITT, B. A. (1970). The treatment of chemical bums: specialised diagnostic, therapeutic and prognostic considerations. Journal of Trauma, 10: 8: 634642. DANIEL, R. K., BALLARD, P. A., HEROUX, P., ZELT, R. G. and HOWARD, C. R. (1988). High-voltage electrical injury: Acute pathophysiology. Journal of Hand Surgery, 13A: 1: 44-49. DENT, A. R. and FATAH, M. F. (1985). The radial forearm island flap in early reconstruction of a severely burned hand. Burns including Thermal Injury, 11: 4: 285-288. DIBBELL, D. G., IVERSON, R. E., JONES, W., LAUB, D. R. and MADISON, M. S. (1970). Hydrofluoric Acid Burns of the Hand. Journal of Bone and Joint Surgery, 52A: 5: 931-936. DICKINSON, J. C. and ROBERTS, A. H. N. (1986). Fascia-Cutaneous CrossArm Flaps in Hand Reconstruction. Journal of Hand Surgery, 11B: 3: 394398. DOLICH, B. H., OLSHANSKY, K. J. and BABAR, A. H. (1978). Use of a cross-forearm neurocutaneous flap to provide sensation and coverage in hand reconstruction. Plastic and Reconstructive Surgery, 62: 4: 550-558. EDSTROM, L., ROBSON, M. C., MACCHIAVERNA, J. R. and SCALA, A. D. (1979). Management of Deep Partial Thickness Dorsal Hand Burns. Study of Operative vs Nonoperative Therapy. Orthopaedic Review, 8: 4: 27-33. FISSETTE, J., ONKELINX, A. and FANDI, N. (1981). Carpal and Guyon tunnel syndrome in bums at the wrist. Journal of Hand Surgery, 6: 1: 13-15. FLATT, A. E. and WOOD, V. E. (1970). Multiple dorsal rotation flaps from the hand for thumb web contractures. Plastic and Reconstructive Surgery, 45: 3 : 258-262. _
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FRANDSEN, P. A., OVERGAARD-NIELSEN, H. and SOMMER, J. (1977). Treatment of second-degree burns of the hand: a comparison of occlusive dressings and gloves. Bums including Thermal Injury, 4: 1: 2&22. FURNAS, D. N. (1965). The tetrahedral Z-plasty. Plastic and Reconstructive Surgery, 35: 3: 291-302. GLASSON, D. W. and LOVIE, M. J. (1988). The ulnar island flap in hand and forearm reconstruction. British Journalof Plastic Surgery, 41: 4: 349-353. GROENEVELT, F. and KREIS, R. W. (1985). Burns of the Hand. Netherlands JournalofSurgery, 37: 6: 167-173. GROENEVELT, F. and SCHOORL, R. (1985). Cross-finger flaps from scarred skin in burned hands. British Journal of Plastic Surgery, 38: i87-189. GROENEVELT, F. and SCHOORL, R. (1985). The reversed forearm flap using scarred skin in hand reconstruction. British Journal of Plastic Surgery, 38: 398-402. GROENEVELT, F., SCHOORL, R. and HERMANS, R. P. (1985). Retrospective study of reconstructive surgery of the burned hand. Burns including Thermal Injury, 11: 5: 351-358. GROENEVELT, F. and SCHOORL, R. (1986). Reconstructive Surgery of the Post-Burn Boutonni&e Deformity. Journal of Hand Surgery, 11B: 1: 23-30. GROSSMAN, J. A. I. (1990). Bums of the Upper Extremity, Hand Clinics, 6: 2: 163-354. HALLOCK, G. G. (1986). Caution in using the Chinese radial forearm flap (Letter). Plastic and Reconstructive Surgery, 77: 1: 164-165. HALLOCK, G. G. (1986). The radial forearm flap in burn reconstruction. Journal of Burn Care and Rehabilitation, 7: 4: 318-322. HANUMADASS, M., KAGAN, R. and MATSUDA, T. (1987). Early Coverage of Deep Hand Bums with Groin Flaps. Journal of Trauma, 27: 2: 109-l 14. HING, D. N., BUNCKE, H. J., ALPERT, B. S. and GORDON, L. (1985). Free Flap Coverage of the Hand. Hand Clinics, 1: 4: 741-758. HIRSHOWITZ, B., KAREV, A. and ROUSSO, M. (1975). Combined double Zplasty and Y-V advancement for thumb web contracture. The Hand, 7 : 3 : 291-293. IVERSON, R. E., LAUB, D. R. and MADISON, M. S. (1971). Hydrofluoric acid bums. Plastic and Reconstructive Surgery, 48: 2: 107-l 12. JACKSON, D. M. and STONE, P. A. (1972). Tangential excision and grafting of burns. British Journal of Plastic Surgery, 25: 41ti26. JACKSON, I. T. and BROWN, G. E. D. (1970). A method of treating chronic flexion contractares of the fingers. British Journal of Plastic Surgery, 23: 373-379. JANZEKOVIC, Z. (1970). A new concept of the early excision and immediate grafting of bums. Journal of Trauma, 10: 12: 1103-1108. JELENKO, C. (1974). Chemicals that “bum”. Journal of Trauma, 14: 1: 65-72. JIN, Y. T., GAUN, W. X., SHI, T. M., QUIAN, Y. L., YU, L. G. and CHANG, T. S. (1985). Reversed island forearm fascial flap in hand surgery. Annals of Plastic Surgery, 15: 4: 340-347. JONES, B. M. and O’BRIEN, C. J. (1985). Acute ischaemia of the hand resulting from elevation of a radial forearm flap. British Journal of Plastic Surgery, 38: 396-397. KETCHUM, L. D., COHEN, I. K. and MASTERS, F. W. (1974). Hypertrophic scars and keloids. A Collective Review. Plastic and Reconstructive Surgery, 53: 2: 140-154. KINGSLEY, N. W., STEIN, J. M. and LEVENSON, S. M. (1979). Measuring Tissue Pressure to Assess the Severity of Burn-Induced Ischemia. Plastic and Reconstructive Surgery, 63 : 3 : 404-408. KRIZEK, T. J., FLAGG, S. V., WOLFORT, F. G. and JABALEY, M. E. (1973). Delayed primary excision and skin grafting of the burned hand. Plastic and Reconstructive Surgery, 51: 5: 524-529. KRIZEK, T. J., ROBSON, M. C. and FLAGG, S. V. (1974). Management of bum syndactyly. Journal of Trauma, 14: 7: 587-593. LABANDTER, H., KAPLAN, 1. and SHAVITT, C. (1976). Burns of the dorsum of the hand: conservative treatment with intensive physiotherapy versus tangential excision and grafting. British Journal of Plastic Surgery, 29: 352354. LARSON, D. L., WOFFORD, B. H., EVANS, E. B. and LEWIS, S. R. (1970). Repair of the boutonniere deformity of the burned hand. Journal of Trauma, 10: 6: 481-487. LEE, R. C. and KOLODNEY, M. S. (1987). Electrical Injury Mechanisms: Dynamics of the Thermal Response. Plastic and Reconstructive Surgery, 80: 5: 663-671. LEE, R. C. and KOLODNEY, M. S. (1987). Electrical Injury Mechanisms: Electrical Breakdown of Cell Membranes. Plastic and Reconstructive Surgery, 80 : 5 : 672-68 1. LEONARD, L. G., SCHEULEN, J. J. and MUNSTER, A. M. (1982). Chemical Burns: Effect of Prompt First Aid. Journal of Trauma, 22: 5: 420-423. LEUNG, P. C. and NG, M. (1980). Pressure treatment for hypertrophic scars resulting from burns. Burns including Thermal Injury, 6: 4: 244250. VOL.
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LEUNG, P. C. and CHOW, Y. Y. N. (1982). Treatment of burned hands. Burns including Thermal Injury, 8: 5: 338-344. LEVINE, B. A., SIRINEK, K. R., PETERSON, H. D. and PRUITT, B. A. (1979). Efficacy of Tangential Excision and Immediate Autografting of Deep Second-degree Burns of the Hand. Journal of Trauma, 19: 9: 670-673. LEVINE, N. S. and BUCHANAN, R. T. (1986). The care of the burned upper extremities. Clinics in Plastic Surgery, 13: 1: 107-l 18. MacDOUGAL, B., WRAY, R. C. and WEEKS, P. M. (1976). Lateral-volar finger flap for the treatment of burn syndactyly. Plastic and Reconstructive Surgery, 57: 2: 167-171. MADDEN, J. W. and ENNA, C. D. (1983). The management of acute thermal injuries to the upper extremity. Journal of Hand Surgery, 8: 5(2): 785-788. MAHLER, I)., BENMEIR, P., BEN YAKAR, Y., GREBER, B., SAGI, A., HAUBEN, D., ROSENBERG, L. and SAROV, B. (1987). Treatmentof the burned hand: early surgical treatment (1975-85) vs. conservative treatment (1964-74). A comparative study. Burns including Thermal Injury, 13: 1: 4548. MATTHEWS, R. N. and MORGAN, B. D. G. (1987). Multiple seagull flaps for distal contractures in electrical bums. British Journal of Plastic Surgery, 40: 47-5 I. MAY, I. W., DONELAN, M. B., TOTH, B. A. and WALL, J. (1984). Thumb reconstruction in the burned hand by advancement pollicization of the second ray remnant. Journal of Hand Surgery, 9A: 4: 484489. MCLEAN, N. R. and CLARKE, J. A. (1985). Resurfacing of the severely burned hand with a radial forearm flap. Burns including Thermal Injury, 11: 5: 371373. MERRELL, S. W., SAFFLE, J. R., SCHNEBLY, W. A., KRAVITZ, M. and WARDEN, G. D. (1986). Full thickness skin grafting for contact burns of the palm in children. Journal of Burn Care and Rehabilitation, 7: 6: 501507. MOYLAN, J. A., INGE, W. W. and PRUITT, B. A. (1971). Circulatory changes following circumferential extremity bums evaluated by the ultrasound flow meter: an analysis of 60 thermally injured limbs. Journal of Trauma, 11: 9: 763-770. MUIR, I. F. K., BARCLAY, T. L. and SETTLE, J. A. D. Bunzs and their treatment, 3rd edn. London, Butterworths, 1987. NGIM, R. C. K. and SOIN, K. (1986). Postburn Nailfold Retraction: A Reconstructive Technique. Journal of Hand Surgery, 11B: 3: 385-387. PARDOE, R., MINAMI, R. T., SATO, R. M. and SCHLESINGER, S. L. (1976). Phenol burns. Burns including Thermal Injury, 3: 29-41. PEGG, S. P., CAVAYE, D., FOWLER, D. and JONES, M. (1984). Results of early excision and grafting in hand bums. Bums including Thermal Injury, 11:99-103. PENSLER, J. M., STEWARD, R., LEWIS, S. R. and HERNDON, D. N. (1988). Reconstruction of the Burned Palm: Full-Thickness versus SplitThickness Skin Grafts-Long-Term Follow-Up. Plastic and Reconstructive Surgery, 81: 1: 46-49. POHL, A. L., LARSON, D. L. and LEWIS, S. R. (1976). Thumb reconstruction in the severely burned hand. Plastic and Reconstructive Surgery, 57: 3: 320328. SALISBURY, R. E., HUNT, J. L., WARDEN, G. D. and PRUITT, B. A. (1973). Management of electrical burns of the upper extremity. Plastic and Reconstructive Surgery, 51: 6: 648-652. SALISBURY, R. E., McKEEL, D. W. and MASON, A. D. (1974). Ischemic Necrosis of the Intrinsic Muscles of the Hand after Thermal Injuries. Journal ofBone and Joint Surgery, 56A: 8: 1701-1707. SALISBURY, R. E. and LEVINE, N. S. The early management of upper extremity thermal injury. In: Salisbury, R. E. and Pruitt, B. A. (Eds) Major Problems in Clinical Surgery. Vol. 19. Burns of the Upper Extremity. Philadelphia, W. B. Saunders, 1976: 3646. SALISBURY, R. E. Burns of the Upper Extremity. In: Artz, C. P. Moncrief, J. A. and Pruitt, B. A. (Eds.) Burns: A Team Approach. Philadelphia. W. B. Saunders, 1979: 320-329. SALISBURY, R. E. and WRIGHT, P. (1982). Evaluation of Early Excision of Dorsal Burns of the Hand. Plastic and Reconstructive Surgery, 69: 4: 67& 675. SALISBURY, R. E. and DINGELDEIN, G. P. The Burned Hand and Upper Extremity. In: Green, D. P. (Ed.) Operative Hand Surgery, 2nd edn. New York, Churchill Livingstone, 1988: Vol. 3: 2135-2164. SETTLE, J. A. D. Bums-the first five days. Romford, Smith and Nephew Pharmaceuticals Ltd, 1986. SHAW, D. T., LI, C. S., RICHEY, D. G. and NAHIGAN, S. H. (1973). Interdigital Butterlly Flap in the Hand (The Double-Opposing Z-Plasty). Journal of Bone and Joint Surgery, 55A: 8: 1677-1679. SHEN, T., SUN, Y., CAO, D. and WANG, N. (1988). The Use of Free Flaps in Bum Patients: Experiences with 70 Flaps in 65 Patients. Plastic and Reconstructive Surgery, 81: 3: 352-357. 11
P. J. SYKES SILVER, L. (1987). Bums of the hand and wrist. Current concepts in diagnosis and treatment. Orthopaedic Review, 16: 6: 394-400. SMITH, D. J., BENDICK, P. J. and MADISON, S. A. (1984). Evaluation of vascular compromise in the injured extremity: A photoplethysmographic technique. Journal of Hand Surgery, 9A: 3: 314-319. SPAUWEN, P. H. M., BROWN, I. F., SAUER, E. W. and KLASLEN, H. J. (1987). Management of fingernail deformities after thermal injury. Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery, 21: 3: 253-255. SPINNER, M. (1969). Fashioned transpositional flap for soft tissue adduction contractme of the thumb. Plastic and Reconstmctive Surgery, 44: 4: 345348. STERN, P. J. and MacMILLAN, B. G. (1983). Reconstruction of the burned thumb by metacarpal lengthening. Burns including Thermal Injury, 10: 2: 127-130. STERN, P. J., NEALE, H. W., CARTER, W. and MacMILLAN, B. G. (1985). Classification and management of burned thumb contractures in children. Bums including Thermal Injury, 11: 3 : 168-174. STERN, P. J., NEALE, H. W., GRAHAM, T. J. and WARDEN, G. D. (1987). Classification and treatment of postburn proximal interphalangeal joint flexion contractures in children. Journal of Hand Surgery, 12A : 3 : 45&457. SYKES, P. J. andBAILEY, B. N. (1976). Treatment ofhand bums withocclusive bags: A comparison of 3 methods. Bums including Thermal Injury, 2: 3: 162-168. TANDON, S. N. and SUTHERLAND, A. B. (1976). Some problems following tangential excision and skin grafting in dermal burns. Bums including Thermal Injury, 3: 2: 96-99. TANNER, J. C., VANDEPUT, J. and OLLEY, J. F. (1964). The mesh skin graft. Plastic and Reconstructive Surgery, 34: 3: 287-292. THIND, R. S., SINGH, H. A. and THIND, M. S. (1988). Severe post bum flexion contractme of hand-A single stage method of management. Acta Chirurgiae Plasticae, 30: 1: 31-38. VANCE, M. V., CURRY, S. C., KUNKEL, D. B., RYAN, P. J. and RUGGERI, S. B. (1986). Digital Hydrofluoric Acid Bums: Treatment with
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Intraarterial
Calcium
Infusion.
Annals of Emergency
Medicine,
15 : 8 : 890-
896. WANG, X.-W., ROBERTS, B. B., ZAPATA-SIRVENT, R. L., ROBINSON, W. A., WAYMACK, J. P., LAW, E. J., MacMILLAN, B. G. and DAVIES, J. W. L. (1985). Early vascular grafting to prevent upper extremity necrosis after electrical bums. Bums including Thermal Injury, 11: 359-366. WANG, X.-W., SANG, H.-H., DAVIES, J. W. L., MacMILLAN, B. G. and ROBINSON, W. A. (1985). Role of escharotomy and fasciotomy as a first aid measure in the early treatment of an electrically burned arm and wrist. Bums including Thermal Injury, 11: 6: 419422. WARD, J. W., PENSLER, J. M. and PARRY, S. W. (1985). Pollicization for Thumb Reconstruction in Severe Pediatric Hand Bums. Plastic and Reconstructive Surgery, 76: 6: 927-932. WATSON, H. K., LIGHT, T. R. and JOHNSON, T. R. (1979). Checkrein resection for tlexion contracture of the middle joint, Journal of Hand Surgery, 4:1:67-71. WEBSTER, M. H. C. and SOUTAR, D. S. PracticalGuide to Free Tissue Tramferr. London, Butterworths, 1986. 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. Plastic and Reconstructive Surgery, 54: 3 : 268-273. WOOLF, R. M. and BROADBENT, T. R. (1972). The four-flap Z-plasty. Plastic and Reconstructive Surgery, 49: 1: 48-51. ZACHARY, L. M., LEE, R. C. and GOTTLIEB, L. J. (1990). Evolving Clinical and Scientific Concepts of Upper Extremity Electrical Trauma. Hand Clinics, 6: 2: 243-252. ZANCOLLI, E. A. and ANGRIGIANI, C. (1988). Posterior interosseous island forearm flap. Journal of Hand Surgery, 13B: 2: 130-135.
0 1991 The British Society for Surgery of the Hand
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P. J. SYKES Consultant Plastic Surgeon, WelshRegional Burns and Plastic Surgery Unit, St. Lawrence Hospital, Chepstow
Those who work regularly in burns units will be familiar with most of the contents of this paper, but it may be helpful for surgeons who treat hand burns less frequently outside this environment. Several reviews have appeared in recent years and this practical guide is intended to complement these (Salisbury, 1979; Leung and Chow, 1982; Madden and Enna, 1983; Groenevelt and Kreis, 1985; Levine and Buchanan, 1986; Silver, 1987; Grossman, 1990).
Assessment of the patient The general treatment of the patient who is likely to have suffered extensive burns takes priority in the acute stage (Settle, 1986; Muir et al., 1987), but thereafter the hands become increasingly important, especially when grafting is necessary.
Local assessment of the burn wound
The treatment of all burns depends on an accurate diagnosis of the depth of the burn. The history of the accident is helpful : for example, flash burns are superficial whereas electrical or molten metal injuries are deep and scalds cause intermediate damage. A superjicial partial-thickness burn is red, painful, wet and shiny. Capillary blanching and return of colour occurs with local pressure and sensation to pin-prick is preserved. It will heal spontaneously in 10 to 14 days. At the other end of the scale, there is usually no difficulty in diagnosing afull-thickness burn, whose dry surface eschar is hard and coagulated with a variable colour from pale white to carbonised black. Pain is not a major feature and the area is insensitive to pin-prick. Healing is by slow marginal epithelial ingrowth. Between these extremes lie the deep partial-thickness or deep dermal burns, which are frequently caused by scalds, have a pale pink or white surface, do not blanch and have reduced sensation to pin-prick. Mis-diagnosis is common even for the experienced. They will heal in three to four weeks from viable cells in deep skin adnexae if infection is controlled, but cause significant scarring. These three depths of burn require different treatment. 6
Emergency measures Circumferential deep burns, which are of full or deep dermal thickness can produce a tourniquet effect so that circulation to the limb and hand is restricted, With the development of burn oedema, rising extra-vascular tissue pressure (Kingsley et al., 1979) threatens capillary perfusion in the limb even before pulses are lost. Emergency escharotomy is essential and can be performed at the bedside, using intravenous analgesia if a deep dermal burn retains some sensation. Monitoring of the distal circulation using ultrasound recordings (Moylan et al., 1971), pulse oximetry (Bardakjian et al., 1988) or photoelectric plethysmography (Smith et al., 1984) has been described but escharotomy should be performed on clinical grounds, especially if the patient is to be transferred a long distance to a burns unit. The skin incision must extend the full length of the area and in deep burns, especially those caused by high-voltage injuries where there is significant muscle swelling, the deep fascia should also be divided (Wang et al., 1985). The technique in the arm, hand and fingers is described by Salisbury and Dingeldein (1988). There is a significant increase in survival of fingers following lateral digital escharotomy compared with those not decompressed (Salisbury and Levine, 1976) and when there is marked swelling of the hand with limitation of finger flexion, the dorsal interosseous compartments must also be released as there is risk of ischaemic necrosis in the intrinsic muscles (Salisbury et al., 1974). The bleeding that results is controlled by dressings and elevation and the escharotomy wound will eventually be covered by the skin grafts used to treat the burn, although in the fingers linear wounds close once swelling subsides.
Large superficial bums These patients require hospitalisation. In young children and some adults, a simple bulky dressing of Vaseline tulle with an antibacterial agent covered with absorbent gauze is used so that the hand is supported and bandaged in a bulky dressing in the safe Edinburgh position. A splint should be used to hold the wrist in moderate extension and the limb elevated. The dressings may be left undisturbed for the healing period and can be patched THE
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with additional absorbent gauze in areas where a little exudate soaks through. More extensive soiling requires repeat dressings but these are not routine. Unnecessary interference causes pain, risks cross-infection and may damage fragile new skin. When the hand has healed at ten to 14 days physiotherapy rapidly restores movement. In co-operative patients these exercises can be started at the onset and continued throughout the healing phase while the wound is observed by placing the hand in a plastic bag bandaged around the wrist (Sykes and Bailey, 1976; Frandsen et al., 1977). An anti-bacterial cream such as silver sulphadiazine is used and the bag can be incorporated into an arm dressing. A cock-up wrist splint is worn to prevent flexion which may lead to clawing of the fingers. The bags are changed when they become full of exudate, which may be once or twice a day in the early period. A full range of active movement can be expected by the time the wound has healed. This technique was originally used to treat deep dermal burns during their lengthy healing phase but can be applied to superficial burns and mixed depth injuries.
Localised full-thickness burns Well-demarcated full-thickness burns should be excised under tourniquet onto viable tissue and grafted. The burns of children who grasp the bars of electric fires (Merrell et al., 1986) and palmar burns in all age-groups are best treated in this way. Pink fat caused by capillary stasis is dead and should be removed. A full-thickness graft cut to the exact pattern of the resulting raw area is then sewn accurately into place and secured with tie-over dressings. The hand is splinted in the functional position until the graft has taken at seven to ten days and is then re-mobilised. Full-thickness grafts do not shrink to produce secondary contractures on the flexor surfaces and are superior in this respect to more superficial skin grafts. When large areas are involved, making full-thickness grafting impractical, an alternative is to use mediumthickness skin grafts taken with the graft knife or dermatome (Burkhardt, 1972). All split-skin grafts will contract to a variable degree and the use of this technique requires a period of prolonged splintage to counteract flexion deformities. The small supple hands of children will tolerate such treatment for many weeks until the phase of contracture is over, but the robust hand of a manual worker will become irreversibly stiff even after a short period of immobilisation and dynamic splintage and exercises are necessary. The choice of either splitskin or full-thickness grafts is much debated. Large fullthickness grafts cause donor site problems but flexion contractures are a risk with split-grafts which take more reliably. There is little difference in the long-term VOL.
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functional outcome when either is used to resurface palmar burns (Pensler et al., 1988). Deep partial thickness or deep dermal burns These commonly affect the dorsum of the hand and their management is controversial. The literature is extensive and confusing. Supporters of early excision around four days (Wexler et al., 1974; Burke et al., 1976; Pegg et al., 1984; Mahler et al., 1987) show that this approach speeds healing and reduces the length of stay in hospital. It may also produce a better scar and allows early mobilisation. However this method requires expertise, theatre time and resources compared to a conservative regime. Several comparative studies have been made. In these reports some surgeons (Labandter et al., 1976; Salisbury and Wright, 1982) operated early, whereas others operated at two weeks (Krizek et al., 1973; Edstrom et al., 1979). Both conservative and surgical methods gave good results. The depth of these burns is also difficult to diagnose, so that the inexperienced surgeon may operate on superficial burns that would have healed in two weeks. A “test shave” may overcome this problem. The technique of tangential excision, employed at around four days, involves the successive shaving of the burnt surface with the graft knife set to cut a thin slice until fine punctate bleeding is encountered as the tips of the vertical dermal capillaries are shaved off (Janzekovic, 1970; Jackson and Stone, 1972). With experience, this can be done under tourniquet and confirmed with this deflated. Between the sites of punctate bleeding, dermal collagen is exposed and some epithelium remains viable in the deep skin adnexae. This surface will support a skin graft applied immediately so that it does not dry out, but delayed exposed grafting can be used and the surface kept moist with saline soaks until the grafts are applied within one or two hours. This reduces the risk of graft failure from haematoma. The grafts survive by picking up a blood supply from the capillary loops which have been transected. The intervening dermis becomes incorporated beneath the graft. Remnants of epithelium which grow for some months after graft take may produce small inclusion cysts on the surface (Tandon and Sutherland, 1977). The conservative approach is safer for those who are not experienced in the diagnosis of deep dermal burns or in the technique of tangential excision. The burnt hand is enclosed in a plastic bag with a suitable antibacterial agent and physiotherapy started immediately, as described previously. The burn often takes more than three weeks to heal and some degree of scar hypertrophy is inevitable. Dorsal scars over the M.P. joints are initially tight, limiting full flexion, and some cracking and excoriation may persist in the scars for several months after healing. The use of pressure (Ketchum et al., 1974) 7
P. J. SYKES
particularly by elasticated gloves (Leung and Ng, 1980), is beneficial for hypertrophic scars and may also be used in cases where skin grafts have been necessary. They need to be worn for around six months. These two methods are both effective for treating deep dermal burns. Each has advantages and drawbacks and these should be considered when selecting the best option for individual patients. The systemic effect of the burn must be taken into account (Salisbury and Wright, 1982) and with life-threatening burns there should be some caution before operating (Levine et al., 1979). Extensive full-thickness burns These are harder to treat and the outcome less satisfactory, particularly when both surfaces of the hand are involved. They are frequently associated with large body burns which limit the available donor sites for skin grafts. Some initial caution is worthwhile and delay may make a decision about treatment easier. Palmar burns are not always as deep as originally thought. Thick keratin is resistant to heat and clasping the hand in response to pain protects the palm. The thin exposed skin on the dorsum is more vulnerable and these burns are common. Rather than allow granulation, large deep burns are better treated by early surgery. Excision with the scalpel, under tourniquet, down to viable tissue followed by the application of partial-thickness grafts is the method of choice. A plane of oedema beneath the dead skin makes this easier at this stage. On the dorsum, this leaves behind a thin layer of viable tissue containing patent veins over the intact extensor tendons. Physiotherapy and splintage are necessary to prevent contractures, particularly in the palm. When burns are very deep and excision exposes avascular structures which will not support skin grafts, flap coverage is necessary. On surfaces where flexion contractures can be expected even if grafts survive, then primary flap coverage may be chosen. When bone, joint or tendon are exposed this is essential and, if later reconstructive surgery is anticipated, the primary use of flaps usually makes this easier. Small defects may be covered by local flaps but these are often unavailable or unreliable in burnt hands and, when large areas are involved, distant flap cover will be needed. The choice is again affected by the extent of the burn. The groin flap is valuable, especially for the dorsum of the hand (Hanumadas et al., 1987), and in some circumstances pedicle random flaps from the abdomen may still be useful (Antia and Pandey, 1976). A reversedpedicle radial forearm flap is extremely versatile (Dent and Fattah, 1985 ; Groenevelt and Schoorl, 1985 ; McLean and Clark, 1985; Hallock, 1986) and can be used for all surfaces of the hand. It can also be used as a fascial flap and covered with a graft (Jin et al., 1985). Some caution 8
is necessary if vessels may not be patent (Jones and O’Brien, 1985; Hannock, 1986) and when burns are caused by high-voltage injuries but, as long as the circulation to the hand through the ulnar artery is not compromised, this technique is very useful, especially to provide thin flap cover for exposed tendons. The operation confines the damage to one limb and does not immobilise the hand by attaching it to the trunk in a dependent position for three weeks. Other forearm flaps on reversed vascular pedicles (Costa and Soutar, 1988; Glasson and Lovie, 1988; Zancolli and Angrigiani, 1988) have similar benefits but are more difficult to raise and have not gained as much popularity. Cross-arm fasciocutaneous flaps can also be used (Dickinson and Roberts, 1986) and, if combined with a nerve suture, may provide sensation (Dolich et al., 1978). Free flaps are also useful for localised areas of deep burn where adjacent undamaged vessels are available for microvascular anastomosis (Shen et al., 1988). There are many possible donor sites (Hing et al., 1985). In larger burns, the requirements of the palm and dorsal skin are different. A thin durable adherent sensitive flap is needed for the palm, whereas the dorsum will tolerate a thicker insensitive layer of flap skin which may be thinned later. Although the appearance may not be particularly pleasing, this will serve the functional requirements of the area. Groin flaps tend to be thick, whereas forearm skin is thinner and more suitable for the palm. These pedicle flaps are insensitive but several free flaps may be planned to allow the microneural link-up of sensory nerves in an attempt to provide some useful sensation (Webster and Soutar, 1986). Where extensive skin grafting is required and donor sites are limited, early coverage of hand burns carries a high priority. Consequently the techniques employed to cover large but functionally less important sites, such as the trunk and lower limbs, are rarely necessary. In these circumstances the surgeon may use homografts or cultured skin with or without a variety of biological dressings. Expanded mesh grafting (Tanner et al., 1964) is another valuable technique but is less acceptable in the hand as the inevitable secondary epithelialisation between the mesh is unsightly and produces hypertrophic scar. A 1 to 1.5 meshed but unexpanded graft does have the advantage of allowing escape of haematoma and is useful. Electrical burns of the hand Much has been written about these burns (Salisbury et al., 1973; Bingham, 1980). Small full-thickness lowvoltage injuries, which frequently have entry and exit sites, are common and are treated by early excision and grafting. High-voltage injuries produce more extensive damage but are fortunately rare. The local and generalised effect of the current is dependent on many physical THE
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factors such as voltage, tissue resistance and length of exposure and much is known about the mechanism causing the tissue damage (Lee and Kolodney, 1987; Daniel et al., 1988; Zachary et al., 1990), which proves more complex than was once thought. Immediate treatment of extensive electrical injuries, which frequently involve the hand and arm, must take into account the risk of compartment syndromes and also renal and cardiac involvement. Muscle damage, with systematic release of dangerous intracellular components, is often more extensive than the surface skin wound indicates and dead tissue must be excised. An overaggressive policy of debridement may remove the risk of leaving dead muscle but can sacrifice tissue which may survive, so repeated removal of what is obviously dead may pay dividends. Skin cover using combinations of flaps and grafts is necessary to preserve function of the limb. Nerves are frequently involved, sometimes only temporarily. Blood vessels are also damaged and distal ischaemia may result. Aggressive early arterial grafting has proved valuable in preserving hand function in these circumstances (Wang et al., 1985). Long-term complex reconstructive procedures are usually necessary.
Chemical bums of the hands Specific reviews of this topic are useful (Curreri and Asch, 1970; Bentivegna and Deane, 1990). The longterm management of these burns, which are frequently full-thickness in depth, varies little from that already discussed but emergency measures are vital and different. Water lavage remains the mainstay of early treatment Bromberg et al., 1965; Leonard et al., 1982) and should be prolonged when exposure to caustic chemicals has been extensive. Phenol, which is insoluble in water, is best removed with glycerol (Pardoe et al., 1976) and lime powder should be removed physically before lavage. Phosphorous particles are identified and neutralised with weak solutions of copper sulphate (Ben-Hur et al., 1972). Hydrofluoric acid burns frequently involve the hands, cause considerable pain and have stimulated many papers (Dibbell et al., 1970; Inverson et al., 1971). They cause extensive damage by absorption into the tissues (Anderson and Anderson, 1988). Active fluoride ions can be neutralised by binding to calcium and the topical application of calcium carbonate gel is most useful for small burns (Chick and Borah, 1989). The local injection of calcium gluconate (Blunt, 1964) or its intra-arterial infusion (Vance et al., 1986) has also been recommended, but early excision of the affected area will prevent continued extensive damage and relieve pain (Buckingham, 1988). It is beyond the scope of this paper to list the numerous other antidotes which, in any case, are not always available at short notice (Jelenko, 1974). VOL.
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When severe hand burns have healed, long-term complications are common and require treatment by an experienced team. Secondary surgery (Beasley, 1981; Groenevelt et al., 1985) is frequently required and may need repeating to release flexion contractures in growing children. Complex soft-tissue and bony reconstructive procedures designed to restore pinch and power grip are necessary following disabling burns. Thumb reconstruction is difficult because of scars and several methods are described (Pohl et al., 1976; Stern and MacMillan, 1983; May et al., 1984; Ward et al., 1985). When the hand is badly deformed, a detailed treatment plan is essential and several operations are often necessary. Common problems caused by secondary skin graft or scar contractures following inadequate primary care or post-operative physiotherapy and splintage are worth a brief mention. They occur most often in children. Various patterns of flexion contracture involving the fingers and thumb are described (Stern et al., 1985 and 1987). The mainstay of treatment remains the use of skin grafts, followed by splintage, after these tight scars have been released by transverse incisions on the volar surface of the hand. This may be at one or multiple joint levels and the use of temporary Kirschner wire immobilisation is controversial (Jackson and Brown, 1970; Alexander et al., 1981; Thind et al., 1988). Capsulotomy of the P.I.P. joint with check-rein release may be necessary (Watson et al., 1979). Care must be taken to avoid division of the neurovascular bundles which may also go into spasm if an attempt is made to extend the finger fully. A compromise correction may be necessary to avoid this complication. Fortunately the severe and often bizarre contractures seen in children burnt and treated in underdeveloped countries are rarely seen here as primary care is better. Skin flaps may be necessary to relieve extensive contractures where incision exposes tendons, nerves and bone. Local flaps may be used in preference to grafts and to avoid post-operative splintage (Groenevelt and Schoorl, 1985 ; Matthews and Morgan, 1987). Secondary contractures on the extensor surface are difficult to treat (Adamson, 1968; Salisbury and Dingeldein, 1988). They are caused by scar tightness limiting flexion of the M.P. joints and, if severe, cancause hyperextension deformities with dislocation of the joint and inability to flex the fingers. Extensor tendons are often involved and may need tenolysis or lengthening. Capsulotomy of the M.P. joint may also be necessary. In less severe cases, scar release and skin grafting may be sufficient but frequently a large skin flap is necessary. Adduction contractures of the thumb are very disabling. They are frequently the result of both scar and secondary fibrotic contracture of the adductor muscle and are sometimes associated with hyperextension of the 9
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M.P. joint which needs release and capsulotomy. In less severe cases, Z-plasties alone may be sufficient (Furnas, 1965; Woolf and Broadbent, 1972; Hirshowitz et al., 1975) but otherwise full release by division of the adductor insertion is necessary. The first and second metacarpals should be held apart temporarily with Kirschner wires. It is then usually best to cover the resulting defect by using either local (Spinner, 1969 ; Flatt and Wood, 1970; Brown, 1972) or distant flaps. Boutonniere deformity is common and harder to treat than that which follows clean traumatic division of the central slip, because skin cover is poor in healed burns. It may result from direct thermal injury to the extensor apparatus but is often seen as a secondary phenomenon produced by oedema and stretching of this structure beneath burnt skin. It can be prevented by early prophylactic splintage and this method may be successful in treating mobile cases of the deformity, although the splint can cause undue pressure on the scarred skin. Attempts may be made to reconstruct the central slip using a number of techniques, but arthrodesis may be the best option where there is significant functional deficit (Larson et al., 1970; Groenevelt and Schoorl, 1986). Burns syndactyly and dorsal hooding of the webs of the fingers is common and is treated by a combination of local flaps, Z-plasties and grafts. Many techniques have been devised over the years (Shaw et al., 1973; Krizek et al., 1974; MacDougal et al., 1976; Browne et al., 1978; Chapman et al., 1987). Recurrence may be prevented by using pressure gloves or web inserts (Alexander et al., 1982). Nail and nail-fold contractures are frequently encountered and, although not functionally debilitating, can be very annoying so that treatment is required (Ngim and Soin, 1986; Alsbjorn et al., 1985; Spanwen et al., 1987). Ulnar and median nerve compression can occur following wrist burns (Fissette, 198 1). Conclusion
Burns commonly involve the hands and severe functional problems will follow if the basic principles of treatment are ignored. Skin grafting and flap coverage are frequently necessary and physiotherapy and splintage play a major role. Long-term functional problems can be avoided with expert primary care, but secondary reconstruction is inevitable when the burns are deep and extensive. The expertise of a hand surgical team familiar with the treatment of burns is required throughout. References ADAMSON, J. E., CRAWFORD, H. H., HORTON, C. E. and BROWN, L. H. (1968). Treatment of dorsal bum adduction contracture of the hand. Plastic and Reconstructive Surgery, 42: 4: 355-359. ALEXANDER, J. W., MacMILLAN, B. G., MARTEL, L. and KRUMMEL, R. (1981). Surgical Correction of Postburn Flexion Contractures of the Fingers in Children, Plastic and Reconstructive Surgery, 68: 2: 218-224. ALEXANDER, J. W.,MacMILLAN,B. G.andMARTEL,L.(1982).Correction 10
of Postburn Syndactyly: An Analysis of Children with Introduction of the VM-Plasty and Postoperative Pressure Inserts. Plastic and Reconstructive Swgery, 70: 3: 345-352. ALSBJORN, B. F., METZ, P. and EBBEHBJ, J. (1985). Nailfold retraction due to burn wound contracture. A surgical procedure. Burns including Thermal Injury, 11: 3: 166167. ANDERSON, W. J. and ANDERSON, J. R. (1988). Hydrofluoric acid burns of the hand: Mechanism of iniurv and treatment. Journal of Hand Sureerv. - . 13A: 1: 52-57. ANTIA, N. H. and PANDEY, S. D. (1976). Semilunar abdominal bipedicled flap for cover of dorsal defects of the hand. British Journal of Plastic Surgery, 29:2: 1299131. BARDAKJIAN, V. B., KENNEY, J. G., EDGERTON, M. T. and MORGAN, R. F. (1988). Pulse oximetry for vascular monitoring in burned upper extremities. Journal of Burn Care and Rehabilitation, 9: 1: 63365. BEASLEY, R. W. (1981). Secondary Repair of Burned Hands. Clinics in Plastic Surgery, 8: 1: 141-162. BEN-HUR, N., GILADI, A., APPLEBAUM, J. and NEUMAN, Z. (1972). Phosphorus burns: The antidote: A new approach. British Journal of Plastic Surgery, 25 : 2455249. BENTIVEGNA, P. E. and DEANE, L. M. (1990). Chemical Burns of the Upper Extremity. Hand Clinics, 6: 2: 2533259. BINGHAM, H. G. (1980). Electrical injuries to the upper extremity-a review. Bums including Thermal Injury, 7 : 3 : 155-l 57. BLUNT, C. P. (1964). Treatment of hydrofluoric acid skin burns by injection with calcium gluconate. Industrial Medicine and Surgery, 33: 869-871. BROMBERG, B. E., SONG, I. C. and WALDEN, R. H. (1965). Hydrotherapy of chemical burns. Plastic and Reconstructive Surgery, 35: 1: 85-95. BROWN, P. W. (1972). Adduction-flexioncontractures ofthe thumb. Correction with dorsal rotation flap and release of contracture. Clinical Orthopaedics and Related Research, 88: 161-168. BROWNE, E. Z., TEAGUE, M. A. and SNYDER, C. C. (1978). Bum syndactyly. Plastic and Reconstructive Surgery, 62: 1: 92-95. BUCKINGHAM, F. M. (1988). Surgery: A Radical Approach to Severe Hydrofluoric Acid Burns. A Case Report. Journal of Occupational Medicine, 30: 11: 873-874. BURKE, J. F., BONDOC, C. C., QUINBY, W. C. and REMENSNYDER, J. P. (1976). Primary surgical management of the deeply burned hand. Journal ofTrauma, 16: 8: 593-598. BURKHARDT, B. R. (1972). Immediate or early excision and skin grafting of full-thickness bums of the palm. Report of two cases. Plastic and Reconstructive Surgery, 49 : 5 : 573-575. CHAPMAN, P., BANERJEE, A. and CAMPBELL, R. C. (1987). Extended use of the Mustard& dancing man procedure. British Journal of Plastic Surgery, 40: 432435. CHICK, L. and BORAH, G. (1989). Topical calciumcarbonategel for treatment of hydrofluoric acid bums to the hand. Proceedings of the American Bum Association, 21: 159. COSTA, H. and SOUTAR, D. S. (1988). The distally based island posterior interosseous flap. British Journal of Plastic Surgery, 41: 221-227. CURRERI, P. W., ASCH, M. J. and PRUITT, B. A. (1970). The treatment of chemical bums: specialised diagnostic, therapeutic and prognostic considerations. Journal of Trauma, 10: 8: 634642. DANIEL, R. K., BALLARD, P. A., HEROUX, P., ZELT, R. G. and HOWARD, C. R. (1988). High-voltage electrical injury: Acute pathophysiology. Journal of Hand Surgery, 13A: 1: 44-49. DENT, A. R. and FATAH, M. F. (1985). The radial forearm island flap in early reconstruction of a severely burned hand. Burns including Thermal Injury, 11: 4: 285-288. DIBBELL, D. G., IVERSON, R. E., JONES, W., LAUB, D. R. and MADISON, M. S. (1970). Hydrofluoric Acid Burns of the Hand. Journal of Bone and Joint Surgery, 52A: 5: 931-936. DICKINSON, J. C. and ROBERTS, A. H. N. (1986). Fascia-Cutaneous CrossArm Flaps in Hand Reconstruction. Journal of Hand Surgery, 11B: 3: 394398. DOLICH, B. H., OLSHANSKY, K. J. and BABAR, A. H. (1978). Use of a cross-forearm neurocutaneous flap to provide sensation and coverage in hand reconstruction. Plastic and Reconstructive Surgery, 62: 4: 550-558. EDSTROM, L., ROBSON, M. C., MACCHIAVERNA, J. R. and SCALA, A. D. (1979). Management of Deep Partial Thickness Dorsal Hand Burns. Study of Operative vs Nonoperative Therapy. Orthopaedic Review, 8: 4: 27-33. FISSETTE, J., ONKELINX, A. and FANDI, N. (1981). Carpal and Guyon tunnel syndrome in bums at the wrist. Journal of Hand Surgery, 6: 1: 13-15. FLATT, A. E. and WOOD, V. E. (1970). Multiple dorsal rotation flaps from the hand for thumb web contractures. Plastic and Reconstructive Surgery, 45: 3 : 258-262. _
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FRANDSEN, P. A., OVERGAARD-NIELSEN, H. and SOMMER, J. (1977). Treatment of second-degree burns of the hand: a comparison of occlusive dressings and gloves. Bums including Thermal Injury, 4: 1: 2&22. FURNAS, D. N. (1965). The tetrahedral Z-plasty. Plastic and Reconstructive Surgery, 35: 3: 291-302. GLASSON, D. W. and LOVIE, M. J. (1988). The ulnar island flap in hand and forearm reconstruction. British Journalof Plastic Surgery, 41: 4: 349-353. GROENEVELT, F. and KREIS, R. W. (1985). Burns of the Hand. Netherlands JournalofSurgery, 37: 6: 167-173. GROENEVELT, F. and SCHOORL, R. (1985). Cross-finger flaps from scarred skin in burned hands. British Journal of Plastic Surgery, 38: i87-189. GROENEVELT, F. and SCHOORL, R. (1985). The reversed forearm flap using scarred skin in hand reconstruction. British Journal of Plastic Surgery, 38: 398-402. GROENEVELT, F., SCHOORL, R. and HERMANS, R. P. (1985). Retrospective study of reconstructive surgery of the burned hand. Burns including Thermal Injury, 11: 5: 351-358. GROENEVELT, F. and SCHOORL, R. (1986). Reconstructive Surgery of the Post-Burn Boutonni&e Deformity. Journal of Hand Surgery, 11B: 1: 23-30. GROSSMAN, J. A. I. (1990). Bums of the Upper Extremity, Hand Clinics, 6: 2: 163-354. HALLOCK, G. G. (1986). Caution in using the Chinese radial forearm flap (Letter). Plastic and Reconstructive Surgery, 77: 1: 164-165. HALLOCK, G. G. (1986). The radial forearm flap in burn reconstruction. Journal of Burn Care and Rehabilitation, 7: 4: 318-322. HANUMADASS, M., KAGAN, R. and MATSUDA, T. (1987). Early Coverage of Deep Hand Bums with Groin Flaps. Journal of Trauma, 27: 2: 109-l 14. HING, D. N., BUNCKE, H. J., ALPERT, B. S. and GORDON, L. (1985). Free Flap Coverage of the Hand. Hand Clinics, 1: 4: 741-758. HIRSHOWITZ, B., KAREV, A. and ROUSSO, M. (1975). Combined double Zplasty and Y-V advancement for thumb web contracture. The Hand, 7 : 3 : 291-293. IVERSON, R. E., LAUB, D. R. and MADISON, M. S. (1971). Hydrofluoric acid bums. Plastic and Reconstructive Surgery, 48: 2: 107-l 12. JACKSON, D. M. and STONE, P. A. (1972). Tangential excision and grafting of burns. British Journal of Plastic Surgery, 25: 41ti26. JACKSON, I. T. and BROWN, G. E. D. (1970). A method of treating chronic flexion contractares of the fingers. British Journal of Plastic Surgery, 23: 373-379. JANZEKOVIC, Z. (1970). A new concept of the early excision and immediate grafting of bums. Journal of Trauma, 10: 12: 1103-1108. JELENKO, C. (1974). Chemicals that “bum”. Journal of Trauma, 14: 1: 65-72. JIN, Y. T., GAUN, W. X., SHI, T. M., QUIAN, Y. L., YU, L. G. and CHANG, T. S. (1985). Reversed island forearm fascial flap in hand surgery. Annals of Plastic Surgery, 15: 4: 340-347. JONES, B. M. and O’BRIEN, C. J. (1985). Acute ischaemia of the hand resulting from elevation of a radial forearm flap. British Journal of Plastic Surgery, 38: 396-397. KETCHUM, L. D., COHEN, I. K. and MASTERS, F. W. (1974). Hypertrophic scars and keloids. A Collective Review. Plastic and Reconstructive Surgery, 53: 2: 140-154. KINGSLEY, N. W., STEIN, J. M. and LEVENSON, S. M. (1979). Measuring Tissue Pressure to Assess the Severity of Burn-Induced Ischemia. Plastic and Reconstructive Surgery, 63 : 3 : 404-408. KRIZEK, T. J., FLAGG, S. V., WOLFORT, F. G. and JABALEY, M. E. (1973). Delayed primary excision and skin grafting of the burned hand. Plastic and Reconstructive Surgery, 51: 5: 524-529. KRIZEK, T. J., ROBSON, M. C. and FLAGG, S. V. (1974). Management of bum syndactyly. Journal of Trauma, 14: 7: 587-593. LABANDTER, H., KAPLAN, 1. and SHAVITT, C. (1976). Burns of the dorsum of the hand: conservative treatment with intensive physiotherapy versus tangential excision and grafting. British Journal of Plastic Surgery, 29: 352354. LARSON, D. L., WOFFORD, B. H., EVANS, E. B. and LEWIS, S. R. (1970). Repair of the boutonniere deformity of the burned hand. Journal of Trauma, 10: 6: 481-487. LEE, R. C. and KOLODNEY, M. S. (1987). Electrical Injury Mechanisms: Dynamics of the Thermal Response. Plastic and Reconstructive Surgery, 80: 5: 663-671. LEE, R. C. and KOLODNEY, M. S. (1987). Electrical Injury Mechanisms: Electrical Breakdown of Cell Membranes. Plastic and Reconstructive Surgery, 80 : 5 : 672-68 1. LEONARD, L. G., SCHEULEN, J. J. and MUNSTER, A. M. (1982). Chemical Burns: Effect of Prompt First Aid. Journal of Trauma, 22: 5: 420-423. LEUNG, P. C. and NG, M. (1980). Pressure treatment for hypertrophic scars resulting from burns. Burns including Thermal Injury, 6: 4: 244250. VOL.
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LEUNG, P. C. and CHOW, Y. Y. N. (1982). Treatment of burned hands. Burns including Thermal Injury, 8: 5: 338-344. LEVINE, B. A., SIRINEK, K. R., PETERSON, H. D. and PRUITT, B. A. (1979). Efficacy of Tangential Excision and Immediate Autografting of Deep Second-degree Burns of the Hand. Journal of Trauma, 19: 9: 670-673. LEVINE, N. S. and BUCHANAN, R. T. (1986). The care of the burned upper extremities. Clinics in Plastic Surgery, 13: 1: 107-l 18. MacDOUGAL, B., WRAY, R. C. and WEEKS, P. M. (1976). Lateral-volar finger flap for the treatment of burn syndactyly. Plastic and Reconstructive Surgery, 57: 2: 167-171. MADDEN, J. W. and ENNA, C. D. (1983). The management of acute thermal injuries to the upper extremity. Journal of Hand Surgery, 8: 5(2): 785-788. MAHLER, I)., BENMEIR, P., BEN YAKAR, Y., GREBER, B., SAGI, A., HAUBEN, D., ROSENBERG, L. and SAROV, B. (1987). Treatmentof the burned hand: early surgical treatment (1975-85) vs. conservative treatment (1964-74). A comparative study. Burns including Thermal Injury, 13: 1: 4548. MATTHEWS, R. N. and MORGAN, B. D. G. (1987). Multiple seagull flaps for distal contractures in electrical bums. British Journal of Plastic Surgery, 40: 47-5 I. MAY, I. W., DONELAN, M. B., TOTH, B. A. and WALL, J. (1984). Thumb reconstruction in the burned hand by advancement pollicization of the second ray remnant. Journal of Hand Surgery, 9A: 4: 484489. MCLEAN, N. R. and CLARKE, J. A. (1985). Resurfacing of the severely burned hand with a radial forearm flap. Burns including Thermal Injury, 11: 5: 371373. MERRELL, S. W., SAFFLE, J. R., SCHNEBLY, W. A., KRAVITZ, M. and WARDEN, G. D. (1986). Full thickness skin grafting for contact burns of the palm in children. Journal of Burn Care and Rehabilitation, 7: 6: 501507. MOYLAN, J. A., INGE, W. W. and PRUITT, B. A. (1971). Circulatory changes following circumferential extremity bums evaluated by the ultrasound flow meter: an analysis of 60 thermally injured limbs. Journal of Trauma, 11: 9: 763-770. MUIR, I. F. K., BARCLAY, T. L. and SETTLE, J. A. D. Bunzs and their treatment, 3rd edn. London, Butterworths, 1987. NGIM, R. C. K. and SOIN, K. (1986). Postburn Nailfold Retraction: A Reconstructive Technique. Journal of Hand Surgery, 11B: 3: 385-387. PARDOE, R., MINAMI, R. T., SATO, R. M. and SCHLESINGER, S. L. (1976). Phenol burns. Burns including Thermal Injury, 3: 29-41. PEGG, S. P., CAVAYE, D., FOWLER, D. and JONES, M. (1984). Results of early excision and grafting in hand bums. Bums including Thermal Injury, 11:99-103. PENSLER, J. M., STEWARD, R., LEWIS, S. R. and HERNDON, D. N. (1988). Reconstruction of the Burned Palm: Full-Thickness versus SplitThickness Skin Grafts-Long-Term Follow-Up. Plastic and Reconstructive Surgery, 81: 1: 46-49. POHL, A. L., LARSON, D. L. and LEWIS, S. R. (1976). Thumb reconstruction in the severely burned hand. Plastic and Reconstructive Surgery, 57: 3: 320328. SALISBURY, R. E., HUNT, J. L., WARDEN, G. D. and PRUITT, B. A. (1973). Management of electrical burns of the upper extremity. Plastic and Reconstructive Surgery, 51: 6: 648-652. SALISBURY, R. E., McKEEL, D. W. and MASON, A. D. (1974). Ischemic Necrosis of the Intrinsic Muscles of the Hand after Thermal Injuries. Journal ofBone and Joint Surgery, 56A: 8: 1701-1707. SALISBURY, R. E. and LEVINE, N. S. The early management of upper extremity thermal injury. In: Salisbury, R. E. and Pruitt, B. A. (Eds) Major Problems in Clinical Surgery. Vol. 19. Burns of the Upper Extremity. Philadelphia, W. B. Saunders, 1976: 3646. SALISBURY, R. E. Burns of the Upper Extremity. In: Artz, C. P. Moncrief, J. A. and Pruitt, B. A. (Eds.) Burns: A Team Approach. Philadelphia. W. B. Saunders, 1979: 320-329. SALISBURY, R. E. and WRIGHT, P. (1982). Evaluation of Early Excision of Dorsal Burns of the Hand. Plastic and Reconstructive Surgery, 69: 4: 67& 675. SALISBURY, R. E. and DINGELDEIN, G. P. The Burned Hand and Upper Extremity. In: Green, D. P. (Ed.) Operative Hand Surgery, 2nd edn. New York, Churchill Livingstone, 1988: Vol. 3: 2135-2164. SETTLE, J. A. D. Bums-the first five days. Romford, Smith and Nephew Pharmaceuticals Ltd, 1986. SHAW, D. T., LI, C. S., RICHEY, D. G. and NAHIGAN, S. H. (1973). Interdigital Butterlly Flap in the Hand (The Double-Opposing Z-Plasty). Journal of Bone and Joint Surgery, 55A: 8: 1677-1679. SHEN, T., SUN, Y., CAO, D. and WANG, N. (1988). The Use of Free Flaps in Bum Patients: Experiences with 70 Flaps in 65 Patients. Plastic and Reconstructive Surgery, 81: 3: 352-357. 11
P. J. SYKES SILVER, L. (1987). Bums of the hand and wrist. Current concepts in diagnosis and treatment. Orthopaedic Review, 16: 6: 394-400. SMITH, D. J., BENDICK, P. J. and MADISON, S. A. (1984). Evaluation of vascular compromise in the injured extremity: A photoplethysmographic technique. Journal of Hand Surgery, 9A: 3: 314-319. SPAUWEN, P. H. M., BROWN, I. F., SAUER, E. W. and KLASLEN, H. J. (1987). Management of fingernail deformities after thermal injury. Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery, 21: 3: 253-255. SPINNER, M. (1969). Fashioned transpositional flap for soft tissue adduction contractme of the thumb. Plastic and Reconstmctive Surgery, 44: 4: 345348. STERN, P. J. and MacMILLAN, B. G. (1983). Reconstruction of the burned thumb by metacarpal lengthening. Burns including Thermal Injury, 10: 2: 127-130. STERN, P. J., NEALE, H. W., CARTER, W. and MacMILLAN, B. G. (1985). Classification and management of burned thumb contractures in children. Bums including Thermal Injury, 11: 3 : 168-174. STERN, P. J., NEALE, H. W., GRAHAM, T. J. and WARDEN, G. D. (1987). Classification and treatment of postburn proximal interphalangeal joint flexion contractures in children. Journal of Hand Surgery, 12A : 3 : 45&457. SYKES, P. J. andBAILEY, B. N. (1976). Treatment ofhand bums withocclusive bags: A comparison of 3 methods. Bums including Thermal Injury, 2: 3: 162-168. TANDON, S. N. and SUTHERLAND, A. B. (1976). Some problems following tangential excision and skin grafting in dermal burns. Bums including Thermal Injury, 3: 2: 96-99. TANNER, J. C., VANDEPUT, J. and OLLEY, J. F. (1964). The mesh skin graft. Plastic and Reconstructive Surgery, 34: 3: 287-292. THIND, R. S., SINGH, H. A. and THIND, M. S. (1988). Severe post bum flexion contractme of hand-A single stage method of management. Acta Chirurgiae Plasticae, 30: 1: 31-38. VANCE, M. V., CURRY, S. C., KUNKEL, D. B., RYAN, P. J. and RUGGERI, S. B. (1986). Digital Hydrofluoric Acid Bums: Treatment with
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Intraarterial
Calcium
Infusion.
Annals of Emergency
Medicine,
15 : 8 : 890-
896. WANG, X.-W., ROBERTS, B. B., ZAPATA-SIRVENT, R. L., ROBINSON, W. A., WAYMACK, J. P., LAW, E. J., MacMILLAN, B. G. and DAVIES, J. W. L. (1985). Early vascular grafting to prevent upper extremity necrosis after electrical bums. Bums including Thermal Injury, 11: 359-366. WANG, X.-W., SANG, H.-H., DAVIES, J. W. L., MacMILLAN, B. G. and ROBINSON, W. A. (1985). Role of escharotomy and fasciotomy as a first aid measure in the early treatment of an electrically burned arm and wrist. Bums including Thermal Injury, 11: 6: 419422. WARD, J. W., PENSLER, J. M. and PARRY, S. W. (1985). Pollicization for Thumb Reconstruction in Severe Pediatric Hand Bums. Plastic and Reconstructive Surgery, 76: 6: 927-932. WATSON, H. K., LIGHT, T. R. and JOHNSON, T. R. (1979). Checkrein resection for tlexion contracture of the middle joint, Journal of Hand Surgery, 4:1:67-71. WEBSTER, M. H. C. and SOUTAR, D. S. PracticalGuide to Free Tissue Tramferr. London, Butterworths, 1986. 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. Plastic and Reconstructive Surgery, 54: 3 : 268-273. WOOLF, R. M. and BROADBENT, T. R. (1972). The four-flap Z-plasty. Plastic and Reconstructive Surgery, 49: 1: 48-51. ZACHARY, L. M., LEE, R. C. and GOTTLIEB, L. J. (1990). Evolving Clinical and Scientific Concepts of Upper Extremity Electrical Trauma. Hand Clinics, 6: 2: 243-252. ZANCOLLI, E. A. and ANGRIGIANI, C. (1988). Posterior interosseous island forearm flap. Journal of Hand Surgery, 13B: 2: 130-135.
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