The Burned Hand - Restoring

Home , Burn scar contracture, Escharotomy, Hand injury, Perforator flaps

IC62-R: The Burned Hand - Restoring

Maximum Function Moderator(s): Roger L. Simpson, MD, MBA

Faculty: Gunter Germann, MD, PhD, Michael W. Neumeister, MD

Session Handouts

75TH VIRTUAL ANNUAL MEETING OF THE ASSH OCTOBER 1-3, 2020

822 West Washington Blvd Chicago, IL 60607 Phone: (312) 880-1900 Web: www.assh.org Email: [email protected]

All property rights in the material presented, including common-law copyright, are expressly reserved to the speaker or the ASSH. No statement or presentation made is to be regarded as dedicated to the public domain.

8/7/2020

Michael W. Neumeister, MD

Speaker has no relevant financial relationships with commercial interest to disclose.

The Treatment of Hand and Upper Extremity Burns

Michael W. Neumeister, MD,FRCSC,FACS

Thermal Burns

1 8/7/2020

Importance of Skin

• Protective • Thermoregulation • Homeostasis • Neurosensory • Immunological • Metabolism • Social

2 8/7/2020

Burn Care

Major Burns

• 2° + 3° > 10% TBSA in children < 10 yrs or adults > 50 yrs • 2° + 3° burns > 20% TBSA • 3° burns over 10% • Special areas: face, hands, genitals

Pathophysiology of the Burn Wound

“Burn wound is the source of virtually all ill effects, local & systemic, seen in the burned patient” 1607

3 8/7/2020

Burn Management

• Treat as a trauma patient • Airway • Breathing • Circulation • 2° Survey • Inhalational injury • Investigation & prophylaxis

Burn Team

• Plastic Surgeons • Intensivists • Anaesthesioligist • Specialized Nurses • Physio & Occupational Therapists • Nutritionist • Clinical Microbiologists • Psychologist

Estimating Burn Size

4 8/7/2020

5 8/7/2020

Burn Depth

1st Degree Burn

2nd Degree Burn

6 8/7/2020

3rd Degree Burn

4th Degree Burn

Myoglobinuria: Respect the Kidneys

7 8/7/2020

The Parkland Formula TBSA = total body surface area

4x weight (kg) x %TBSA burn = ml/24 h of Ringer lactate solution (Hartmann’s solution)

Half the calculated dose is given in the first 8 hours, the rest being given in divided doses at regular intervals over the following 16 hours

8 8/7/2020

Fluid Resusitation Formulas

Improved Survival Rates

• Appropriate resuscitation • Early excision and wound closure • Optimize tissue perfusion • Nutritional support

Escharotomy: Maintain Vascularity

9 8/7/2020

10 8/7/2020

Topical Agents

• Silver Sulfadiazine • Mafenide • Silver nitrate • Bacitacin • Cesiumnitrate - SSD • Nirtrofurazone • Chlorhexidine • Provodone • Nystatin

11 8/7/2020

Zone of Thermal Injury

The Surgery

12 8/7/2020

Excision

Early 24 - 96 hrs

Ultra-early < 24 hrs

Delayed > 96 hrs

Early Excision

• Excise before inflammatory peak • Decrease propogation of metabolic derangements • Decrease septic episodes • Diminish pain and suffering • Decrease hospital stay

13 8/7/2020

Early Excision

Improves Survival Janzekovic ‘70 J Trauma Burke ‘74 J Trauma Tompkins & Burke ‘88 Ann Surg SBI - Galveston ‘89 Ann Surg Peters ‘90 J Trauma Demling ‘95 J Trauma

Wound Closure

• Autografts • Allografts • Get initial biological cover • Replace with re-harvested autograft • Massive burns • Difficult closure

Dermatomes

14 8/7/2020

15 8/7/2020

16 8/7/2020

17 8/7/2020

Alternative Wound Coverings

• Massive burns

• Temporary vs Permanent

• Wound coverage vs closure

• Biological vs Non-biological

18 8/7/2020

19 8/7/2020

Shortcomings of Cultural Epidermal Cell Technology

• 3-4 weeks of culture

• Low rate of engraftment

• Prolonged immobilization

• Graft fragility resulting in “delayed loss”

• High cost

Alternative Wound Closure “Artificial Skin”

• Cultrured epidermal autografts

• Noncellular matrix

• Combination of matrix & cell culture

Suggested Clinical Indications for the Use of Cultural Epidermal Cell Technology

• Patients with burn injuries > 90% TBSA • Recommended • Patients with burn injuries between 70 & 90% TBSA • Clinical judgment • Patient with burn injuries < 70% TBSA • Not usually necessary

Heinbach D.M.J. Burn Care Rehabil 1992

20 8/7/2020

Thank You

21 Burns of the Hand in Children and Adults Instructional Course IC 62-R

Faculty:

Dr. Günter Germann, MD, PhD. Director of Ethianum Clinic Professor of Plastic, Hand, and Reconstructive Surgery University of Heidelberg, Heidelberg, Germany

Michael Neumeister, MD, FRCS, FACS Chairman and Professor Department of Surgery Chief Division of Plastic Surgery Southern Illinois University, Carbondale, Illinois

Roger Simpson, MD, MBA, FACS Director Burn Center and Chief Division Plastic Surgery Nassau University Medical Center Long Island Plastic Surgical Group, Garden City, NY

Course Description:

Introduction Course and Faculty Roger Simpson - 3 minutes

The Acutely Burned Hand Michael Neumeister - 15 Minutes

The Principles of Reconstructing the Burned Hand - Predicting Outcome Roger Simpson -15 Minutes

Simple to Advanced Reconstruction of the Burned Hand Gunter Germann - 15 Minutes

Questions for the Faculty – 12 minutes

Acute Period I. General Assessment for Children and Adults

A. Anatomy of the Skin

B. Heat Transfer 1. Post Injury Changes in Burned Skin 2. Zone of Stasis

C. Classification of Burns 1. First degree burn: confinement to epithelium. Short-term contact. Characterized by erythema, moderate pain, no blister formation, and rapid healing. Topical application of ointment for symptomatic relief. No scarring anticipated.

2. Second degree burn: confinement to dermis. Subdivided into superficial second-degree and deep second-degree relative to depth of injury and length of time to epithelialization. Erythema and blisters are common. Blisters that remain intact characterize the superficial second-degree burn, which is expected to heal within a ten-day period. Scarring is often minimal without functional restriction. Deep second-degree burn penetrates to the deeper portion of the dermis. Blisters have usually ruptured. Epithelialization will occur between 14 and 21 days. Moderate scarring is expected. Functional restriction in the hands and fingers is common with this depth burn.

3. Third degree burn: full thickness loss of tissue including adnexal elements from which epithelialization occurs. Healing will occur by contraction if the area of burn injury is small enough. Loss of tissue usually requires replacement with split thickness skin graft. If loss of tissue is not compensated, functional restriction of the hand and fingers is expected. The burn is characterized by deep injury with tenacious eschar. Initial presentation is insensate and leathery.

4. Fourth degree burn: long contact time. Loss of tissue extends beyond skin and subcutaneous tissue. Clinical appearance is consistent with char. Burn may extend to include muscle, tendon, and bone. Loss of function is immediate. Amputation is often the treatment of choice.

D. Edema Formation in the Hand and Fingers 1. Increased microvascular permeability

2. Increased interstitial osmolality

3. Venous obstruction

II. Management of Burns of the Hand during the Acute Period

A. Assessment of Depth of Injury 1. Associated injuries 2. Anticipated joint injury 3. Patient compliance

B. Initial Treatment, Debridement, Dressing 1. Escharotomy and monitoring 2. Initial dressing 3. Selection of splinting 4. Best practices at the bedside

C. Early excision and grafting 1. Tangential or full thickness excision 2. Selection of graft and timing 3. Postoperative care and motion protocol a. Recipient site b. Donor site

Maturation Period

I. Functional expectations

A. Scar and tissue maturation

B. Maximum function obtained

C. Therapy plateau

D. When (or if) is the patient ready for reconstructive surgery?

Reconstructive Period

I. Principles of reconstruction:

A. Evaluation of anticipated deficit and need

B. Convex or concave surface (three-dimensional assessment)

E. Expected degree of functional return

F. Quality of final result

E. Long-term follow-up 5

II. Surgical Reconstruction

A. Planning the procedure-the deficit will always be greater than you think

B. Split or full thickness graft, sheet or meshed

C. Dorsal hand burns 1. Hand and/or finger resurfacing 2. Preventing dorsal webs 3. Splinting positions

D. Palmar burns 1. Predicting the deficit 2. Associated joint releases 3. Choice of donor skin

E. Burn scar syndactyly 1. Web space reconstruction with flaps and grafts 2. Thumb-index web space a. Local rotation or skin graft? b. Adduction contracture and basal joint stiffness 3. Use of conformers postoperatively

III. Advanced Reconstruction

A. Soft tissue to skeletal relationship 1. progression of changes 2. secondary reciprocal contractures

B. Intractable joint contracture-planning for salvage

C. Tissue expansion including composite tissue expansion of tendons

D. Skin substitutes

Outpatient Management of Burn Injuries

I. Common etiologies and care plan; who should be admitted?

II. Protocol for dressing changes and frequency of visits.

III. Pain management.

IV. Social support.

Burns of the Hand in Adults and Children Selected Bibliography

1. Management of the Burned Hand

Achauer, B. M., R. H. Bartlett, et al. (1974). “Internal fixation in the management of the burned hand.” Arch Surg 108(6): 814-20.

Al-Qattan, M. M. and J. Pitkanen (2001). “Delayed primary excision and grafting of full thickness alkali burns of the hand and forearm.” Burns 27(4): 398-400. In a prospective study, 15 cases of domestic alkali drain cleaner burns involving the dorsal aspect of the hand and forearm were included. There were ten males and five females. The average age was 27 years and the mean total body surface area burnt was 2%. All patients failed to do immediate water lavage at home and hence all wounds ultimately required excision and grafting. Patients were initially treated with daily silver sulfadiazine dressing on an out-patient basis. Seven to 9 days after injury, patients were admitted to hospital and underwent excision and grafting. On final follow-up, there was excellent return of function, which was assessed using the grip strength of the hand and the range of motion of the wrist and fingers. Cosmetic appearance and texture of the graft were assessed according to a proposed grading system. The cosmetic result was considered satisfactory in 12 patients and poor in three patients. There were no excellent cosmetic results, because of hyperpigmentation of the healed graft. Advantages of delayed primary excision and grafting of full thickness alkali burns of the hand and forearm are discussed.

Bache, J. (1988). “Clinical evaluation of the use of Op-Site gloves for the treatment of partial thickness burns of the hand.” Burns Incl Therm Inj 14(5): 413-6. Twenty-five patients with partial thickness burns of the hand were treated with Op-Site gloves in order to assess the clinical effectiveness of the treatment in promoting healing, and to assess the acceptability of the gloves to patients and to medical and nursing staff. The Op-Site gloves were found to be at least as effective as conventional treatments in promoting healing, and very acceptable to patients and to medical and nursing staff.

Bailey, B. N. and S. N. Desai (1973). “An approach to the treatment of hand burns.” Injury 4(4): 335-40.

Baker, M. S. (1996). “Management of soft-tissue wounds, burns, and hand injuries in the field setting.” Mil Med 161(8): 469-71. In combat, the tactical situation can prevent rapid evacuation to definitive care, or casualty overload can tie up the surgical teams. All medical personnel and their supporting cadre should have the ability to manage wounds and burns. Controlling 7 bleeding and airways, cleaning and debriding wounds, and dressing or splinting injuries is essential knowledge and training for enlisted and officer personnel of all medical departments.

Baux, S., M. Mimoun, et al. (1987). “Recent burns of the hand. Early excision-graft versus conventional treatment. A retrospective study during two years.” Ann Chir Main 6(4): 276-81. Early excision-graft of burned hands seems to have totally superseded the conventional method of progressive detorsion often with late grafting. Does this treatment merit acceptance under these conditions? Do the theoretical advantages of aggressive methods counter-balance the primary difficulty of diagnosing the initial depth of burn? Are these fewer difficulties and risks in early excision-graft than in the slower methods? Can we ascribe the failure of conventional method to a poor technical realisation? Following a short summary of the principles of the two methods, we attempt to answer these questions by a retrospective study comparing identical series of patients. We have begun a prospective randomized trial and present the preliminary results here.

Boeckx, W., M. Vandevoort, et al. (1992). “Fibrin glue in the treatment of dorsal hand burns.” Burns 18(5): 395-400. This paper analyses two groups of patients with only dorsal hand burns: groups I contains patients with a total of 15 burned hands and group II patients with 12 hand burns. The patients in group I were all treated by full sheet skin grafts using a two- component fibrin glue. Patients in group II underwent the traditional operative treatment without fibrin glue and the same postoperative physical therapy programme. After follow-up periods of 6-11 months (group I) and 12-21 months (group II), we investigated in both groups, grip strength, key pinch, mobility, two-point discrimination and with the Semmes-Weinstein monofilaments. Our results prove that after the respective follow-up periods group I patients developed far better results for two-point discrimination, touch recognition and mobility.

Boswick, J. A., Jr. (1970). “Management of the burned hand.” Orthop Clin North Am 1(2): 311-9.

Boswick, J. A., Jr. (1974). “The management of fresh burns of the hand and deformities resulting from burn injuries.” Clin Plast Surg 1(4): 621-31.

Brandsma, J. W. (1999). “Development of a uniform record for patients with burns of the hand.” J Hand Ther 12(4): 333-6. This study reports the development of a uniform record for patients with burns of the hands. The steps in the development of the record are outlined and discussed. The use of a uniform standardized record is intended to improve communication within a network of three burn centers and to facilitate joint research projects. A data entry method to facilitate pooling and subsequent data analysis is also described.

Hales, E., M. Simons, et al.(2011) "A review of full-thickness and split-thickness 8 graft outcomes in pediatric hand burns." J Burn Care Res 32(3): e109.

Bhavsar, D. and M. Tenenhaus (2008). "The use of acellular dermal matrix for coverage of exposed joint and extensor mechanism in thermally injured patients with few options." Eplasty 8: e33. Introduction: One of the most devastating complications of deep burn injuries to the hand and finger is the exposure of joint, tendon, and neurovascular structures. The inevitable consequence of such injuries is severe deformity, often requiring joint fusions and digital amputations. Complicating this scenario is the anatomic limitation of few local and reliable soft tissue flaps available for this intricate distal distribution. This is particularly true for the patient who has suffered very large and deep thermal injuries. Methods: This series of cases describes the use of thin and meshed acellular dermal matrix to cover the exposed joint, tendon, and neurovascular structures, which resulted from severe thermal injuries. Securing the position of the lateral tendinous bands is a key component of the reconstruction. Composite staged reconstructions with either autologus split thickness skin graft or Integra provided definitive soft tissue coverage. Digits and joints were gently ranged when the overlying skin graft or Integra was adherent. Results: Of 26 digits treated in 4 patients, 19 digits demonstrated supple and durable skin coverage with acceptable joint mobility. One digit had to be amputated because of infection. Four digits developed Boutonniere deformity. Three digits underwent joint fusion at proximal interphalangeal joint. Conclusions: Early flap coverage, whenever possible, remains our preferred method of treatment of exposed joint, tendon, and neurovascular structures. When flaps are not feasible and faced with potentially salvageable yet terribly injured hands and fingers with complicated exposure, thin and meshed acellular dermal matrix may provide durable and vascularized soft tissue coverage while minimizing eventual deformities.

Brcic, A. (1990). “Primary tangential excision for hand burns.” Hand Clin 6(2): 211-9. The article describes the correct technique of primary tangential excision in deep dermal and third-degree hand burns. The operation performed under tourniquet facilitates the preservation of viable tissue, which is of utmost importance in hand burns. The therapeutic results depend on the extent of destroyed tissue. Primary tangential excision prevents fibrosis due to prolonged infection and impaired circulation, thus creating much more favorable conditions for reconstruction and rehabilitation.

Burm, J. S. and S. J. Oh (2000). “Fist position for skin grafting on the dorsal hand: II. Clinical use in deep burns and burn scar contractures.” Plast Reconstr Surg 105(2):581-8. The fundamental problem in all types of hand burns is a loss of skin and subsequent deformities. The goal of skin grafting on the dorsal hand is to graft a sufficient amount of skin, as much as the original amount, and to restore normal hand function without secondary deformities. The safe, or Michigan, position commonly has been used for immobilizing the hand. However, this position is to protect hand function rather than to provide for adequate skin grafting. This institution has developed a new hand position (the fist position) for grafting the greatest amount of skin on the dorsal side 9 of the hand. In the fist position, the hand is positioned flexing all joints of the wrist and the fingers and maximally stretching the dorsal surface of the hand before skin grafting. Ten hands with deep second- or third- degree burn (n = 6) and burn scar contracture (n = 4) of the dorsal hand in eight patients were treated with split-thickness skin grafting after immobilizing in the fist position. The burns and contractures involved nearly the total area of the dorsal hand. The hand was kept in the fist position for 7 to 9 days after skin grafting. Excellent functional and cosmetic results were observed in all cases during the follow-up period of 6 months to 2 years. Complications resulting from hand immobilization for a short period did not occur. The fist position may be a proper hand position for skin grafting to reconstruct the dorsal hand.

Borschel, G. H. (2009). "A Three-Subunit Latissimus Dorsi Muscle Free Flap for Single- Stage Coverage of the Hand and Three Adjacent Fingers." Hand (N Y). A latissimus dorsi muscle flap was used to simultaneously resurface the dorsal index, middle, and ring fingers of a 10-year-old child who had sustained a severe abrasion burn from a go-kart injury. Rather than performing multiple individual flaps, or a single flap in which a secondary division procedure would have been needed, the flap was divided into three vascular territories, permitting a single-stage reconstruction. Use of this strategy minimized the need for prolonged rehabilitation, and the functional outcome was optimized.

Cartotto, R. (2005). "The burned hand: optimizing long-term outcomes with a standardized approach to acute and subacute care." Clin Plast Surg 32(4): 515-27, vi. Deep partial- and full-thickness burns to the hands are common and the source of significant potential morbidity for the patient. This article emphasizes that when these burns are managed by an experienced team of burn surgeons, rehabilitation therapists, and nurses, using a standardized protocol, good long-term functional outcomes may be reliably obtained in most cases. The details of the author's standardized protocol, as well as late outcomes achieved using this approach, are discussed.

Cole, R. P., S. G. Jones, et al. (1990). “Thermographic assessment of hand burns.” Burns 16(1): 60-3. Twenty-three patients with 32 burned hands were studied thermographically within 48 h of injury to investigate the potential value of thermography in the assessment of the depth of hand burns. Superficial and deep partial thickness burns were treated conservatively, with excision and grafting of those which had not healed by 2-3 weeks after injury. This delayed surgery group and the healed group were retrospectively analysed to determine the predictive value of the initial clinical and thermographic assessments of the depth of the burns. Full skin thickness burns were excised and grafted within 5 days and were not included in the study. Initial thermographic assessment correctly predicted the outcome (whether healed or excised and grafted) in 33 of 36 burns. This relationship was highly significant. Initial clinical assessment of depth had no significant relationship with the time taken to heal. Thermography may help in the selection of patients who might benefit from early surgery.

Corlett, R. J. (1979). “The treatment of deep burns of the hand.” Aust N Z J Surg 49(5): 567-72. Early debridement of deep dermal or full thickness burns to the dorsum of the hand is recommended as a means of promoting early healing and mobilization, and therefore less residual disability. The results of treatment of 27 patients with deep hand burns are reviewed and some illustrative examples are discussed. A plan of management for these injuries is presented.

Craig, R. D. (1972). “The management of deformities following electric fire burns.” Hand 4(3): 247-52.

Davies, D. M. and A. M. Yiacoumettis (1978). “A method of grafting hand burns following early excision.” Br J Surg 65(8): 539-42. Early excision and delayed primary grafting of burns of the hand is presented as a method of achieving rapid healing, thus allowing early full mobilization. The results of 19 consecutively treated patients are reported.

Evans, E. B., D. L. Larson, et al. (1970). “Prevention and correction of deformity after severe burns.” Surg Clin North Am 50(6): 1361-75.

Maslauskas, K., R. Rimdeika, et al. (2005). "Analysis of burned hand function (early versus delayed treatment)." Medicina (Kaunas) 41(10): 846-51. The aim of this study was analyze the results of hand function in adult patients with deep partial thickness hand burns. All patients were treated in Kaunas University of Medicine Hospital in Lithuania during the period 2001-2004. MATERIAL AND METHODS. A total of 79 cases were reviewed prospectively. We divided the studied patients into two groups by the envelope method (A group of early and B of delayed necrectomy and plasty). Two treatment methods--early and delayed surgery--have been analyzed. We present results of analysis of hand function in the periods of 3 and 12 months after the burn injuries of the hands. RESULTS. During the study we ascertain that the deficiency of hand function in group A 3 and 12 months after the injury was lower than that in group B. The deficiencies of hand and arm functions decreased over time. After a period of 12 months the deficiency of hand and arm functions in group A reached 12%, while in group B the deficiencies of hand and arm function reached 23% and 26.5%, respectively. The study revealed that the deficiency of hand function because of wrist and hand burn depended on the age of patient, the area of hand burn, time period from the injury to the arriving to a hospital and time to the operation. The strength of digit pinch and hand grasp was larger in group A. Twelve months after the burn the strength measured in A and B groups was larger than that measured 3 months after the burn. The strength of hand grasp in group A in male patients regenerated up to 76%, in female--61% of norm. In group B the strength of hand grasp in male patients regenerated up to 60.8% and in female--39.36%. CONCLUSIONS. During the perspective analysis it was determined that after periods of 3 and 12 months after the injury the strength pinch and grip was statistically significantly larger in group A. The deficiency of hand function, which indicates the general hand function, was statistically significantly lower in group A. 11

Mazzetto-Betti, K. C., A. C. Amancio, et al. (2009). "High-voltage electrical burn injuries: functional upper extremity assessment." Burns 35(5): 707-13. High-voltage electric injuries have many manifestations, and an important complication is the damage of the central/peripheral nervous system. The purpose of this work was to assess the upper limb dysfunction in patients injured by high-voltage current. The evaluation consisted of analysis of patients' records, cutaneous-sensibility threshold, handgrip and pinch strength and a specific questionnaire about upper limb dysfunctions (DASH) in 18 subjects. All subjects were men; the average age at the time of the injury was 38 years. Of these, 72% changed job/retired after the injury. The current entrance was the hand in 94% and grounding in the lower limb in 78%. The average burned surface area (BSA) was 8.6%. The handgrip strength of the injured limb was reduced (p<0.05) and so also that of the three pinch types. The relationship between the handgrip strength and the DASH was statistically significant (p<0.001) as well as the relationship between the three pinch types (pnerve area. These data indicate a reduction of the hand muscular strength and sensibility, reducing the function of the upper limb in patients who received high-voltage electrical shock.

Frist, W., F. Ackroyd, et al. (1985). “Long-term functional results of selective treatment of hand burns.” Am J Surg 149(4): 516-21. Four hundred seventy-eight patients with hand burns (786 hands) were treated at the burn service of the Massachusetts General Hospital. Long- term evaluation showed that early incision and immediate autografting of deep second degree, mixed second and third degree, and third degree full-thickness hand burns resulted in 93 percent, 95 percent, and 93 percent, respectively, excellent to good functional results. There was no significant differences in results in patients with superficial second degree burns treated nonsurgically with silver nitrate dressings and early physical therapy compared with results in patients with deep second degree, mixed second and third degree, and third degree hand burns treated with early excision and grafting. No patient with fourth degree burns had excellent to good results. Permanent damage was related to extent of original injury to the extensor tendons and joint capsules. On the basis of this broad experience, it is believed that all burned hands judged unlikely to heal within 3 weeks will benefit from early excision and grafting by experienced surgical personnel.

Gant, T. D. (1980). “The early enzymatic debridement and grafting of deep dermal burns to the hand.” Plast Reconstr Surg 66(2): 185-90. Thirty-four hands in 24 patients with clinically diagnosed, deep second- degree burns have been treated for 24 hours, immediately after the burn with Sutilains bacterial enzymatic ointment. The ages of the patients range from 16 months to 65 years. Follow- up was from 3 to 12 months. After 24 hours' treatment with the enzyme, the patient is taken to the operating room, where the soft eschar is scraped from the wound and thin split-thickness grafts are applied. Ninety-one percent had full take of the grafts and were 12 able to move their hands actively and passively through a full range of movement within 1 week after the burn. The long-term aesthetic and functional results were excellent.

Tambuscio, A., M. Governa, et al. (2006). "Deep burn of the hands: Early surgical treatment avoids the need for late revisions?" Burns 32(8): 1000-4. An eight years experience in the management of deep hand burns is presented. We reviewed 116 cases of patients surgically treated with escarectomy and skin autograft. Seventy eight of them underwent early surgery within the first 4-6 days from injury, while 38 were conservatively treated in the fist stage and only lately surgery was performed (usually after the 14th day). In all patients, we applied the same post operative topic treatment and rehabilitation protocol. Several months after first admission, only 6(7.7%) of early treated patients needed secondary correction for unaesthetic and functionally debilitating scars versus 14(36.8%) of the late treated group. Our review confirm the importance of performing early surgery of deep burns of the hands, whenever possible, in order to achieve best results and shows it's utility in reducing re-admissions for secondary revisions.

Groenevelt, F. and R. W. Kreis (1985). “Burns of the hand.” Neth J Surg 37(6): 167-73. Estimating the depth of burns of the hand remains difficult and requires considerable experience. One reason for this is that the depth of the burn can change in the first three days as a result of vascular spasm and thrombotic processes in the microcirculation of the skin. Extensive burns over the rest of the body and edema development also influence skin perfusion. The pathophysiological changes of thermal injury of the hand are discussed together with the interaction between infection reaction, edema development and mobility. The guidelines for primary treatment of burns of the hand are discussed. In essence the therapy consists of closing the skin as soon as possible, to eliminate the edema and to prevent infection. Recently a clear controversy has developed between conservative treatment or surgery of deep second degree burns and deep mixed burns of the hand. The advantages and disadvantages of these two therapies are discussed.

Habal, M. B. (1978). “The burned hand: a planned treatment program.” J Trauma 18(8): 587-95. A planned treatment program for burned hands has been developed and was used in 72 burns of the dorsum of the hands. Treatment was individualized on the basis of whether hand burns were superficial or deep. In the former, there was evidence of spontaneous reepithelialization within 14 to 21 days. In the latter, immediate or delayed excision, followed by resurfacing with autografts was done. Both groups received topical antibiotic creaming, elevation, an exercise program as soon as they were able, and splinting of the burned hand in the antideformity position. Hypertrophic scars and unacceptable epithelium were excised when they interfered with function. Initially, this program allowed us to avoid unnecessary surgical procedures in 94% of the second- degree burns of the dorsum of the hand. The third-degree burned hand needed excision and autografting in 100% of the burned hands. This treatment program has as its goals: prevention of deformity by early motion and protection of the unburned and regenerating epithelium by creaming with topical antibiotic ointment. 13

Halliday, A. T. (1974). “Use of Mafenide in burns of the hand.” Proc Mine Med Off Assoc 54(419): 21-2.

Hanumadass, M., R. Kagan, et al. (1987). “Early coverage of deep hand burns with groin flaps.” J Trauma 27(2): 109-14. Deep burns of the hands require skin flap coverage in order to protect the exposed vital structures. The groin flap is a safe and effective method of obtaining early closure of these defects. We have used groin flaps to cover deep hand burn defects in nine patients. In each case, groin flaps effectively covered the various defects, such as the volar aspect of the wrist, dorsum of the hand, first web space, thumb, and fingers.

Dornseifer, U., A. M. Fichter, et al. (2009). "The Ideal Split-Thickness Skin Graft Donor Site Dressing: Rediscovery of the Polyurethane Film." Ann Plast Surg. The almost single disadvantage of polyurethane film dressings, an uncontrolled leakage, is probably as often described as its numerous advantages for split-thickness skin graft donor sites. We solved this problem by perforating the polyurethane film, which permits a controlled leakage into a secondary absorbent dressing. The study included 30 adult patients. Skin graft donor sites at the proximal thigh were dressed with the modified film dressing. Our results indicate that this dressing concept is associated with a reliable, rapid rate of epithelization. Both, controlled leakage and minimal pain caused particular comfort for patients and ward staff. Furthermore, this dressing was also suited for differently shaped and large donor sites. We conclude that the modification results in a more practicable, comfortable, and cost-effective film dressing, which requalifies the polyurethane film as an ideal dressing material for split-thickness skin graft donor sites.

Hentz, V. R. (1985). “Burns of the hand. Thermal, chemical, and electrical.” Emerg Med Clin North Am 3(2): 391-403. The principles of emergency management of the burned hand include early estimate of the depth of injury; prevention of unnecessary post-burn sequelae, such as edema formation and joint stiffness; and measures to ensure prompt healing of the wound. A successful outcome requires correct splinting interspersed with early active motion, control of infection with frequent dressing changes, and early referral to a hand surgeon if the wound cannot be expected to heal by two weeks.

Huang, T. T., D. L. Larson, et al.(1975). “Burned hands.” Plast Reconstr Surg 56(1):21-8. Hand involvement is common in patients with severe burns. Our experience indicates that almost one-third of the patients admitted to the Shriner's Burns Institute and The University of Texas Medical Branch Hospitals with burns exceeding 30 per cent of the body surface had concomitant burns of the hand. Our approach in managing the burned hand during the acute phase of unjury, as well as during secondary reconstruction of the deformities, is presented and discussed.

Hunt, J. L., R. Sato, et al. (1979). “Early tangential excision and immediate mesh autografting of deep dermal hand burns.” Ann Surg 189(2): 147-51.

Hunt, J. L. and R. M. Sato (1982). “Early excision of full-thickness hand and digit burns: factors affecting morbidity.” J Trauma 22(5): 414-9. Full-thickness dorsal hand and digit burns result in serious acute and chronic functional disability. Early wound closure is paramount to minimize functional impairment and improve ultimate cosmetic appearance. Fifty patients were followed for 2 to 6 years after excision and immediate autografting of full-thickness hand and digit burns. Based on the depth of injury distal to the metacarpal phalangeal joints, two groups of hand burns emerged in this series. Group I: Patients had uninjured and intact extensor mechanisms. Near normal range of motion was obtained by the end of the second postoperative week. Local wound sepsis and/or inadequate depth of excision resulted in autograft loss and additional surgical procedures in 10% of the hands. Group II: Patients with thermal damage to some portion of the extensor mechanism of the digit. Seventy- five per cent of these hands had thermal damage to bone. An average of three operative procedures was required on each hand for ultimate wound closure. Prolonged immobilization, persistent edema, and local wound sepsis were common to all Group II hands. Reconstructive surgery was necessary within 1 year in 43% of all hands. Hands in Groups I and II required surgery 12% and 75% of cases, respectively. Early surgical excision coupled with aggressive physical and occupational therapy has decreased but not eliminated many of the acute and chronic sequelae of full-thickness hand and digit burns.

Jostkleigrewe, F., K. A. Brandt, et al. (1995). “Treatment of partial thickness burns of the hand with the preshaped, semipermeable Procel Burn Cover: results of a multicentre study in the burn centres of Berlin, Duisburg and Munich.” Burns 21(4): 297-300. The results of a prospective clinical study conducted in three German burn centres are reported. The subject of the evaluation was to show the effectiveness of a new, preshaped, semipermeable burn dressing that is resistant to fluids and bacteria but highly permeable to vapour. The dressing was used in conjunction with 1 per cent silver sulphadiazine cream in treating partial thickness burns of the hand. In 49 patients, 72 partial thickness burned hands were treated. The application proved to be very easy. The time for a dressing change was short (5-10 min). The duration of treatment was 13 days on average. Complications due to infections did not occur. Because of the semipermeable properties of the dressing material, skin macerations occurred in only a few instances (13 per cent) as a result of inappropriate cream application or extremely high exudation rates, and these did not adversely affect the healing process. Patients achieved the ability to perform activities of daily living early with positive results for the patients, the physician and the nursing team.

Kneafsey, B., M. O'Shaughnessy, et al. (1996). “The use of calcium alginate dressings in deep hand burns.” Burns 22(1): 40-3. Deep burns of the hand are a common serious surgical problem with major occupational and economic implications. Control of haemorrhage during excision and grafting is difficult and postoperative haematoma may reduce graft take. Following excision, important deep structures such as extensor tendons or joints may be exposed. 15

Such tissues do not take free skin grafts satisfactorily. We have found calcium alginate dressings can be of immense help in minimizing these technical problems. We describe our experience in one patient; three other patients have been treated with equal success.

Krizek, T. J., S. V. Flagg, et al. (1973). “Delayed primary excision and skin grafting of the burned hand.” Plast Reconstr Surg 51(5): 524-9.

Labandter, H., I. Kaplan, et al. (1976). “Burns of the dorsum of the hand: conservative treatment with intensive physiotherapy versus tangential excision and grafting.” Br J Plast Surg 29(4): 352-4.

Larson, D. L., S. Abston, et al. (1974). “Contracture and scar formation in the burn patient.” Clin Plast Surg 1(4): 653-6.

Lattari, V., L. M. Jones, et al. (1997). “The use of a permanent dermal allograft in full- thickness burns of the hand and foot: a report of three cases.” J Burn Care Rehabil 18(2): 147-55. The standard method of grafting deep, thermal hand-and-foot burns with either full-thickness sheet grafts or narrowly meshed, thick, split- thickness skin grafts not only leaves a deep donor site, but also becomes complicated by infection, hypertrophic scarring, blistering, and hyper- or hypopigmentation. The availability now of an acellular, immunologically inert dermal transplant (AlloDerm; LifeCell Corp., The Woodlands, Texas) allows the successful use of ultrathin autografts while maximizing the amount of dermis delivered to the wound site. These autografts leave thin donor sites that heal faster and with fewer complications. This case report describes the use of AlloDerm dermal grafts on three patients with full-thickness burns of the distal extremities. Grafts were applied to the hand in two cases and the dorsum of the foot in the third. Range of motion, grip strength, fine motor coordination, and functional performance were quantitatively evaluated. As demonstrated by these patients, cosmetic and functional results were considered good to excellent after the use of AlloDerm grafts with thin autografts.

Leis, S. N. (1980). “Treatment of hand burns using debrisan.” J Am Osteopath Assoc 80(1): 53-5.

Leonard, L. G., A. M. Munster, et al. (1980). “Adjunctive use of intravenous fluorescein in the tangential excision of burns of the hand.” Plast Reconstr Surg 66(1): 30-3. The use of fluorescein as an aid to the differentiation of viable from nonviable tissue facilitates early tangential excision of hand burns. This technique, applied as part of an overall treatment program that includes immediate autografting with unexpanded meshed grafts and early mobilization, has resulted in excellent functional recovery from a potentially devastating injury.

Levine, B. A., K. R. Sirinek, et al. (1979). “Efficacy of tangential excision and immediate autografting of deep second-degree burns of the hand.” J Trauma 19(9): 670-3. Fifty patients, with 71 hands affected by deep dermal burns, underwent tangetial excision and immediate autografting at a mean of the fifth postburn day. Assessment of 16 the group at 6 weeks showed an 8% mortality, good hand function in 50%, fair function in 18%, and poor function in 24%. The total group was partitioned into patients with burns of 40% or less and those with burns of greater than 40% of body surface. The former group had significantly better hand function than the latter. Early tangetial excision with immediate autografting of deep dermal hand burns is recommedned for almost all patients with small to moderate thermal cutaneous injury. However, only after careful evaluation should patients with large, life-threatening thermal injuries be selected for this procedure.

Luster, S. H., P. E. Patterson, et al. (1990). “An evaluation device for quantifying joint stiffness in the burned hand.” J Burn Care Rehabil 11(4): 312-7. An electronic device capable of measuring finger joint stiffness has been developed and used to evaluate the effects of dynamic flexion splinting on the recovery of joint motion in patients with burned hands. The device locates an angle of primary (greatest) resistance and the reactive torque at that angle for a selected joint. Using the device, four subjects with stiff hands were measured before and after dynamic splinting treatments. During the 3-day treatment period, there were statistically significant differences in the angle of primary resistance (p less than 0.0001) and reactive torque (p less than 0.001). This initial trial suggests that: (1) finger stiffness can be quantified in terms of reactive torque as well as joint excursion, (2) dynamic rubber-band flexion splinting does alter joint condition and allow increased motion, (3) the amount of initial joint stiffness may be an indicator of treatment outcome, and (4) increasing treatment time may not enhance outcome.

Mahler, D. and B. Hirshowitz (1975). “Tangential excision and grafting for burns of the hand.” Br J Plast Surg 28(3): 189-92.

Malfeyt, G. A. (1976). “Burns of the dorsum of the hand treated by tangential excision.” Br J Plast Surg 29(1): 78-81.

Manstein, C. M., M. E. Manstein, et al. (1987). “Circumferential electric burns of the ring finger.” J Hand Surg [Am] 12(5 Pt 1): 808.

Mooney, E. K. (1998). “Daniel Drake's account of his own hand burns (1830).” Plast Reconstr Surg 102(5): 1748-54.

Newmeyer, W. L. and E. S. Kilgore, Jr. (1977). “Management of the burned hand.” Phys Ther 57(1): 16-23. Current concepts in the management of acute and chronic injury to hands due to thermal burns are presented. A review of relevant functional anatomy and its alteration by the burn process is outlined. The maintenance of wrist extension, metacarpophalangeal flexion, and an open thumb web is critical in the acute phase. The physical therapist, using splints and regular exercise, is the key person in maintaining this position. The use of antibacterial agents, surgical debridement, and skin grafting is discussed. Surgical methods of reconstruction in chronic burns, the long-term role of the physical therapist, and the use of compression garments to minimize scar are stressed. 17

Nuchtern, J. G., L. H. Engrav, et al. (1995). “Treatment of fourth-degree hand burns.” J Burn Care Rehabil 16(1): 36-42. Fourth-degree hand burns are rare but devastating injuries. They cannot be grafted readily but often require flaps and amputation, and impairment is significant. We report our 10-year experience (1981 to 1990) with deep hand burns to characterize our treatment and outcome. A total of 25 patients (35 hands) were treated. Eight local flaps, nine distant flaps, and two free-tissue transfers were performed. Eleven hands were treated with K- wire immobilization and grafting. Thirty- three amputations were done. Postburn function was evaluated in 25 salvaged hands. Eleven hands had good outcomes, whereas seven had moderate sequelae and seven were severely affected. Patients who were treated with flap coverage of exposed tendons and joints had better functional outcomes than those treated with delayed closure with immobilization and grafting. The excellent outcomes in the flap coverage group justifies the added commitment of technical and therapeutic resources that this treatment requires.

Paavolainen, P. and B. Sundell (1976). “The effect of dextranomer (Debrisan) on hand burns. A preliminary report on a new method in the treatment of hand burns.” Ann Chir Gynaecol 65(5): 313-17. Dextranomer (Debrisan, Pharmacia, Uppsala, Sweden) is synthetized by cross- linking of dextran chains with epichlorohydrin. It is an insoluble hydrophilic substance which is suitable for topical treatment of secreting wounds, such as burns. Thirteen patients with 17 burned hands were treated. The result of the treatment - decrease in pain, healing time and improved hand function - was registered clinically. No crust was formed. The risk of permanent restriction in range of movements decreased, since the treated hands were soft and mobile throughout the entire period of treatment. All hands treated recovered full mobility. Physiotherapy could be performed daily. No infection appeared because exudate and bacteria were continuously removed from the treated area. Pain rapidly decreased. No side reactions were observed.

Parks, D. H., E. B. Evans, et al. (1978). “Prevention and correction of deformity after severe burns.” Surg Clin North Am 58(6): 1279-89.

Pegg, S. P., D. Cavaye, et al. (1984). “Results of early excision and grafting in hand burns.” Burns Incl Therm Inj 11(2): 99-103. A total of 658 admissions to the Burns Unit at the Royal Brisbane Hospital were reviewed over a 4-year period. During this time, 73 hand burns were treated. The policies of the Burns Unit regarding hand burns are detailed; and, where possible, early excision and grafting is performed. The results of these hand burns are discussed and indicate minimal requirements for reconstructive surgery. The most common reconstructive surgery needed was for web space release in 10 patients and excision of hypertrophic scar in 2 patients. It is concluded that early excision and grafting of hand burns is safe and practical, and combined with adequate splinting, exercise and pressure garments, gives good results and lessens hospital stay in patients with relatively small injuries. The duration of stay in hospital in patients with large burns is not due to the treatment of their hand burns, but to their overall large body surface area burnt. 18

Peterson, R. A. (1966). “Electrical burns of the hand. Treatment by early excision.” J Bone Joint Surg Am 48(3): 407-24.

Robotti, E. B. (1990). “The treatment of burns: an historical perspective with emphasis on the hand.” Hand Clin 6(2): 163-90. Since the use of fire became part of life, mankind has sought remedies to treat burns. The upper extremity, due to its frequency of exposure as the foremost organ in the everyday exploration of the environment and in manipulative and social interactions, is often involved. This article discusses the history of burn treatment.

Salisbury, R. E., J. L. Hunt, et al. (1973). “Management of electrical burns of the upper extremity.” Plast Reconstr Surg 51(6): 648-52.

Salisbury, R. E. and N. S. Levine (1976). “The early management of upper extremity thermal injury.” Major Probl Clin Surg 19: 36-46.

Salisbury, R. E. and P. Wright (1982). “Evaluation of early excision of dorsal burns of the hand.” Plast Reconstr Surg 69(4): 670-5. To determine the best method for treating deep second- and third-degree burned hands in our institution, a prospective study comparing early excision and grafting with nonsurgical treatment was undertaken. The patients were randomly assigned to two groups, and the hands in the first group were excised and grafted within 5 days after the burn. In the second group, burns were treated with topical chemotherapy and hydrotherapy, and the eschar was allowed to separate spontaneously and heal. Some required skin grafting, forming a subgroup. All hands in the study received the same vigorous physical therapy twice daily, and splints were applied according to the patient's individual needs to maintain an anti-deformity position. Grip strength, power pinch, and accurate range-of-motion measurements of each finger joint were measured upon discharge and 1, 2, 3, 6, and 12 months after the burn. A mean total degrees of motion (including flexion and extension) in each joint and strength values were determined for comparison among the three groups. At discharge, the spontaneously healed hands had the best range of motion and function. Although the rate of improved function was greatest in the interval from discharge to 6 months in all groups, by 1 year there was no statistical difference in function regardless of the initial treatment. Thus in deep second- and third-degree burns of the dorsum of the hand, care may be individualized according to other systemic factors without fear of sacrificing ultimate function.

Pradier, J. P., C. Oberlin, et al. (2007). "Acute deep hand burns covered by a pocket flap- graft: long-term outcome based on nine cases." J Burns Wounds 6: e1. OBJECTIVE: We evaluated the long-term outcome of the "pocket flap-graft" technique, used to cover acute deep burns of the dorsum of the hand, and analyzed surgical alternatives. METHODS: This was a 6-year, retrospective study of 8 patients with extensive burns and 1 patient with a single burn (11 hands in all) treated by defatted abdominal wall pockets. We studied the medical records of the patients, and conducted a 19 follow-up examination. RESULTS: All hands had fourth-degree thermal burns caused by flames, with exposure of tendons, bones, and joints, and poor functional prognosis. One third of patients had multiple injuries. Burns affected an average of 36% of the hand surface, and mean coverage was 92.8 cm(2). One patient died. The 8 others were seen at 30-month follow-up: the skin quality of the flap was found to be good in 55% of the cases, the score on the Vancouver Scar Scale was 2.4, the Kapandji score was 4.5, and total active motion was 37% of that of a normal hand. Hand function was limited in only 2 cases, 8 patients were able to drive, and 3 patients had gone back to work. CONCLUSION: The pocket flap-graft allows preservation of hand function following severe burns, when local or free flaps are impossible to perform. Debulking of the flap at the time of elevation limits the need for secondary procedures.

Sanford, S. and D. Gore (1996). “Unna's boot dressings facilitate outpatient skin grafting of hands.” J Burn Care Rehabil 17(4): 323-6. Present day economics have challenged health care providers to minimize the length of hospitalization without sacrificing quality of care. Within this context, the purpose of this study was to determine whether supporting the hand and wrist with an Unna's boot dressing (Medicopaste bandage; Graham-Field, Inc., Hauppauge, N.Y.) and splint, and covering the skin graft donor site with calcium alginate (Kaltostat; Calgon Vestal, St. Louis, Mo.), would allow successful outpatient skin grafting of burns to the upper extremity. Twelve patients with burns underwent debridement and split-thickness skin grafting on a total of 16 upper extremities with this method. Only patients who were otherwise healthy, had adequate home environments, and had burns limited to distal to the elbow were included for this initial trial. All skin graft donor sites were obtained from either the upper thigh or buttocks. Patients were discharged to home after 4 to 6 hours of observation and given amoxicillin for 5 days after surgery. Patients returned to the burn unit on the fifth postgrafting day for removal of the Unna's boot dressing, initiation of occupational therapy to the hands, and reapplication of a new calcium alginate dressing if needed. This and subsequent follow-up visits revealed a 95% or more take on all skin grafts, without any infectious complications. These results demonstrate the efficacy of Unna's boot support and calcium alginate dressings of donor sites in limited skin graft procedures. Furthermore, these results suggest that more extensive surgical debridements and skin graftings may be successfully shifted to outpatient procedures with use of these adjuvants.

Sheridan, R. L., J. Hurley, et al. (1995). “The acutely burned hand: management and outcome based on a ten-year experience with 1047 acute hand burns.” J Trauma 38(3): 406-11. Optimal hand function has a very positive impact on the quality of survival after burn injury. Over a 10-year period, 659 patients with 1047 acutely burned hands were managed at the Sumner Redstone Burn Center of the Massachusetts General Hospital. Our approach to acutely burned hands emphasizes ranging and splinting throughout hospitalization, prompt sheet autograft wound closure as soon as practical, and the selective use of axial pin fixation and flaps. This approach is associated with normal function in 97% of those with superficial injuries and 81% of those with deep dermal and full- thickness injuries requiring surgery. Although only 9% of those with injuries 20 involving the extensor mechanism, joint capsule, or bone had normal functional outcomes, 90% were able to independently perform activities of daily living.

Sauerbier, M., N. Ofer, et al. (2007). "Microvascular reconstruction in burn and electrical burn injuries of the severely traumatized upper extremity." Plast Reconstr Surg 119(2): 605-15. BACKGROUND: As the versatility and variability of free flaps have significantly increased during recent years, so have the indications for free tissue transplantation in burn reconstruction expanded. METHODS: The authors report retrospectively the results of 42 free flaps for upper extremity reconstruction in 35 severely burned patients using 13 different free flaps. This experience enabled the authors to establish reconstructive principles pertinent to the type of injury (burn versus high-voltage injuries) and the timing of reconstruction procedures. RESULTS: In high-voltage injuries (n = 17), early free flap coverage with muscular flaps was the most frequently used type of reconstruction. The reconstruction site was predominately the forearm. In burn injuries, free flap coverage was performed during a later stage of the treatment course. Reconstruction with cutaneous or fascial flaps was the preferred method. The elbow and dorsum of the hand underwent defect coverage in most circumstances. For reconstruction of complex or large defects (n = 6), combined "chimeric" flaps were used. Overall, the flap failure rate was 12 percent (n = 5). Interestingly, there was a relationship between flap failure rate and timing of the procedure. Four of five flap failures occurred within 5 to 21 days after trauma, and all five flap failures occurred between 5 days and 6 weeks. No flap failure occurred during secondary reconstruction. CONCLUSIONS: The authors' data demonstrate that burn and high-voltage injuries are distinct entities, each requiring custom-tailored reconstructive solutions for limb salvage. Even if the authors' flap failures all occurred during the first 6 weeks, it should not be forgotten that this type of coverage is the only alternative to amputation in selected cases.

Sheridan, R. L., L. Petras, et al. (1995). “Planimetry study of the percent of body surface represented by the hand and palm: sizing irregular burns is more accurately done with the palm.” J Burn Care Rehabil 16(6): 605-6. Sizing irregular burns is commonly done with use of the patient's hand as a template representing 1% of the body surface. To verify that this is accurate over a broad range of ages or to see if the surface of the palm is a more consistent template, a planimetry study was done. This revealed that the surface area of the palm averaged 0.52% total body surface area (+/- 0.07) and the palmar surface of the hand 0.85% total body surface area (+/- 0.08). The surface of the palm was a more consistent template and represented 0.5% of the body surface over a broad range of ages.

Sherif, M. M. and R. M. Sato (1989). “Severe thermal hand burns--factors affecting prognosis.” Burns Incl Therm Inj 15(1): 42-6. This paper presents the results of the analysis of clinical data from a series of 132 thermally injured patients with 214 burned hands. The objective was to identify the factors affecting the pathogenesis of postburn hand deformities. The study indicates that deep burns have the worst prognosis and that circumferential burns are always followed 21 by secondary sequelae. The incidence of secondary hand deformity rises sharply when the burn affects more than 25 per cent of the total body surface area (TBSA). Given the same physical therapy programme, early tangential excision and immediate grafting yield better results than conservative treatment. The results underline the role of patient motivation in maximal hand rehabilitation.

Silver, L. (1987). “Burns of the hand and wrist. Current concepts in diagnosis and treatment.” Orthop Rev 16(6): 394-400. Correct acute care is critical in the treatment of burns of the hand, particularly in the younger patient in order to avoid complications that may interfere with the patient's quality of life and ability to be self-sufficient and self-supportive. Objectives of management are to prevent edema, prevent prolonged immobilization and poor position and prevent infection and preserve viable tissue. The various modalities that are used to achieve these objectives and how they may be individualized to meet the patient's specific needs are described and discussed.

Simpson, R. L. and M. E. Flaherty (1992). “The burned small finger.” Clin Plast Surg 19(3): 673-82. Postburn deformities are common in the small finger. A boutonniere-like deformity may develop when no injury has been noted in the central slip of the extensor tendon. Attention to the anatomic differences of the fifth digit and principles of graft contraction make this deformity preventable. In the long-standing burn hyperextension deformity of the metacarpophalangeal joint, recurrence of the deformity may occur after reconstruction. Evaluation of extrinsic extensor tightness may indicate an alteration in the soft tissue-to-skeleton relationship. Composite tissue expansion of the tendon and overlying skin graft provides an alternative reconstruction method.

Smith, M. A., A. M. Munster, et al. (1998). “Burns of the hand and upper limb--a review.” Burns 24(6): 493-505. This review article addresses the principles and controversies associated with thermal injury to the hand and upper limb. Accepted principles are outlined and areas of controversy are discussed in a balanced manner. The importance of hand burns is described functionally and epidemiologically. Burns appropriate to outpatient care are defined and treatment discussed, including debridement, topical therapy, rehabilitation and follow-up. The general principles of inpatient management are given, including the controversial issue to timing of surgery and treatment of the exposed tendon or joint. The extent of surgery, methods of wound closure and difficult problem of palm burns are also discussed. Reconstructive principles are outlined and a problem oriented approach to the most common reconstructive problems given.

Solnit, A. J. and B. Priel (1975). “Psychological reactions to facial and hand burns in young men. Can I see myself through your eyes?” Psychoanal Study Child 30: 549-66.

Sorensen, B. (1968). “Electrical hand burns.” Scand J Plast Reconstr Surg 2(1): 67-70.

Stuart, J. D., R. F. Morgan, et al. (1990). “Single-donor fibrin glue for hand burns.” Ann Plast Surg 24(6): 524-7. Early tangential excision sometimes results in considerable blood loss, prolonged operative time, and partial loss of the graft secondary to hematoma formation. Previous reports document positive hemostatic effects and improved skin fixation with fibrin "glue." The commercial preparation used in Europe, however, has not been approved by the United States Food and Drug Administration because of the high risk of hepatitis and human immunodeficiency virus transmission. Using a method developed at the University of Virginia, we applied single-donor fibrin glue as an adjunct in early excision and grafting in 16 patients (26 hands). The overall graft take was 99%. In all patients, better adherence of the split-thickness graft to the recipient bed, during and immediately after application, was noted. We have observed no negative effects with regard to infection or healing. We recommend the use of single-donor fibrin glue to reduce operative blood loss, improve survival and ease of graft application, and possibly to accelerate healing.

Sykes, P. J. (1991). “Severe burns of the hand: a practical guide to their management.” J Hand Surg [Br] 16(1): 6-12.

Terrill, P. J., S. M. Kedwards, et al. (1991). “The use of GORE-TEX bags for hand burns.” Burns 17(2): 161-5. Clinical and laboratory studies were made to compare the water vapour permeability, bacteriological properties and clinical performance of polythene and polytetrafluoroethylene fabric (GORE-TEX) bags in the treatment of hand burns. Polythene bags are virtually impermeable to saline, whereas GORE-TEX bags containing silver sulphadiazine cream show a water vapour permeability of 0.53 ml/cm2/day, resulting in a 30 per cent weight reduction of added water after 48 h. Clinically, hand maceration and accumulation of exudate are significantly reduced in hands treated in GORE-TEX bags. The mean daily volume of accumulated exudate for GORE-TEX bags was 37 ml compared to 83 ml for polythene (P less than 0.01). When adjusted for the percentage area of the hand surface burned, this reduction remained significant (P less than 0.005). A tendency for less pain and better hand movement was noted with GORE- TEX bags. There were no significant differences in rate of healing or bacterial colonization of the burned hand between the two type of bags. GORE-TEX bags prevent skin maceration and accumulation of exudate, allowing ease of burn assessment and improved hand function. They are also durable and non-slip, thus increasing patient independence. van Zuijlen, P. P., R. W. Kreis, et al. (1999). “The prognostic factors regarding long-term functional outcome of full- thickness hand burns.” Burns 25(8): 709-14. The treatment of the burned hand has always been a subject of special interest. In order to obtain a better understanding of the parameters involved in the long-term functional outcome of hand burns a retrospective study was performed on 88 consecutive patients with hand burns (143 hands), treated according to a standardised protocol. Patients were followed for at least 12 months postburn. Hand function was assessed by the seven objective test criteria (7-OTC) described by Jebsen. Logistic regression analysis 23 produced five parameters that were found to have a significant predictive value for long- term hand function. In order of predictive value, these were finger amputations, age on admission, impaired autograft take, the full-thickness hand burn surface area and the full- thickness total body burn surface area. By fitting these five variables into an equation, a probability model was obtained, which could be applied to estimate a prognosis concerning the final hand function of an individual patient with a hand burn. No relationship was found between the postburn day of operation and the long-term hand function. This finding is inconsistent with the current consensus that functional outcome is improved by early excision and grafting. In practice, it suggests that hand function is well preserved when burns of uncertain depth are treated expectantly, followed by selective debridement and grafting. Advantages include reduced blood loss, no loss of vital tissue and a reduction of the need for donor sites.

Verdan, C. (1967). “Basic principles in surgery of the hand.” Surg Clin North Am 47(2): 355-77.

Wang, X. W., Y. H. Sun, et al. (1984). “Tangential excision of eschar for deep burns of the hand: analysis of 156 patients collected over 10 years.” Burns Incl Therm Inj 11(2): 92-8. Deep burns affecting the dorsum of the hand have been treated by tangential excision of the eschar in 156 patients involving 208 hands. From our 10-year experience we have concluded that: If the patient's general condition permits it all hands with deep partial and full thickness skin loss burns are suitable for early tangential excision of the eschar. The best time for the operation is within the first week after injury. If the burn is of limited extent and the requirement for autograft skin is small the operation may be carried out under nerve block anaesthesia. When the burn is more extensive (i.e. involving both hands) intravenous ketamine anaesthesia is recommended. During tangential excision sequential layers of tissue must be removed until the base of the burn appears porcelain white in colour, has a lustrous appearance with many small bleeding points and is firm in consistency. If there are deep burns of the finger webs they are incised or excised and then grafted. Postoperatively an absence of fever, pain or exudation from the wound indicates that inspection of the wound can be delayed for about 2 weeks. By this time the wound is usually healed and functional rehabilitation and physiotherapy can commence.

Wexler, M. R., R. Yeschua, et al. (1974). “Early treatment of burns of the dorsum of the hand by tangential excision and skin grafting.” Plast Reconstr Surg 54(3): 268-73.

Haslik, W., L. P. Kamolz, et al. (2011) "Management of full-thickness skin defects in the hand and wrist region: first long-term experiences with the dermal matrix Matriderm." J Plast Reconstr Aesthet Surg 63(2): 360-4. The gold standard for the coverage of full-thickness skin defects is autologous skin grafts. However, poor skin quality and scar contracture are well-known problems in functional, highly strained regions. The use of dermal substitutes is an appropriate way to minimise scar contraction and, thereby, to optimise the quality of the reconstructed skin. The aim of this study was to evaluate the impact 24

of the collagen-elastin matrix, Matriderm, for the single-step reconstruction of joint-associated defects of the upper extremity. Seventeen patients with full- thickness skin defects of the upper extremity were treated with the dermal substitute, Matriderm, and unmeshed skin graft in the functional critical region of the distal upper extremity in a single-step procedure. The take rate of the matrix- and-skin graft was 96%. Long-term follow-up revealed an overall Vancouver scar scale of 1.7. No limitation concerning hand function was observed; DASH-score analysis revealed excellent hand function in patients with burn injury and patients with a defect due to the harvest of a radial forearm flap achieved satisfying hand function. This matrix represents a viable alternative to other types of defect coverage and should therefore be considered in the treatment of skin injuries, especially in very delicate regions such as the joint regions. The possibility of performing a one-stage procedure is supposed to be a major advantage in comparison to a two-stage procedure.

Agrawal, N. K. and V. Bhattacharya( 2010) "Aluminium hand splint for postoperative immobilisation of flexion deformity of digits and palm: a simple method." Burns 37(3): 541-2.

Al-Qattan, M. M., K. Al-Zahrani, et al. (2011) "Friction burn injuries to the dorsum of the hand after car and industrial accidents: classification, management, and functional recovery." J Burn Care Res 31(4): 610-5. A total of 65 cases of friction burn injuries to the dorsum of the hand after car and industrial accidents were reviewed. The mean age of the study population was 31 years (range 18-68 years). The injury sustained from friction was graded into four grades: grade I (n = 6), isolated second-degree skin burn, grade II (n = 6), full- thickness skin burn without extensor tendon exposure, grade III (n = 45) the friction injury affected and exposed the extensor tendons, and grade IV (n = 8) the friction injury extended to bones and joints. Management was by dressing, split skin grafting, local/pedicle flap, and free muscle flap in grades I to IV, respectively. Functional recovery of the hand in terms of percentage normal range of motion and grip strength was best in grade I and worst in grade IV injury. Complications of reverse-pedicled forearm flaps were higher than free muscle flaps. However, the aesthetic appearance of grafted free muscle flaps on the dorsum of the hand was inferior to fasciocutaneous flaps.

Mohammadi, A. A., A. R. Bakhshaeekia, et al. (2010) "Early excision and skin grafting versus delayed skin grafting in deep hand burns (a randomised clinical controlled trial)." Burns 37(1): 36-41. INTRODUCTION: Early excision and grafting (E&G) of burn wounds has been reported to decrease hospital stay, hospital costs and septic complications, and 25

some purport reduced mortality while decreasing hospital costs. In today's practice, all burn wounds unlikely to achieve spontaneous closure within 3 weeks are excised and grafted. Early studies did not demonstrate dramatic differences in cosmetic or functional results. This is particularly true with burns of the face, hands and feet. In this study, early excision and skin grafting was compared with delayed skin grafting in deep hand burns. MATERIALS AND METHODS: From September 2006 to February 2008, 50 patients with hand burns and average burn size less than 30% total body surface area (TBSA) deep second- and third-degree were randomly divided into early E&G group (group I) and delayed grafting group (group II). Gradual and careful limb and digit range of motion was started on about 10th-14th postoperative day. We used a questionnaire based on the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire to evaluate final functional outcome. Further, hypertrophic scar formation, contracture and deformities were followed and managed accordingly. RESULTS: The most common site of involvement was the metacarpophalangeal (MCP) joint with frequency of 39% and 40% in groups I and II, respectively. There were no statistically significant differences between both groups regarding deformity severity, scar formation, sensation, major activities and overall satisfaction. DISCUSSION: In treating burns of the hand, the primary goal should always be to restore the functionality of the hand. Although early surgery shortens the healing time and lessens the hospital stay, our results did not show any significant difference between these two methods regarding the function, scar formation, daily activity limitation and overall satisfaction.

Omar, M. T. and A. A. Hassan( 2011) "Evaluation of hand function after early excision and skin grafting of burns versus delayed skin grafting: a randomized clinical trial." Burns 37(4): 707-13. INTRODUCTION: Thermal injury of the hand is characterized by disfigurement and deformity with marked problems because the patient is no longer able to perform the daily living activities and function at school or work. Early excision and grafting (E&G) were introduced to decrease hospital stay, hospital cost, and septic complications and to eliminate burn toxins. In this study, E&G was compared with delayed skin grafting in deep hand burns. MATERIALS AND METHOD: 40 patients with deep second- and third- degree hand burns with average burn size less than 30% total body surface area (TBSA) were randomly divided into E&G group and delayed grafting group. All hands in both groups were subjected to pre and post operative program of physiotherapy. Measurement of total active motion (TAM) of each digit and grip strength was recorded pre and post operative. Hand function using Jebsen-Taylor hand function test (JTHFT) was recorded three months after operation in both groups. RESULTS: There were statistically significant differences in both groups regarding to TAM, hand grip strength and Jebsen-Taylor hand function test favoring the E&G group. CONCLUSION: The study concluded that early excision and skin grafting with physiotherapy gave better results than delayed grafting in terms of preservation of hand function and shortened hospital stay.

Ryssel, H., G. Germann, et al. (2010) "Dermal substitution with Matriderm((R)) in burns on the dorsum of the hand." Burns 36(8): 1248-53. BACKGROUND: Dermal substitutes are used increasingly in deep partial and full-thickness burn wounds in order to enhance elasticity and pliability. In particular, the dorsum of the hand is an area requiring extraordinary mobility for full range of motion. The aim of this comparative study was to evaluate intra- individual outcomes among patients with full-thickness burns of the dorsum of both hands. One hand was treated with split-thickness skin grafts (STSG) alone, and the other with the dermal substitute Matriderm((R)) and split-thickness skin grafts. MATERIAL AND METHODS: In this study 36 burn wounds of the complete dorsum of both hands in 18 patients with severe burns (age 45.1+/-17.4 years, 43.8+/-11.8% TBSA) were treated with the simultaneous application of Matriderm((R)), a bovine based collagen I, III, V and elastin-hydrolysate based dermal substitute, and split-thickness skin grafting (STSG) in the form of sheets on one hand, and STSG in the form of sheets alone on the other hand. The study was designed as a prospective comparative study. Using both objective and subjective assessments, data were collected at one week and 6 months after surgery. The following parameters were included: After one week all wounds were assessed for autograft survival. Skin quality was measured 6 months postoperatively using the Vancouver Burn Skin Score (VBSS). Range of motion was measured by Finger-Tip-Palmar-Crease-Distance (FPD) and Finger-Nail- Table-Distance (FNTD). RESULTS: Autograft survival was not altered by simultaneous application of the dermal matrix (p>0.05). The VBSS demonstrated a significant increase in skin quality in the group with dermal substitutes (p=0.02) compared to the control group with non-substituted wounds. Range of motion was significantly improved in the group treated with the dermal substitute (p=0.04). CONCLUSION: From our results it can be concluded that simultaneous use of Matriderm((R)) and STSG is safe and feasible, leading to significantly better results in respect to skin quality of the dorsum of the hand and range of motion of the fingers. Skin elasticity was significantly improved by the collagen/elastin dermal substitute in combination with sheet-autografts.

Ryssel, H., C. A. Radu, et al. "Single-stage Matriderm(R) and skin grafting as an alternative reconstruction in high-voltage injuries." Int Wound J 7(5): 385-92. This article presents a retrospective analysis of a series of nine patients requiring reconstruction of exposed bone, tendons or joint capsules as a result of acute high- voltage injuries in a single burn centre. As an alternative to free tissue transfer, the dermal substitute Matriderm((R)) was used in a one-stage procedure in combination with split-thickness skin grafts (STSG) for reconstruction. Nine patients, in the period between 2005 and 2009 with extensive high-voltage injuries to one or more extremities which required coverage of exposed functional structures as bone, tendons or joint capsule, were included. A total of 11 skin graftings and 2 local flaps were performed. Data including regrafting rate, complications, hospital stays, length of rehabilitation and time until return to work were collected. Eleven STSG in combination with Matriderm((R)) were performed on nine patients (success rate 89%). One patient died. One patient 27

needed a free-flap coverage as a secondary procedure. The median follow-up was 30 months (range 6-48 months). The clinical results of these nine treated patients concerning skin-quality and coverage of exposed tendons or joint capsule were very good. In high-voltage injuries free-flap failure occurs between 10% and 30% if performed within the first 4-6 weeks after trauma. The use of single-stage Matriderm((R)) and skin grafting for immediate coverage described in this article is a reliable alternative to selected cases within this period.

Sever, C., Y. Kulahci, et al. (2010) "Thermal crush injury of the hand caused by roller type ironing press machine." Acta Orthop Traumatol Turc 44(6): 496-9. Industrial garment machines may cause occupational hand injuries. However, combined thermal and crush injuries are uncommon, and their etiologies are varied. We present a case of thermal crush injury of the hand caused by laundry roller type ironing press machine. The circumstances of this injury and preventive measures are discussed.

Verhaegen, P. D., A. J. van Trier, et al. (2010) "Efficacy of skin stretching for burn scar excision: a multicenter randomized controlled trial." Plast Reconstr Surg 127(5): 1958- 66. BACKGROUND: Burn survivors are frequently faced with disfiguring scars. Various techniques exist to improve scar appearance, such as laser treatment and dermabrasion. Next to that, surgical reconstruction, such as scar excision is an option. This randomized controlled trial investigates whether a larger burn scar can be excised using a skin-stretching device for wound closure, thereby optimizing use of adjacent healthy skin. This technique may allow scar excision in a one-step procedure instead of two or more steps, which is necessary for serial excision and tissue expansion. METHODS: Two arms were compared: scar excision and closure by skin stretch and scar excision without additional techniques. The primary outcome measure was scar surface area reduction. In addition, complications were registered. RESULTS: Fifteen patients were randomized for skin stretch and 15 patients were randomized for scar excision only. In the skin stretch group, 10 of 15 scars were completely excised compared with three of 15 in the scar excision-only group (p = 0.025). In the skin stretch group, a significantly larger reduction in scar area was achieved: 95 +/- 11 percent of the scar was excised versus 78 +/- 17 percent in the scar excision-only group (p = 0.003). One patient in the skin stretch group and three patients in the scar excision-only group experienced partial wound dehiscence (p = 0.598). CONCLUSIONS: In burn scar reconstructions, a significantly larger reduction in scar area can be achieved using a skin-stretching device compared with scar excision with no additional techniques, without an increased risk of complications. It was shown that skin stretching is of added value for scars that cannot be excised in a one-step procedure.

Weigert, R., H. Choughri, et al. (2011) "Management of severe hand wounds with Integra(R) dermal regeneration template." J Hand Surg Eur Vol 36(3): 185-93. 28

We report our experience with the use of Integra(R) for the management of severe traumatic wounds of the hand. Fifteen patients were treated with follow-up ranging from 10 to 37 months. Wounds were associated with an osseous and/or joint and/or tendon exposure. Following Integra(R) placement, patients were managed with dressings and subsequent split-thickness skin grafting an average of 26 days later. Integra(R) was successful in achieving durable, functional and aesthetic definitive coverage in 13 of 15 applications while allowing a satisfying pollicidigital prehension. Regarding our clinical experience, Integra(R) is an effective technique to deal with severe wounds of the hand with exposed tendon and/or bone and/or joint, even in the absence of paratenon or periosteum. This can potentially lessen the need for local rotational or free flap coverage and should be taken into consideration as a viable alternative in traumatic reconstruction of the hand.

Zaroo, M. I., B. A. Sheikh, et al. (2011) "Use of preputial skin for coverage of post-burn contractures of fingers in children." Indian J Plast Surg 44(1): 68-71. OBJECTIVE: Hand burns are common injuries. Children frequently sustain burn injuries, especially to their hands. Contractures are a common sequel of severe burns around joints. The prepuce, or foreskin, has been used as a skin graft for a number of indications. We conducted this study to evaluate the feasibility of utilising the preputial skin for the management of post-burn contractures of fingers in uncircumcised male children. MATERIALS AND METHODS: Preputial skin was used for the coverage of released contractures of fingers in 12 patients aged 2-6 years. The aetiology of burns was "Kangri" burn in eight patients and scalding in four patients. Six patients had contracture in two fingers, four patients in one finger, and two patients had contractures in three fingers. RESULTS: None of the patients had graft loss, and all the wounds healed within 2 weeks. All patients had complete release of contractures without any recurrence. Hyperpigmentation of the grafts was observed over a period of time, which was well accepted by the parents. CONCLUSIONS: Preputial skin can be used successfully for male children with mild-to-moderate contractures of 2-3 fingers for restoration of the hand function, minimal donor site morbidity.

Kubota Y, Mitsukawa N, Chuma K, Akita S, Sasahara Y, Rikihisa N, et al. Hyperpigmentation after surgery for a deep dermal burn of the dorsum of the hand: partial-thickness debridement followed by medium split-thickness skin grafting vs full- thickness debridement followed by thick split-thickness skin grafting. Burns Trauma. 2016;4:9.

BACKGROUND: Early excision and skin grafting are commonly used to treat deep dermal burns (DDBs) of the dorsum of the hand. Partial-thickness debridement (PTD) is one of the most commonly used procedures for the excision of burned tissue of the dorsum of the hand. In contrast, full-thickness debridement (FTD) has also been reported. However, it is unclear whether PTD or FTD is 29

better. METHODS: In this hospital-based retrospective study, we compared the outcomes of PTD followed by a medium split-thickness skin graft (STSG) with FTD followed by a thick STSG to treat a DDB of the dorsum of the hand in Japanese patients. To evaluate postoperative pigmentation of the skin graft, quantitative analyses were performed using the red, green, and blue (RGB) and the hue, saturation, and brightness (HSB) color spaces. We have organized the manuscript in a manner compliant with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. RESULTS: Data from 11 patients were analyzed. Six hands (five patients) received grafts in the PTD group and eight hands (six patients) received grafts in the FTD group. Graft take was significantly better in the FTD group (median 98 %, interquartile range 95-99) than in the PTD group (median 90 %, interquartile range 85-90) (P < 0.01). Quantitative skin color analyses in both the RGB and HSB color spaces showed that postoperative grafted skin was significantly darker than the adjacent control area in the PTD group, but not in the FTD group. CONCLUSIONS: There is a possibility that FTD followed by a thick STSG is an option that can reduce the risk of hyperpigmentation after surgery for DDB of the dorsum of the hand in Japanese patients. Further investigation is needed to clarify whether the FTD or the thick STSG or both are the factor for the control of hyperpigmentation.

Dornseifer U, Lonic D, Gerstung TI, Herter F, Fichter AM, Holm C, et al. The ideal split- thickness skin graft donor-site dressing: a clinical comparative trial of a modified polyurethane dressing and aquacel. Plast Reconstr Surg. 2011;128(4):918-24.

BACKGROUND: The almost single disadvantage of conventional polyurethane film dressings, uncontrolled leakage, is probably as often described as its numerous advantages for split-thickness skin graft donor sites. This shortcoming can be overcome by perforating the polyurethane dressing, which permits controlled leakage into a secondary absorbent dressing. The study was conducted to compare the polyurethane dressing system and Aquacel, a hydrofiber wound dressing, which also seems to fulfill all criteria of an ideal donor-site dressing. METHODS: This prospective, randomized, double-blind clinical trial included 50 adult patients. Skin graft donor sites were divided equally for the application of Aquacel and polyurethane dressing. The dressings were kept unchanged for 10 days. After removal of the dressing at day 10, the epithelialization rate of both sites was evaluated. Pain scores were assessed according to a 0 to 5 numeric pain scale every postoperative day and during dressing removal. RESULTS: On postoperative day 10, 86.4 percent of the polyurethane dressing donor sites showed complete reepithelialization compared with 54.5 percent of the Aquacel- treated donor sites (p<0.001). Polyurethane dressing was significantly less painful until and during removal of the dressing (p<0.001). There was no significant difference with respect to scar formation. CONCLUSIONS: Overall, polyurethane dressing was superior to Aquacel. Further attributes of the polyurethane dressing such as ease of application, low labor input, high patient comfort, and protection against secondary wound infection qualify this dressing system as an ideal wound 30

covering for donor sites.

Davami B, Pourkhameneh G. Correction of severe postburn claw hand. Tech Hand Up Extrem Surg. 2011;15(4):260-4.

Burn scar contractures are perhaps the most frequent and most frustrating sequelae of thermal injuries to the hand. Unfortunately, stiffness occurs in the burned hand quickly. A week of neglect in the burned hand can lead to digital malpositioning and distortion that may be difficult to correct. The dorsal contracture is the most common of all the complications of the burned hand. It is the result of damage to the thin dorsal skin and scant subcutaneous tissue, which offers little protection to the deeper structures. Consequently, these injuries are deep resulting in a spectrum of deformities that has remained the bane of reconstructive surgery. Flap coverage will be required in the event of exposure of joints and tendons with absent paratenons. Multiple different flap types are available to treat complex severe postburn hand contractures. In our center, which is the largest regional burn center in northwest Iran, we have considerable experience in the treatment of thermal hand injuries. Between 2005 and 2010, we treated 53 consecutive patients with 65 severe postburn hand deformities. There were 35 men and 18 women with a mean age of 35+/-3 years. Flame injury was the inciting traumatic event in each patient. The severity of original injury and inadequate early treatment resulted in all of the fingers developing a severe extension contracture with scarred and adherent extensor tendons and subluxed metacarpophalangeal joints. In 36 cases, the injury was in the patients' dominant hand. We first incised the dorsal aspect of the contracted hands where there was maximum tension, then tenolysed the extensor tendons and released the volar capsules, collateral ligaments, and volar plate in all cases. In 30 cases, we also tenolysed the flexor tendons. We reduced the subluxed metacarpophalangeal joints and fixed them with Kirschner wires in 70 to 90 degrees flexion. Then, we planned and performed axial groin flaps to reconstruct the defects in all of them. In all of these patients, there was availability of intact skin in the territory of groin flap. However, in case of burn scars in this region, we had other options such as posterior interosseous flap in mind. Six patients experienced superficial necrosis at the distal margin of the flap, which was successfully treated with local wound care and dressing changes. There were no other complications. Physical therapy was initiated after Kirschner wire removal.

Bache SE, Fitzgerald O'Connor E, Theodorakopoulou E, Frew Q, Philp B, Dziewulski P. The Hand Burn Severity (HABS) score: A simple tool for stratifying severity of hand burns. Burns. 2017;43(1):93-9.

Hand burns represent a unique challenge to the burns team due to the intricate 31

structure and unrivalled functional importance of the hand. The initial assessment and prognosis relies on consideration of the specific site involved as well as depth of the burn. We created a simple severity score that could be used by referring non-specialists and researchers alike. The Hand Burn Severity (HABS) score stratifies hand burns according to severity with a numerical value of between 0 (no burn) and 18 (most severe) per hand. Three independent assessors scored the photographs of 121 burned hands of 106 adult and paediatric patients, demonstrating excellent inter-rater reliability (r=0.91, p<0.0001 on testing with Lin's correlation coefficient). A significant relationship was shown between the HABS score and a reliable binary outcome of the requirement for surgical excision on Mann-Whitney U testing (U=152; Z=9.8; p=0.0001). A receiver operator characteristic (ROC) curve analysis found a cut off score of 5.5, indicating that those with a HABS score below 6 did not require an operation, whereas those with a score above 6 did. The HABS score was shown to be more sensitive and specific that assessment of burn depth alone. The HABS score is a simple to use tool to stratify severity at initial presentation of hand burns which will be useful when referring, and when reporting outcomes.

Cuadra A, Correa G, Roa R, Pineros JL, Norambuena H, Searle S, et al. Functional results of burned hands treated with Integra(R). J Plast Reconstr Aesthet Surg. 2012;65(2):228-34.

INTRODUCTION: Dermal substitutes, such as Integra((R)) introduced as a new alternative to our surgical arsenal and its use in burn treatment, in both acute and chronic phases, have gained great importance. OBJECTIVE: The aim of the experiment is to describe the results of the functional evaluation of patients with burned hands treated with Integra((R)) in both acute and chronic phases. MATERIAL AND METHODS: A retrospective review of a transversal cohort. Patient characteristics evaluated were sociodemographic characteristics, burn mechanism, burn extension and depth, treatments received previous to Integra((R)) and complications related to its use. Clinical and photographic evaluations were performed evaluating skin elasticity, range of articular movement, prehensile strength, pain and functional evaluation using the validated 400 Point Evaluation Test. RESULTS: A total of 17 burned hands in 14 right- handed patients, were treated with Integra((R)), three being bilateral hand burns. Eleven were treated in the acute phase and in nine in the scar reconstruction phase. Range of articular motion was complete in 15 of 17 hands. In 88% of the hands, flexible skin coverage was achieved. No statistically significant difference was observed in prehension strength of the burned hand versus the contralateral non-burned hand. Sixteen hands had a painless evolution. The 400 Point Evaluation score was 92.8 +/- 6.3% (80 - 100%). Nearly four-fifths (79%) of the patients returned to normal active working activities.

Mohammadi AA, Bakhshaeekia AR, Marzban S, Abbasi S, Ashraf AR, Mohammadi 32

MK, et al. Early excision and skin grafting versus delayed skin grafting in deep hand burns (a randomised clinical controlled trial). Burns. 2011;37(1):36-41.

INTRODUCTION: Early excision and grafting (E&G) of burn wounds has been reported to decrease hospital stay, hospital costs and septic complications, and some purport reduced mortality while decreasing hospital costs. In today's practice, all burn wounds unlikely to achieve spontaneous closure within 3 weeks are excised and grafted. Early studies did not demonstrate dramatic differences in cosmetic or functional results. This is particularly true with burns of the face, hands and feet. In this study, early excision and skin grafting was compared with delayed skin grafting in deep hand burns. MATERIALS AND METHODS: From September 2006 to February 2008, 50 patients with hand burns and average burn size less than 30% total body surface area (TBSA) deep second- and third-degree were randomly divided into early E&G group (group I) and delayed grafting group (group II). Gradual and careful limb and digit range of motion was started on about 10th-14th postoperative day. We used a questionnaire based on the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire to evaluate final functional outcome. Further, hypertrophic scar formation, contracture and deformities were followed and managed accordingly. RESULTS: The most common site of involvement was the metacarpophalangeal (MCP) joint with frequency of 39% and 40% in groups I and II, respectively. There were no statistically significant differences between both groups regarding deformity severity, scar formation, sensation, major activities and overall satisfaction. DISCUSSION: In treating burns of the hand, the primary goal should always be to restore the functionality of the hand. Although early surgery shortens the healing time and lessens the hospital stay, our results did not show any significant difference between these two methods regarding the function, scar formation, daily activity limitation and overall satisfaction.

Edgar DW, Fish JS, Gomez M, Wood FM. Local and systemic treatments for acute edema after burn injury: a systematic review of the literature. J Burn Care Res. 2011;32(2):334-47.

Burn injury is a complex trauma that results in local and generalized edema. Edema fluid limits the exchange of vital nutrients in healing the burn wound and will compromise vulnerable tissues. Although the importance of edema control in tissue salvage is recognized, treatments targeted at edema control have not been critically reviewed. Thus, the objective was to assess the evidence for the effectiveness of local and systemic treatments for edema management immediately after burn injury. Searches for randomized controlled trials were conducted of online databases, research and thesis registers, and grey literature repositories. Handsearches included journals, bibliographies, and proceedings. Authors were contacted to clarify and submit extra study details. Eight studies were included. Management of acute major burn resuscitation including colloid increases lung edema (mean difference [MD], 0.04 ml/ml alv vol; 95% 33

confidence interval [CI], 0.03-0.04; P < .00001) and mortality (risk ratio, 3.67; 95% CI, 1.16-11.58; P = .03). Continuous administration of vitamin C in acute burn resuscitation reduces local wound edema (MD, -3.50 ml/g; 95% CI, -4.63 to -2.37; P < .00001) and systemic fluid retention (MD, -8.60 kg; 95% CI, -13.47 to -3.73; P = .0005). Local acute hand burn edema is reduced (MD, -29.00 ml; 95% CI, -53.14 to -4.86; P = .02), and active hand motion increased (MD, 10.00 degrees ; 95% CI, 4.58-15.42; P = .0003), using electrical stimulation with usual physiotherapy. Each review outcome was based on a small single-facility study. Thus, future research in intervention for acute burn edema must focus on multicentre trials and validation of outcome measures in the burn population.

2. Pediatric Hand Burns

Dodd, A. R., K. Nelson-Mooney, et al. "The effect of hand burns on quality of life in children." J Burn Care Res 31(3): 414-22. There is limited data regarding the long-term outcomes for children with hand burns. The objective of this study was to prospectively document recovery after burn injury using a validated health outcomes burn questionnaire for infants, children, and adolescents. A single center prospective study was conducted on consecutive children aged 0 to 4 years and 5 to 18 years comparing outcomes between children with and without hand burns. Age specific American Burn Association/Shriners Hospitals for Children Burn Outcomes Questionnaires were administered at admission, first clinic after discharge, 3, 6, 12, 18, and 24 months after injury. One hundred eighty-one consecutive patients were enrolled in the study. Demographic, injury, and survey outcome data were available for 145 patients for at least 24 months after injury. Children with hand burns had significantly longer hospitalization, intensive care unit days, ventilator days, and TBSA burns. Initial Burn Outcomes Questionnaire scores for children with hand burns were significantly lower than controls and children with burns not involving the hand. For ages 0 to 4 years and 5 to 18 years, only the domain specific to upper extremity function was significantly decreased between the groups over the entire study period. Despite severe injury, children with hand burns have continued improvement in quality of life for at least 2 years after injury. The presence of a hand burn in the context of large TBSA burn is a marker of more severe acute illness and predicts increased resource utilization. Rehabilitative efforts after upper extremity injury should continue to target both physical function and the psychosocial impact of burn injury.

Al-Qattan, M. M. (2009). "Campfire Burns of the Palms in Crawling Infants in Saudi Arabia: Results Following Release and Graft of Contractures." J Burn Care Res. In Saudi Arabia, camping in the desert is commonly practiced by families. A campfire is usually lit and unsupervised crawling infants are at risk of burns from these campfires. During a 12-year period, a total of 53 children with hand contractures related to campfire burns were treated. The mean age at the time of burn was 9 months (range: 5- 34

12 months). All patients presented with isolated palmar contractures of one (n = 24) or both (n = 29) hands. Surgical release and skin grafting were performed for a total of 82 hands. Full-thickness skin grafts from the groin area were used in mild cases, and thick split-thickness skin grafts harvested from the thigh were used in severe contractures. Graft take ranged from 90 to 100% "take" in all patients. Follow-up ranged from 6 months to 10 years. Recurrence of contracture was calculated for 30 children (52 grafted hands) who had follow-up for more than 5 years. Twenty hands (group I) had thick split- thickness skin grafts, and 10 (50%) of these required a second release and grafting procedure. The remaining 32 hands (group II) had full-thickness grafts and only 3 (9.4%) required a second release and grafting procedure. The difference was statistically significant (P = .003), indicating that group I are more likely to require secondary surgery on long-term follow-up.

Barret, J. P., M. H. Desai, et al. (2000). "The isolated burned palm in children: epidemiology and long-term sequelae." Plast Reconstr Surg 105(3): 949-52. The isolated burn of the palm is a typical injury in young children. Positioning and splinting in small hands is difficult, and long-term sequelae of these injuries are not uncommon. The objective of the present study was to assess the outcome of palm burns and to identify the risk factors for long-term sequelae. All patients admitted to our hospital affected with isolated palm injuries between January of 1988 and January of 1998 were reviewed. In total, 120 pediatric patients were admitted with isolated palm burns; 110 patients (91.7 percent) had partial-thickness burns, and 10 patients (8.3 percent) had full-thickness burns. Only four patients (3.3 percent) required excision and skin autografting, but all patients whose palms were operated on in the acute phase developed burn contractures. Sixteen patients (13.3 percent) developed palmar contractures, and more than half of them (56 percent) required reconstructive procedures. All palm burns that healed in more than 3 weeks developed scarring and sequelae (p<0.05 compared with no sequelae). Pediatric palmar burns are benign injuries with a low incidence of late sequelae. However, flame and contact burns are more prone to develop scarring. Excision and autografting should be performed on wounds that take over 3 weeks to heal, but it does not prevent late sequelae.

Feldmann, M. E., J. Evans, et al. (2008). "Early management of the burned pediatric hand." J Craniofac Surg 19(4): 942-50. Unique anatomic and pathophysiologic features of the thermally burned pediatric hand are reviewed, with a focus on direct management of the injured tissue in the early phases of the treatment process. A nonoperative approach to most pediatric hand burns is advocated, and principles of early wound care, including antimicrobial therapy, and escharotomy are described. Specific emphasis is placed on distinctive characteristics of the fifth digit which make it prone to contracture patterns resembling a boutonniere-type deformity and on newer wound care technologies that simplify the application process without loss of antimicrobial and barrier function. The technical principles of full- thickness burn excision, as well as considerations in selecting suitable graft for burn closure, are also discussed. Finally, basic techniques for splinting, positioning, and exercising the burned pediatric hand are described. When properly applied, the principles discussed herein have rendered the severely scarred, functionless hand a rarity after 35 thermal injury.

Han, T., K. Han, et al. (2005). "Pediatric hand injury induced by treadmill." Burns 31(7): 906-9. Korea has recently seen an increase in pediatric hand injuries associated with treadmills. This study was conducted to identify the frequency, patterns, treatment and outcome of these injuries, in the hope of developing preventive programs. A retrospective review of the medical records of 25 children, all with treadmill-induced friction hand injuries, was conducted at the Hallym Burn Centre, Hangang Sacred Heart Hospital, Seoul, Korea, during the period of January 2002 to March 2004. The injuries constituted 1.4% of the total number of pediatric burn injury admissions. Male toddlers were affected more than female. The mean age of the children was 3.9+/-3.2 (3, 1-15) years old. Most injuries occurred in spring. Treadmill friction inflicted deep second or third degree burns, small in area (1.6+/-1.0% of TBSA). All lesions involved the hands and forearms, with 60% on the right. Most patients (64%) underwent surgical management 13+/-5 days after the injury. The volar surface of the hand was more affected than the dorsal side (27 versus 8). Treatment was mainly with full thickness skin graft (60%) and long-term surgical outcomes were excellent. Such injuries may be prevented by educating the public about the potential risks of the treadmill, and by the development of additional safety designs. Changes in management protocols and treatment policies would improve the provision of appropriate care.

Scott, J. R., B. A. Costa, et al. (2008). "Pediatric palm contact burns: a ten-year review." J Burn Care Res 29(4): 614-8. Management and proper approach to pediatric palm burns remains unclear. Our burn center's approach includes early, aggressive range of motion therapy, combined with a period of watchful waiting, reserving grafting only for those palms that do not heal in a timely manner. We reviewed our experience using this approach over a 10-year period. We performed a retrospective review of all pediatric patients with palm burns admitted to our burn center from 1994 to 2004. A total of 168 patients (194 palms) were included in the study. The average patient was 1.3 years old. A total of 168 of the injured palms (87%) healed without need for surgery. The average time to healing was 13 days (range 5-34). The 19 patients (26 palms, 13.4%) who underwent excision and grafting were managed with thick split thickness skin grafts. Of these, four patients (five palms, 19.2%) underwent secondary reconstruction, at an average of 166 days after the initial surgery. Of the 168 (87%) palms managed without surgery, only three patients (four palms) required late reconstruction (2.4%). Reconstructive procedures consisted of full-thickness skin grafts (n = 7) and z-plasty (n = 2). We have found that the majority of patients in this study healed without need for acute or reconstructive surgery. We therefore recommend aggressive hand therapy and conservative surgical management of palm burns in children.

Maguina, P., T. L. Palmieri, et al. (2004). "Treadmills: a preventable source of pediatric friction burn injuries." J Burn Care Rehabil 25(2): 201-4. Treadmills are a burn risk for children. A child's hand can get trapped in the conveyor belt, causing friction burns to the underlying tissue. The purpose of this 36 retrospective study was to review the characteristics and treatment of treadmill-related burns in children from 1998 to 2002. Ten patients, at a mean age of 3.4 years, sustained injuries associated with treadmill use. Trapping of the hand between the conveyor belt and the base was the most frequent injury mechanism. Burn location was predominantly on fingers and palms. Four patients required operative intervention. All patients required specialized wound care as well as scar management and occupational therapy. Treadmills pose a danger to children. Current safety devices are ineffective for preventing serious hand injuries in children. New design modifications and public awareness are needed to improve child safety.

Alperovitch, R. and R. Haddad (1984). “[Hand burns in children. Retrospective study of 137 cases from 1973- 1982 representing 177 hands].” Chir Pediatr 25(1): 43-7. One hundred and seventy seven burnt hands observed in children during the last ten years were reviewed at our hospital. One third were severely injured with burns deeper than 2nd degree. The infrequent greasy occlusive dressing was performed under general anesthesia in 87% of the burnt hands as the primary treatment. Out of 19 cases, five necessitated a secondary procedure one year or more later. Excision followed by full thickness skin grafts or flaps was used initially in 11%. Besides the common sequelae of burnt hands, we found some proper to children: clinodactyly, inhibition of longitudinal growth following epiphyseal plate destruction. The annual increase in the observed number of cases which doubled in ten years, shows the importance of prevention.

Ayala Montoro, J., J. Blanco Lopez, et al. (1989). “[Digito-lateral flaps in the treatment of retraction after hand burns in children].” Cir Pediatr 2(2): 52-4. The hand's severe burns are frequent in the children. The skin of the hand is bordering skin which develop towards a retractable consequence with scar. In a sample of 10 children with this consequence same type of digital side flap in 26 fingers is carried. A great uniformity of the results is obtained, the functional normality has reached to 96% and a low index of complications has arisen which can't be attributed to the technique.

Baindurashvili, A. G., E. V. Tsvetaev, et al. (2000). “[Early surgical treatment of low- voltage electric burns of the hand in children].” Vestn Khir Im I I Grek 159(5): 44-6. Electrical burns give not more than 8% in the structure of burns in children. Most of the children suffer from burns by electrical current of 220 V, and invalidisation of the children can result from inadequate surgical treatment. Advantages of early operative treatment (primary or delayed necrectomy with different kinds of primary skin plastic) are proved as compared with traditional plastic of the granulating wounds. This method can be considered to be the method of choice in treatment of children with low voltage electrical burns of the hand.

Ogilvie, M. P. and Z. J. Panthaki (2008). "Electrical burns of the upper extremity in the pediatric population." J Craniofac Surg 19(4): 1040-6. Electrical burns of the upper extremity, particularly high-voltage injuries, are becoming more prevalent in today's society and are often times devastating to the patients' appearance and functionality. The basic tenants of flame burn reconstruction apply to electrical injuries. Namely, a patient should undergo basic trauma resuscitation, 37 decompression and debridement within a reasonable timeframe, and definitive closure as soon as possible. Reconstruction of the 3 main areas of injury (hand, elbow, and axilla) follows the basic reconstructive ladder from least invasive, that is, local wound revision, to most extensive, that is, free tissue transfers. Whereas the role of the surgeon continues to be the creation of ingenious techniques to deal with complications, the real treatment lies in education and prevention. This article will look to do a comprehensive review of electrical injuries to the upper extremity.

Barnett, J. S. (1966). “Contact burns of the hands in children.” Med J Aust 2(23): 1118-9.

Borman, H. and N. Kostakoglu (1998). “Hand burns in young patients--loss of self- sufficiency and economic productivity.” Ann Plast Surg 41(3): 335.

Chait, L. A. (1975). “The treatment of contact burns of the palm in children.” S Afr Med J 49(44): 1839-42. A combination of early tangenital excision and skin grafting, with early continuous splinting in an acrylic sandwich-splint, is described as a method of management of contact burns of the palm in children.

Clarke, H. M., G. P. Wittpenn, et al. (1990). “Acute management of pediatric hand burns.” Hand Clin 6(2): 221-32. The pattern of injury seen in pediatric hand burns differs from adults because scald burns are most common. Many of these are difficult to assess at initial presentation. In addition, children develop less stiffness in response to immobilization. For these reasons, we have developed a conservative, expectant approach for treating most pediatric hand burns. Meticulous wound care, positioning, splinting, and exercise are required to safely accomplish the goals of rapid healing with minimal loss of function. These regimens are adapted specifically to suit the age of the child and are applied by the burn team. Normal hand function can be obtained in the majority of cases.

Guitard, J., J. M. Foliguet, et al. (1990). “[Is early excision-graft justified in hand burns in children? Report of 201 cases].” Chir Pediatr 31(4-5): 225-8. The authors wish to show the difference between hand burns in children and adults. Throughout a group of 201 observations, they confirm the predominance in children of hands burns on palmar face. For them, the directed cicatrization by fat dressing associated with splints set in position of maximum cutaneous stretching is the first therapeutic. The early tangential excision and grafting is suitable only in rare indications, for instance in electric burns.

Gunn, A. L. (1970). “Late complications of burns of the hand in children and their treatment.” Guys Hosp Rep 119(1): 71-80.

Newton, N. and M. Bubenickova (1977). “Rehabilitation of the autografted hand in children with burns.” Phys Ther 57(12): 1383-8.

Roberts, L., M. I. Alvarada, et al. (1993). “Longitudinal hand grip and pinch strength recovery in the child with burns.” J Burn Care Rehabil 14(1): 99-101. Hand strength of seven patients was evaluated prospectively. A range-of- motion exercise program, compression therapy, and splinting schedules were provided. Fine prehension; lateral, tip-to-tip, and tripod pinch were measured by pinch meter. Grip strength was measured by dynamometer. Comparisons were made between test strengths and published norms for age and sex with analysis of variance. Significance was accepted at p 0.05. At discharge, all four strength measurements were significantly less than normal for age and sex. Grip and tripod strengths were improved by 6 weeks. All measurements were improved at 6 months after discharge, although grip and lateral pinch remained significantly less than norms. In conclusion, the measurements of tip- to-tip and tripod pinch at 6 months may not signify limitations in performance of activities of daily living. In spite of significantly lower than normal grip and lateral strength measurements at 6 months, it cannot be determined whether this hinders performance of daily living skills.

Schwanholt, C., M. B. Daugherty, et al. (1992). “Splinting the pediatric Palmar burn.” J Burn Care Rehabil 13(4): 460-4. Children younger than 4 years of age who have sustained deep palmar burns pose a significant challenge to the burn care team. Flexion contractures of the palm and digits are all too common because the hand is maintained in flexion when at rest and while engaged in functional activities. A splint that positions the wrist in extension and the metacarpophalangeal joints of digits 2 to 5 in some hyperextension was evaluated. Nine patients with acute burns and two patients who required palmar reconstruction were studied. (The total number of hands was 15.) With this splinting technique, we have successfully maintained the antideformity position in patients with acute injuries and in those who have undergone reconstructive procedures.

Sheridan, R. L., M. J. Baryza, et al. (1999). “Acute hand burns in children: management and long-term outcome based on a 10-year experience with 698 injured hands.” Ann Surg 229(4): 558-64. OBJECTIVE: To document long-term results associated with an coordinated plan of care for acutely burned hands in children. SUMMARY AND BACKGROUND DATA: Optimal hand function is a crucial component of a high- quality survival after burn injury. This can be achieved only with a coordinated approach to the injuries. Long- term outcomes associated with such a plan of care have not been previously reported. METHODS: Over a 10-year period, 495 children with 698 acutely burned hands were managed at a regional pediatric burn facility; 219 children with 395 injured hands were followed in the authors' outpatient clinic for at least 1 year and an average of >5 years. The authors' approach to the acutely burned hand emphasizes ranging and splinting throughout the hospital stay, prompt sheet autograft wound closure as soon as practical, and the selective use of axial pin fixation and flaps. Long- term follow-up, hand therapy, and reconstructive surgery are emphasized. RESULTS: Normal functional results were seen in 97% of second-degree and 85% of third-degree injuries; in children with burns involving underlying tendon and bone, 70% could perform activities of daily living and 20% had normal function. Reconstructive hand surgery was required in 4.4% of second- 39 degree burns, 32% of third-degree burns, and 65% of those with injuries involving underlying bone and tendon. CONCLUSIONS: When managed in a coordinated long- term program, the large majority of children with serious hand burns can be expected to have excellent functional results.

Strachan, R. D., A. W. McCombe, et al. (1989). “The long-term results of electric fire hand burns in children.” Br J Plast Surg 42(4): 468-72. An 11-year retrospective series of 95 deep, electric fire hand burns in children was studied and the epidemiology, treatment and operative management analysed. From this series a group of 14 patients was recruited to assess the long-term results of this injury. At long-term follow-up (mean 14.4 years) the recorded parameters included range of movement, hand sensation, power and size. Photographs were taken and any subjective problems noted. Analysis of these data showed a marked variation in range of movement, sensation, size and appearance of the injured hands. Despite this, complaints about cosmetic results or any restriction of activities were rare. In conclusion, these injuries are particularly destructive but with appropriate surgical management, albeit protracted, and despite imperfect cosmetic results, excellent function can be obtained in the growing hand.

Ward, J. W., J. M. Pensler, et al. (1985). “Pollicization for thumb reconstruction in severe pediatric hand burns.” Plast Reconstr Surg 76(6): 927-32. Our experience in pollicization of the index ray for severely burned hands in children is reviewed with attention to severity of burn, functional impairment, age at pollicization, procedure used, operative time, length of hospital stay, and long-term functional results. Fifteen pollicizations were performed in 11 patients with an average follow-up of over 5 years. Indication for pollicization was lack of prehension due to total loss of the thumb with the presence of a transposable index ray. The bipedicle flap method was used in two cases and the neurovascular pedicle technique was employed in all others. Skin grafts were necessary in all cases. Results were graded according to presence or absence of tip pinch, key pinch, grasp, and opposition. Significant functional improvement was seen in 14 of 15 cases (94 percent). Four patients (27 percent) developed complications requiring secondary procedures. In our experience, pollicization provides the most rapid and effective means of restoration of thumb function in the severe pediatric hand burn with multiple digit loss.

Zamboni, W. A., M. Cassidy, et al. (1987). “Hand burns in children under 5 years of age.” Burns Incl Therm Inj 13(6): 476-83. In order to evaluate the epidemiology and functional results of hand burns in young children, 92 consecutive patients (126 hand burns) under age 5 years admitted to a Burn Center were reviewed. Scald burns (49 per cent) were most common, followed by flame (34 per cent), contact (14 per cent) and electrical burns (3 per cent). The child was left unattended by an adult in 53 per cent of cases and documented abuse was present in 6 per cent. The mean total body surface area (TBSA) burned was 17 per cent, and 77 patients (85 per cent) had additional burns in other areas (arms 34 per cent, legs 31 per cent, chest 29 per cent and face 27 per cent). Palmar burns occurred in 24 hands (19 per cent), dorsal in 41 (33 per cent), while both surfaces were burned in 61 (48 per cent). 40

Joints involved included the MP in 96 (76 per cent), PIP in 87 (69 per cent) and DIP in 80 (63 per cent). The depth was superficial partial thickness in 53 (47 per cent), deep partial in 55 (44 per cent), and full thickness in 18 hands (14 per cent); a total of 29 hands were grafted (15 deep partial and 14 full thickness). Escharotomies were required in 12 hands (9 per cent) (9 flame and 3 scald) and partial amputation of digits was required in 3 (2 per cent). Follow-up was available in 46 hands from 7 to 120 months (mean 39 months). Partial thickness burns (34) healed with normal (32) or near- normal (2) hand function and developmental delay occurred in one patient.(ABSTRACT TRUNCATED AT 250 WORDS)

Juang D, Fike FB, Laituri CA, Mortellaro VE, St Peter SD. Treadmill injuries in the pediatric population. J Surg Res. 2011;170(1):139-42.

BACKGROUND: Exercise equipment such as treadmills are becoming commonplace in residential homes, placing small children at risk for injury. These injuries can be severe and may require surgical intervention. While it is our clinical perception that these injuries are on the rise, they remain largely unreported in the literature. Therefore, we reviewed our experience to evaluate the incidence and outcomes of treadmill-associated injuries in children. METHODS: After receiving exempt IRB approval, we retrospectively reviewed all patients who sustained treadmill-related injuries that required evaluation by a surgeon from July 2005 to February 2010. Data collected included patient demographics, injury details, injury management, and outcomes. RESULTS: We identified 19 children who required treatment for treadmill-related injuries. Mean age at injury was 4.1 y (1.3-10.5 y), and 63% were male. The treadmill was in use by another person in 17 cases (89%). The hand was involved in 79%. All burns were <10% body surface area and 18 (90%) were <5 %. Admission was required in two cases, and four (21%) children required skin grafting. Healing was complicated by hypertrophic scarring in four patients (21%). Mean length of active therapy was 9.2 +/- 7.0 d and involved a mean of 6.0 +/- 3.5 healthcare visits. Mean hospital charges were $5700. CONCLUSION: Treadmill-related burn injuries in children are preventable injuries that can pose a substantial burden on patients and families. Supervision is paramount in prevention of these injuries, and strategies should include child safety features in equipment designs along with consumer awareness.

Park YS, Lee JW, Huh GY, Koh JH, Seo DK, Choi JK, et al. Algorithm for Primary Full- thickness Skin Grafting in Pediatric Hand Burns. Arch Plast Surg. 2012;39(5):483-8.

BACKGROUND: Pediatric hand burns are a difficult problem because they lead to serious hand deformities with functional impairment due to rapid growth during childhood. Therefore, adequate management is required beginning in the acute stage. Our study aims to establish surgical guidelines for a primary full- thickness skin graft (FTSG) in pediatric hand burns, based on long-term 41

observation periods and existing studies. METHODS: From January 2000 to May 2011, 210 patients underwent primary FTSG. We retrospectively studied the clinical course and treatment outcomes based on the patients' medical records. The patients' demographics, age, sex, injury site of the fingers, presence of web space involvement, the incidence of postoperative late deformities, and the duration of revision were critically analyzed. RESULTS: The mean age of the patients was 24.4 months (range, 8 to 94 months), consisting of 141 males and 69 females. The overall observation period was 6.9 years (range, 1 to 11 years) on average. At the time of the burn, 56 cases were to a single finger, 73 to two fingers, 45 to three fingers, and 22 to more than three. Among these cases, 70 were burns that included a web space (33.3%). During the observation, 25 cases underwent corrective operations with an average period of 40.6 months. CONCLUSIONS: In the volar area, primary full-thickness skin grafting can be a good indication for an isolated injured finger, excluding the web spaces, and injuries of less than three fingers including the web spaces. Also, in the dorsal area, full-thickness skin grafting can be a good indication. However, if the donor site is insufficient and the wound is large, split-thickness skin grafting can be considered.

Chateau J, Guillot M, Zevounou L, Braye F, Foyatier JL, Comparin JP, et al. Is there any place for spontaneous healing in deep palmar burn of the child? Ann Chir Plast Esthet. 2017;62(3):238-44. Child palm burns arise by contact and are often deep. The singular difficulty of such a disease comes from the necessity of the child growth and from the potential occurrence of constricted scars. In order to avoid sequelae, the actual gold standard is to practice an early excision of the burn, followed by a skin graft. The aim of this study is to evaluate the results of spontaneous healing combined with rehabilitation versus early skin grafting and rehabilitation concerning the apparition of sequelae. We performed a retrospective study in two burn centers and one rehabilitation hospital between 1995 and 2010. Eighty-seven hands have been included in two groups: one group for spontaneous healing and the other group for excision and skin grafting. Every child benefited from a specific rehabilitation protocol. The two main evaluation criteria were the duration of permanent splint wearing and the number of reconstructive surgery for each child. The median follow-up duration is about four years. The two groups were comparable. For the early skin grafting group, the splint wearing duration was 1/3 longer than for the spontaneous healing group. Concerning the reconstructive surgery, half of the grafted hands needed at least one procedure versus 1/5 of spontaneous healing hands. Our results show the interest of spontaneous healing in palmar burn in child, this observation requires a specific and intense rehabilitation protocol.

3. Reconstruction of the Burned Hand

Kreymerman, P. A., L. A. Andres, et al. (2011) "Reconstruction of the burned hand." Plast Reconstr Surg 127(2): 752-9. This article summarizes the initial management of acute burn injuries to the hand, in addition to treatment and reconstructive options. The goal of treatment for a burn injury to the hand is primarily a functional hand. This is best achieved by appropriate early treatment, the right selection from a wide range of possible reconstructive procedures, and focused occupational hand therapy.

Salisbury, R. E. (2000). "Reconstruction of the burned hand." Clin Plast Surg 27(1): 65-9. There is no "cookbook" for reconstructing the burned hand. Multiple issues can color the chances for a successful outcome. What is the endpoint of surgical effort? Is it when the patient tires, becomes discouraged, or ceases to return? These questions are not rhetorical. Whereas an appendectomy cures appendicitis, no single surgical procedure or series of procedures cures burns. Many patients spend their lives searching to be as they were preinjury. Although physicians as healers do not want to destroy hope, ethics command that we attempt to keep these patients focused on reality. Although there is always something that could be done, judgment dictates what should be done. The major goals are early independence and resumption of preburn lifestyle for the patient. A thoughtful surgical plan set up in conjunction with the burn team and with timed goals gives the patient the best chance for success.

Kim, D. C., S. A. Wright, et al. (2007). "Management of axillary burn contractures." Tech Hand Up Extrem Surg 11(3): 204-8. This article will review the basic principles and techniques of managing axillary burn contractures in both industrialized and developing nations. Surgeons specializing in hand and upper extremity surgery should be adept in treating axillary soft tissue deficits secondary to burn contractures. The focus of this article will be to provide suggestions for performing skin grafts and latissimus dorsi musculocutaneous flaps, as well as illustrate guidelines for postoperative rehabilitation.

Schneider, J. C., R. Holavanahalli, et al. (2008). "Contractures in burn injury part II: investigating joints of the hand." J Burn Care Res 29(4): 606-13. This study prospectively examines the incidence and severity of hand contractures after burn injury and determines predictors of contracture development. Data were collected prospectively from 1993 to 2002 for adult burn survivors admitted to a regional burn center. Demographic and medical data were collected on each subject. Primary outcome measures include presence of contractures, number of contractures, and the severity of contractures at each of the hand joints at hospital discharge. The metacarpal- phalangeal, proximal inter-phalangeal (PIP), and distal inter-phalangeal joints of all digits and the wrist joints are included in this study. Regression analysis was performed to determine predictors of the presence, severity, and number of contractures. Of the 985 43 study patients, 23% demonstrated at least one hand contracture at hospital discharge. Those with a contracture averaged ten contractures per person. Most contractures were mild (48%) or moderate (41%) in severity. The wrist was the most frequently affected joint (22%). Statistically significant predictors of contracture development include concomitant medical problems, total body surface area grafted and presence of hand burn and hand grafting (P < .05). Predictors of the number of contractures include length of stay, concomitant medical problems, burn size and presence of hand burn and grafting (P < .05). Contractures of the hand are a significant complication of burn injury. Clinicians can use the contracture predictors to help target interventions for those patients most at risk of developing hand contractures. Given the functional importance of the hand in daily living, the burn care community is challenged to find new ways of preventing and treating hand contractures.

Moon, S. H., S. Y. Lee, et al. (2011) "Use of split thickness plantar skin grafts in the treatment of hyperpigmented skin-grafted fingers and palms in previously burned patients." Burns 37(4): 714-20. Palmar and finger burns are often seen in children, and are usually as a result of contact burns. Some patients with deep hand burns are treated with full-thickness or split-thickness skin grafts. Skin graft is commonly used for hand reconstruction. However, the grafted skin would be more pigmented than the adjacent skin and different from skin texture. 19 patients who showed hyperpigmentation after skin graft of finger and palm were treated. They all were injured by hand burns. We performed mechanical dermabrasion of the hyperpigmentation scar and application of a split thickness skin harvested from medial aspect of plantar of foot. Patients were asked about their level of satisfaction with the procedure and scar appearance was assessed using a five- point Likert scale. Also scar appearances were assessed using a Vancouver Scar Scale (VSS). The grafts were completely taken in all 19 patients. The color of the graft became similar to adjacent tissue. 15 patients were very satisfied, and four patients were relatively satisfied. The average score of the patients postoperative appearance improvement was 4.5 (improved to significantly improved postoperative appearance). Average VSS score was improved from 9.53 to 2.53. There was no hypertrophic scar on plantar donor site. The technique of the split- thickness plantar skin graft after mechanical dermabrasion is simple and provided good results in both color and texture for the patients who showed hyperpigmentation after grafting.

Sabapathy, S. R., B. Bajantri, et al. (2010) "Management of post burn hand deformities." Indian J Plast Surg 43(Suppl): S72-9. The hand is ranked among the three most frequent sites of burns scar contracture deformity. One of the major determinants of the quality of life in burns survivors is the functionality of the hands. Burns deformities, although largely preventable, nevertheless do occur when appropriate treatment is not provided in the acute situation or when they are part of a major burns. Reconstructive procedures can greatly improve the function of the hands. Appropriate choice of procedures and 44

timing of surgery followed by supervised physiotherapy can be a boon for a burns survivor.

Liu, Y., B. Song, et al. (2010) "Reconstruction of the burned hand using a super-thin abdominal flap, with donor-site closure by an island deep inferior epigastric perforator flap." J Plast Reconstr Aesthet Surg 63(3): e265-8. A pedicled super-thin superficial inferior epigastric artery flap can provide a thin and pliable skin coverage for the hand dorsum, and debulking of the flap during elevation limits the need for secondary procedures. Simultaneously, an island deep inferior epigastric perforator flap transferred to reconstruct the flap donor site in the abdomen subsequently minimises donor-site morbidity.

Yoon, S. W., A. M. Rebecca, et al. (2007). "Reverse second dorsal metacarpal artery flap for reconstruction of fourth-degree burn wounds of the hand." J Burn Care Res 28(3): 521-3. We sought to show how severe soft-tissue injuries of the proximal index finger caused by fourth-degree electrical burns to the hand may be surgically reconstructed. Soft-tissue coverage was provided with a reverse second dorsal metacarpal artery flap in two patients. Both digits were successfully salvaged by use of this reconstructive method. Both donor sites were closed primarily and healed without difficulty. The reverse second dorsal metacarpal artery flap provides well-vascularized tissue without excess bulk and allows near-normal hand function.

Wu, L. C. and L. J. Gottlieb (2005). "Glabrous dermal grafting: a 12-year experience with the functional and aesthetic restoration of palmar and plantar skin defects." Plast Reconstr Surg 116(6): 1679-85. BACKGROUND: Glabrous skin on the palmar aspect of the hands and the plantar aspect of the feet has special attributes. These attributes define the skin on the palm, fingers, and sole as functionally and aesthetically different from skin on other parts of the body. When there is a glabrous skin defect, it should be replaced with similar skin to restore function and aesthetics. The authors report their 12-year experience with the technique of glabrous dermal grafting for the reconstruction of palmar and plantar skin defects. METHODS: From 1992 to 2004, 13 patients with 14 defects underwent glabrous dermal grafting of either palmar or plantar defects. Defects included nine hand and five foot defects. Causes included nine acute burns, one secondary burn reconstruction, two delayed reconstructions of traumatic injuries, one congenital nevus, and one malignant melanoma. Donor sites included 12 glabrous dermal grafts from the foot and two from the hand. RESULTS: Follow-up ranged from 1 month to 65 months. All glabrous dermal grafts demonstrated complete epithelialization and no incidence of complete loss. There was return of sensation without hyperkeratosis or breakdown. The grafts demonstrated good color match with the surrounding skin. The donor site healed without complications, and there were no incidences of significant hypopigmentation, hyperpigmentation, or hypertrophic scarring. CONCLUSION: Glabrous dermal grafting of palmar and plantar defects is the ideal way of reconstructing glabrous skin to restore 45 both function and aesthetics and minimize donor-site morbidity.

Yenidunya, M. O. and E. Seven (2007). "The non-algorithmic nature of the hand burn contractures." Burns 33(8): 1046-50.

Araico, J., J. L. Valdes, et al. (1971). “An internal wire splint for adduction contracture of the thumb.” Plast Reconstr Surg 48(4): 339-42.

Asko-Seljavaara, S., J. Pitkanen, et al. (1984). “Microvascular free flaps in early reconstruction of burns in the hand and forearm. Case reports.” Scand J Plast Reconstr Surg 18(1): 139-44. In the reconstructive plastic surgery a free flap provides a one-stage method to achieve an optimal functional an aesthetic result. We report five acute burns or early contractions of the hand and forearm with free-flap reconstruction. In each case an attempt was made to design the flap to restore missing tissue components. We used three different musculocutaneous free flaps and two free skin flaps: a latissimus dorsi, a rectus abdominis and a rectus femoris renervated musculocutaneous flap, as well as a dorsalis pedis and a horizontal fasciocutaneous upper arm flap. In all five cases, the hand and wrist showed early restoration of function.

Martin, J. P., J. A. Chambers, et al. (2008). "Use of radial artery perforator flap from burn-injured tissues." J Burn Care Res 29(6): 1009-11. The hands and forearms are frequent sites of burn injury, and due to the high concentration of superficial tendons, bones, and joints, flaps are frequently needed to cover defects in these areas. We present a patient who suffered remote electrical injury to the right forearm which later developed into an open wound with exposed tendon. Successful coverage of this defect was accomplished with an islanded fasciocutaneous flap based on perforating arterial branches of the radial artery, which was harvested from an area of burn injury. Surgical treatment of hand and forearm wounds with axial pedicled flaps from areas of burn injury have been reported, but to our knowledge no reports describe the use of perforator flaps.

Colson, P., H. Janvier, et al. (1970). “[Dorsal burns of the hand. Problems raised by secondary repair of web space area].” Ann Chir Plast 15(1): 14-26.

Hallock, G. G. (1997). “Distal-based flaps for reconstruction of hand burns.” J Burn Care Rehabil 18(4): 332-7. Any burn injury, even if considered minimal in extent, can still be catastrophic, if hand burns are severe enough to result in deformities that render the individual unable to perform his own personal daily functions. Usually any necessary skin coverage of the hand can be achieved with skin grafts alone; but occasionally, seemingly heroic measures requiring vascularized flaps will be justified to ensure maximum rehabilitation. Previously, available options included proximal- based local flaps, or distant flaps either pedicled while remaining attached to another body region, or transferred immediately by use of microsurgical techniques. Another new concept that may still be somewhat in the 46 investigational stage for burns is the distal-based local flap. These use more traditional proximal skin territories, but with a distal vascular pedicle that can allow such flaps to reach even the fingertips. More expeditious and technically simpler than the transfer of distant flaps, this alternative deserves further consideration in the appropriate circumstances.

Tomaino, M. M. and A. Plakseychuk (2000). "Two-stage extensor tendon reconstruction after composite tissue loss from the dorsum of the hand." Am J Orthop 29(2): 122-4. Restoration of digital extension after chronic extensor loss has not been detailed extensively in the literature. The present report details an unusual case of composite tissue loss from the dorsum of the hand after a chronic burn wound. After debridement for chronic carpal osteomyelitis and free-tissue transfer were performed, staged wrist fusion and two-stage extensor tendon reconstruction resulted in a stable, pain-free wrist and functional digital extension. The present case illustrates that two-stage extensor tendon reconstruction, when necessary, is indeed feasible.

Uygur, F., C. Sever, et al. (2008). "Reverse flow flap use in upper extremity burn contractures." Burns 34(8): 1196-204. Upper extremity contractures still happen and constitute one of the most trying challenges in burn patients. This series comprised of 4 radial forearm flaps, 14 dorsoulnar artery flaps, and 4 medial arm flaps, all of which were used in a reverse pattern for upper extremity postburn contractures. The reverse flow radial forearm flap (RRFF) was chosen for reconstruction of extensive palmar contractures after burn. The reverse flow dorsoulnar flap (RDUF) was used particularly for reconstruction of the hypothenar aspect of the hand which requires moderate size tissue transfer. The reverse medial arm flap (RMAF) was used for elbow contractures after burn. In the first RMAF, venous congestion occurred and was finaly resolved with minimal flap loss, which was managed with STSG later. In the following 3 cases the flap was supercharged with anastomosis of the brachial vein into the antebrachial vein. Both RRFF and RDUF may provide a smooth and efficient solution. However, RMAF has a significant venous problem, which may result in flap loss, therefore, this flap should not be considered as a first option in the elbow area.

Matsumura, H., L. H. Engrav, et al. (1999). “The use of the Millard "crane" flap for deep hand burns with exposed tendons and joints.” J Burn Care Rehabil 20(4): 316-9. Deep hand burns with exposed tendons and joints are rare but devastating injuries. They cannot be grafted and require flaps. Abdominal or groin flaps are commonly used, but they are bulky and require separation of the digits. We tried the Millard "crane" flap for these burns and compared our patients' results with those of patients who had received standard abdominal skin flaps. Eleven deep hand burns that had been treated with flaps were evaluated. Six patients had been treated with the crane flap and 5 had been treated with conventional abdominal skin flaps. All crane procedures provided graftable wound beds. The total active ranges of motion of all 11 patients 6 months after the surgical procedures showed no statistical difference. The crane method also provides good cosmetic results. None of the hands treated with crane flaps required procedures to 47 separate the digits or debulk the flaps, but all of the hands treated with conventional abdominal skin flaps required these types of procedures.

Parry, S. W. (1989). “Reconstruction of the burned hand.” Clin Plast Surg 16(3): 577-86. Several basic principles of burned hand care must be kept in mind at all times. Intervention should be early and aggressive, small splints should be placed within 24 hours, and early tangential excision of the burn should be done within 72 hours. Hemostasis should be absolutely meticulous prior to grafting. Depending upon the availability of donor site skin, full-thickness skin grafts, split-thickness grafts, or meshed split-thickness grafts (expanded or not expanded) are preferred. I have found the functional and cosmetic results to decrease with use in exactly the order stated. The skin graft should be placed with stent or bolster dressings and observed for "take" early. Light active range of motion is usually begun on the tenth postoperative day. Escharotomy or fasciotomy should be performed for any signs of ischemia. In order to control edema, one should be meticulous in the positioning of burned hands, emphasizing elevation, and early range of motion exercises. Pressure garments may be employed when the wound is stable and should continue for 6 to 12 months to control hypertrophic scar formation. Linear scars should not cross any hand joints; Z-plasties are employed over the web spaces. Whenever possible, flaps should be employed to preserve all web spaces and skin grafts used to cover the remainder of the hand. I am aggressive in releasing and reconstructing late deformities such as extension contractures of the wrist, the metacarpal hand, absence of the thumb, finger contractures, and burn syndactyly. These are listed in order of treatment priority. Only in this manner can the patient be returned to "normal life." Patient self-esteem will thus be increased markedly, as will quality of life. It is strongly urged that the surgeon be "captain of the team." The key person in this treatment regimen is the hand therapist, who uses appropriate splints, range of motion exercises, and desensitization programs. I encourage the use of multiple personnel on the "burn team." This may include psychotherapists and, in children, teachers with extraordinary qualities.

Grishkevich, V. M.(2011) "Flexion contractures of fingers: contracture elimination with trapeze-flap plasty." Burns 37(1): 126-33. Scar flexion contracture of fingers is one of the most serious consequences of hand burns and patient disability after burn. Many kinds of reconstructive 48

techniques are currently used and new procedures are being investigated. The author presents a new method of finger contracture reconstruction developed in the process of burn reconstructive operations on hands of over a thousand patients. Finger flexion contractures are caused by a semilunar fold, both sheets of which are scars. The sheets have a surface deficiency in length, which causes a contracture, and excess of skin in width, which allows contracture elimination with local flaps. The length deficiency extends from the crest of the fold to the joint rotation axis and has a trapezoid form. To compensate for skin deficiency and to address the contracture, it is necessary to convert both fold sheets into trapezoid flaps by radial incisions. Because the fold is of semilunar (crescent) shape, the flaps accept a trapezoid form. One or several pairs of the flaps are mobilized with the split fat layer from the fold's crest to the joint rotation axis level. The oppositely transposed flaps fully or partially cover the wound in the proximal interphalangeal (PIP) zone first. The remaining smaller wounds are covered with full-thickness skin grafts. The flaps have a reliable blood circulation; partial flap loss is an exception. The flap's surface does not decrease, the skin grafts shrink insufficiently, and the distant results, as a rule, are good. Two hundred and seventy-five patients were operated upon. Scar contractures were satisfactorily addressed in all patients. Incomplete extension was found in 46 patients; this was caused by interphalangeal joint injuries (ligaments, capsule, cartilage), ankylosis or boutonniere deformity.

Grishkevich, V. M.(2010) "Postburn hand border contractures and eliminating them with trapeze-flap plasty." J Burn Care Res 31(2): 286-91. The hand burns can be complicated with the scar contracture of the ulnar or radial hand border. The contracture restricts the mobility of adjacent joints (fifth interphalangeal, wrist joints), causing deviation of the small finger and the whole hand. The contracture and deviation are caused by semilunar fold sheets of which are scars (medial contracture). The fold sheets have the trapeze-shaped surface deficiency in length and surface surplus in width. Thus, the local tissue flaps should have the corresponding form (trapeze-shaped flaps) for surface deficiency compensation. The sheets are transformed into trapezoid flaps along the total length of the semilunar fold with radial incisions until the full tension release is achieved. The incision's ends are split to complete the scar tension release. The distance between radial incisions at the fold's top is approximately 2 to 3 cm, which matches the width of the flap's end. The flaps are mobilized with the full fatty layer and transposed toward each other until the end of one flap reaches the base of the opposite flap. As a result, the skin surface lengthens by two to three times, which allows complete contracture elimination. The contractures were liquidated in all 16 patients without complications. The trapeze-flap plasty is recommended for a wide use in treatment of hand boarder contractures.

Robitaille, A., D. Halpern, et al. (1973). “Correction of keloids and finger contractures in burn patients.” Arch Phys Med Rehabil 54(11): 515-20 passim.

Snelling, C. F. (1983). “Delayed skin graft application following burn scar release of the face and hand.” Ann Plast Surg 10(5): 349-58. Hypertrophic scars and contractures involving the face and hand secondary to burns were excised and the defects covered with saline compresses changed every 4 hours. Banked split-thickness skin grafts were applied 24 to 48 hours later. Upper and lower lip, cheek, forehead, scalp, neck, the first web space of the hand, and the flexor surfaces of the fingers were treated. Head and neck defects were grafted open. Hand defects created by release were maintained with dynamic splints and grafted open or covered with bolus dressings kept in place with sutures inserted at the time of creation of the defect. Jobst compression with elastomer inserts for added pressure was started postoperatively. It is believed that delay permitted natural hemostasis to occur without extensive electrocoagulation, which produces additional necrotic tissue. Anesthetic time was shortened. Delay also permitted capillary proliferation to start in the defect, hastening revascularization of the grafts.

Grishkevich, V. M.(2011) "First web space post-burn contracture types: contracture elimination methods." Burns 37(2): 338-47. First web space adduction contractures are a common consequence of hand burns. Many reconstructive techniques are used and investigation for more effective methods continues. Effective hand reconstruction usually considers anatomy as its foundation. Based on the experience of over 500 web space contracture elimination cases, three anatomical types of thumb adduction contractures were identified: edge, medial and total. Edge contractures (80% of all thumb adduction contractures) are caused by a fold in which only one sheet is scarred, either the palmar or dorsal surface. The contraction is caused by a trapeze-shaped length deficiency of the scar sheet, which has a surface surplus in width. Reconstruction consists of surface deficiency compensation with trapezoid flap prepared from the non-scarred side and skin-fat tissues of the web space. In most cases, the small scar-fat trapezoid flaps should be prepared from the non-scarred side to cover the donor wounds on both sides of the main flap. Medial contractures (10% of thumb adduction contractures) are caused by the fold, both sheets of which are scarred and have trapeze-shaped surface deficiency in length and surplus in width. Both fold sheets are converted into one or several pairs of trapezoid scar-fat flaps by radial incisions. The oppositely located flaps are transposed towards each other. As a result of the counter flaps transposition, the contracture is eliminated; the web space's shape and depth are restored by the use of flaps alone or in combination with skin grafting. The trapeze-flap plasty is very simple and effective with the length gain of up to 100-200%. Neither flap loss nor re- contracture occurs. Total contractures (about 10% of all) have no fold. Reconstruction consists of the creation of the central zone of the first web space depth with the rectangular subdermal pedicle flap; the wounds on both sides of the flap are skin grafted. The flap sustains normal web depth and prevents the contracture recurrence and skin graft shrinkage. 50

Souter, W. A. (1974). “The problem of boutonniere deformity.” Clin Orthop 0(104): 116- 33.

Fankhauser, G., A. Klomp, et al. (2010) "Use of the pedicled tensor fascia lata myocutaneous flap in the salvage of upper extremity high-voltage electrical injuries." J Burn Care Res 31(4): 670-3. High-voltage electrical burns of the upper extremity are often limb threatening. Typically, emergency fasciotomies are followed by serial debridements until only viable tissue remains. After debridement, flap coverage is required to preserve viable but exposed tendons, nerves, vessels, bones, and joints and to salvage these seriously injured upper extremities. Flap options are generally limited to large pedicle flaps or free tissue transfer. Despite the array of flaps available, surgical options become limited when upper extremity injuries are extensive or the initial flap fails. The most commonly used pedicle flap, the groin flap, may not provide adequate soft tissue coverage in these cases. In addition, free tissue transfer can be difficult due, in part, to the uncertainty in determining the complete zone of injury and whether the flap recipient vessels are suitable for the transfer.An ideal flap for coverage would be relatively thin and pliable; have a constant, reliable pedicle; and be large enough to cover wounds of significant size. Few surgeons have experience with the pedicled tensor fascia lata (TFL) flap for upper extremity coverage. The authors demonstrate its use in the salvage of extensive upper extremity injuries on three limbs in two patients. We believe that this flap offers a distinct advantage compared with the groin flap when pedicled flap coverage of the upper extremity is required. PATIENT 1: A 23-year-old man sustained severe electrical burns to his right upper extremity. After serial debridements, a pedicled TFL myocutaneous flap was used to provide soft tissue coverage of this extensive injury. The flap was delayed at 2 weeks and inset at 3 weeks. There was complete survival of the flap, leading to salvage of the extremity. PATIENT 2: A 27-year- old man sustained bilateral upper extremity electrical burns. Initial free tissue transfers to both arms were unsuccessful. The patient subsequently underwent simultaneous bilateral pedicled TFL myocutaneous flaps. Both flaps were delayed at 2 weeks and divided at 3 weeks. There was complete flap survival bilaterally, leading to salvage of both upper extremities.Limb salvage in severe upper extremity electrical injuries is difficult even in the best circumstances. Dependable flap coverage is mandatory to prevent infection and avoid the need for early or late amputation. The pedicled TFL flap in our series of patients has served to be a dependable flap in these severe upper extremity injuries and should be added to the surgical armamentarium of those caring for these difficult surgical problems.

Byrne M, O'Donnell M, Fitzgerald L, Shelley OP. Early experience with fat grafting as an adjunct for secondary burn reconstruction in the hand: Technique, hand function assessment and aesthetic outcomes. Burns. 2016;42(2):356-65. 51

INTRODUCTION: Fat transfer is increasingly used as part of our reconstructive armamentarium to address the challenges encountered in secondary burn reconstruction. The aim of this study was to review our experience with autologous fat transfer in relation to hand function, scarring and cosmesis, in patients undergoing secondary reconstruction after burns. METHOD: Retrospective analysis of burn patients (2010-2013) who underwent autologous fat transfer to improve scarring, contour deformity and/or scar contracture was performed. Hand function was assessed using grip strength measurement, Total Active Movement (TAM), the Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire and Michigan Hand Outcome Questionnaire (MHQ). Patients' satisfaction was assessed using the Patient Observer Scar Assessment Scale (POSAS). RESULTS: Thirteen patients were included in this analysis. The average time from burns and from fat transfer were 2.3 years (10 months-3.9 years) and 9.1 months (3 months-1.3 years), respectively. There was a statistically significant improvement in TAM measurement. The total score, activity of daily living score and satisfaction score of the MHQ also statistically increased following fat transfer. The changes in function score, work score and pain score of the MHQ were not significant. Grip strength measurement and DASH score did not show improvement. For scar assessment, total score and overall score of POSAS improved significantly. Similarly, scores for scar colour, scar thickness, scar stiffness and scar regularity increased significantly. DISCUSSION: Autologous fat transfer directly replaces volume loss in the subcutaneous layer, physically releases tethered skin from underlying tissues and exerts downstream regenerative effects. Skin quality improvements combined with replacement of the subcutaneous adipose volume in the hand reduces overall scar tightness and tissue tethering and has the potential to enhance hand therapy. In our series, modest improvement in range of movement, scar quality and hand outcome scores were demonstrated following a single session of fat transfer.

Grishkevich VM. First web space post-burn contracture types: contracture elimination methods. Burns. 2011;37(2):338-47.

First web space adduction contractures are a common consequence of hand burns. Many reconstructive techniques are used and investigation for more effective methods continues. Effective hand reconstruction usually considers anatomy as its foundation. Based on the experience of over 500 web space contracture elimination cases, three anatomical types of thumb adduction contractures were identified: edge, medial and total. Edge contractures (80% of all thumb adduction contractures) are caused by a fold in which only one sheet is scarred, either the palmar or dorsal surface. The contraction is caused by a trapeze-shaped length deficiency of the scar sheet, which has a surface surplus in width. Reconstruction consists of surface deficiency compensation with trapezoid flap prepared from the non-scarred side and skin-fat tissues of the web space. In most cases, the small scar-fat trapezoid flaps should be prepared from the non-scarred side to cover the 52

donor wounds on both sides of the main flap. Medial contractures (10% of thumb adduction contractures) are caused by the fold, both sheets of which are scarred and have trapeze-shaped surface deficiency in length and surplus in width. Both fold sheets are converted into one or several pairs of trapezoid scar-fat flaps by radial incisions. The oppositely located flaps are transposed towards each other. As a result of the counter flaps transposition, the contracture is eliminated; the web space's shape and depth are restored by the use of flaps alone or in combination with skin grafting. The trapeze-flap plasty is very simple and effective with the length gain of up to 100-200%. Neither flap loss nor re- contracture occurs. Total contractures (about 10% of all) have no fold. Reconstruction consists of the creation of the central zone of the first web space depth with the rectangular subdermal pedicle flap; the wounds on both sides of the flap are skin grafted. The flap sustains normal web depth and prevents the contracture recurrence and skin graft shrinkage.

Germann G. Hand Reconstruction After Burn Injury: Functional Results. Clin Plast Surg. 2017;44(4):833-44.

Frequently burns of the hand occur as part of a major thermal injury, but appropriate treatment of the hands has high priority, because even small burns of the hand may result in severely limited function and compromised aesthetic appearance. The functional importance of the hand cannot be overemphasized, because the patient's ability to perform useful work after recovery or the ability to care for themselves is to a great degree determined by residual hand function. This article describes the management of burn injuries involving the hand, stressing the importance of appropriate initial treatment. A comprehensive review of hand reconstruction and rehabilitation, to optimize form and function, is provided.

De la Garza, Sauerbier, Germann, Cetrulo, Bueno, , Russell, Neumeister Microsurgical Reconstruction of the Burned Hand and Upper Extremity Hand Clin. 2017 May;33(2):347-361. Improvements in critical care and burn victim resuscitation have led to increased survival of burned patients. Initial resuscitation, early excision of burned tissues, prevention of burn wound sepsis, and wound coverage remain mainstays of care. Many burn wounds require complex reconstruction. This is particularly important in the hand. Coverage of tendons, ligaments, joints, vessels, nerves, and bones of the hand requires healthy vascularized tissue to maintain viability and function. Local flaps or regional flaps may be within the burn zone of injury. Refined microvascular free tissue transfer techniques offer free tissue transfer as a procedure that can be safely performed.

4. Etiology of the Burn Injury

Attalla, M. F., A. A. al-Baker, et al. (1991). “Friction burns of the hand caused by jogging machines: a potential hazard to children.” Burns 17(2): 170-1. Three children with full skin thickness friction burns of the hand caused by treadmill jogging machines are presented. The mechanism of injury, the potential hazards and poor safety precautions in design of the machine are highlighted.

Baack, B. R., T. Osler, et al. (1993). “Steam press burns of the hand.” Ann Plast Surg 30(4): 345-9. Steam presses pose an occupational hazard to workers in the dry cleaning industry. Three patients with thermal burns to the hand from steam press accidents were recently treated at this institution. Each patient sustained deep second and third degree burns to the dorsum of the hand. Two patients required split-thickness skin grafts and have retained full range of motion and returned to full employment. One patient sustained destruction of extensor tendons and required a groin flap for coverage. Late tendon reconstruction will be necessary. Investigation revealed that older steam press models do not have an emergency release lever in case of accidental closure on a worker's hand. Although newer models are equipped with a thigh-activated emergency release lever, a contact burn remains likely if the press closes on the operator's hands. Some of the newest models have an attached safety bar that prevents the press from closing on the operator's hands. It is recommended that older models either be modified with the attachment of a safety bar or replaced entirely.

Benmeir, P., S. Lusthaus, et al. (1993). “Very deep burns of the hand due to low voltage electrical laboratory equipment: a potential hazard for scientists.” Burns 19(5): 450-1. A low voltage (24 V) electrical deep burn of the hand injured a professor of applied physics when performing an experiment in his laboratory. The potential hazard of the equipment is described, the injuries are reported and the literature is reviewed.

Bill, T. J., D. J. Bentrem, et al. (1996). “Grease burns of the hand: preventable injuries.” J Emerg Med 14(3): 351-5. 54

Grease burns to the hand represent a serious and preventable hazard. These injuries account for over 10% of all major burns seen in the emergency department. These burns occur when the cook attempts to move a pan with burning cooking oil and inadvertently spills the oil on the hand holding the pan. These burns are usually full thickness because of either the high temperatures of the flaming oils or the subsequent ignition of clothing. This article describes a patient who received severe partial and full thickness burns to the dominant hand following a grease burn in the domestic setting. Prevention through improved consumer education and warning labels for cooking oils should reduce the incidence of these serious injuries.

Brown, R. L., D. G. Greenhalgh, et al. (1997). “Iron burns to the hand in the young pediatric patient: a problem in prevention.” J Burn Care Rehabil 18(3): 279-82. Iron burns to the hand may result in both functional and cosmetic deformities in the young pediatric patient. To gain a better understanding of these injuries in terms of demographics, treatment, and outcome, and to address possible measures for prevention, the medical records of 82 pediatric patients suffering iron burns to the hand during the period 1987 to 1993 were reviewed. Iron burns to the hand occurred most commonly in male children less than 2 years of age. Most were minor partial-thickness burns that were treated in the outpatient setting with no adverse sequelae. Fifteen percent of patients, however, sustained full-thickness burns that required grafting. Ten percent of patients developed complications including hypertrophic scarring and scar contractures requiring surgical release. Socioeconomic factors and parental inexperience appeared to play a significant role, as most of these injuries occurred in low-income, single-parent, single- child households. Most injuries were unintentional, however, many were caused by carelessness or neglect. Abuse was suspected or proven in 7% of cases. Parents may be unaware of the consequences of leaving a child unattended in the presence of a hot iron. The incidence of these injuries could be reduced effectively by improved public awareness of the problem and education in prevention.

Jakubik, J. (1972). “[Hand burns caused by a laundry press].” Acta Chir Orthop Traumatol Cech 39(1): 49-54.

Olney, D. B. (1983). “A review of the long term results of electric bar fire burns of the hand in children.” Hand 15(2): 179-84. This paper reports on the long term problems of a group of patients who had sustained burns to the palmar aspect of one or both hands between eleven and eighteen years previously. Two of the eight patients who were re-examined had abnormalities of bony development in the hand. It is thought that the contracted scars resulting from the injury affect the growth of the bones of the hand. As development of contracted scars can develop at any time until growth of the hand is complete it is necessary to follow up these children until they reach maturity.

Parks, B. J. and R. L. Horner (1973). “Electric burns of the hand.” J Occup Med 15(12): 967-70.

Shugerman, R., F. Rivara, et al. (1987). “Contact burns of the hand.” Pediatrics 80(1): 18- 21. Contact burns of the hand in children present difficult management questions. Because visual inspection of the acute wound often fails to distinguish major burns requiring inpatient treatment from minor burns amenable to outpatient therapy, we sought to identify characteristics of patients that would aid in decision making at the time the burn patient is seen. During the 5-year period, 1980 to 1984, 32 children less than 14 years of age were admitted to our medical center with contact burns of the hand. Patients were divided into two groups: those with major burns requiring greater than or equal to seven days of hospitalization (n = 16) and those with minor burns requiring less than seven days of hospitalization (n = 16). Compared with patients in the minor burn group, patients in the major burn group were hospitalized longer (16.9 v 2.8 days), were more likely to require surgical excision and grafting (63% v 0%), and had more extensive follow-up (5.3 v 2.5 visits). There were no significant differences between the two groups with regard to percentage of area burned, age, sex, primary admission v referral, and cause of burn. These data support the recommendation that all such burns be managed initially on an inpatient basis.

Smith, J. R. and A. F. Bom (1968). “Penetrating molten plastic burns of the hand. Report of two cases.” Br J Plast Surg 21(1): 63-7.

Stone, P. A. (1973). “Hand burns caused by electric fires.” Injury 4(3): 240-6.

Tay, Y. G. and K. K. Tan (1996). “Unusual ritual burns of the hand.” Burns 22(5): 409- 12. Six hands from five patients were seen with full-thickness burns following a ritual practice between June 1993 and June 1994. Three hands were treated with excision and medium-thickness split-skin grafts, one patient was treated with a medium-thickness split skin graft taken from the instep of the foot. The first patient with bilateral burns of the palms refused surgery and returned 3 months later with contractures of the palms. The results of the treated hands are presented.

Woods, J. A., A. T. Cobb, et al. (1996). “Steam press hand burns: a serious burn injury.” J Emerg Med 14(3): 357-60. Steam presses cause full-thickness burns when the operator's extremity is caught between the buck and the head of the steam press. Patients with serious steam press burns should be referred to a regional burn center for excision of the full-thickness burn and coverage by either a split-thickness skin graft or a flap. The safety features in steam presses that could prevent this serious injury include: (1) emergency safety releases, (2) peripheral safety bars, and (3) two-hand operator control.

Zoltie, N., M. D. Eve, et al. (1987). “Electrical burns to the hand from lawn-mowers.” Burns Incl Therm Inj 13(3): 248-52. Fifteen cases of electrical burns to the hand are described resulting from the use of electric lawn-mowers. These injuries caused significant morbidity and time off work, and 56 one death. Most of the burns appear to have been preventable, and ways of averting these injuries are discussed.

Lee, G. K., K. J. Suh, et al. (2010) "MR imaging findings of high-voltage electrical burns in the upper extremities: correlation with angiographic findings." Acta Radiol 52(2): 198- 203. BACKGROUND: A high-voltage electrical burn is often associated with deep muscle injuries. Hidden, undetected deep muscle injuries have a tendency for progressive tissue necrosis, and this can lead to major amputations or sepsis. MRI has excellent soft tissue contrast and it may aid in differentiating the areas of viable deep muscle from the areas of non-viable deep muscle. PURPOSE: To describe the MR imaging findings of a high-voltage electrical burn in the upper extremity with emphasis on the usefulness of the gadolinium-enhanced MRI and to compare the MR imaging findings with angiography. MATERIAL AND METHODS: We retrospectively reviewed the imaging studies of six patients with high-voltage electrical burns who underwent both MRI and angiography at the burn center of our hospital from January 2005 to December 2009. The imaging features were evaluated for the involved locations, the MR signal intensity of the affected muscles, the MR enhancement pattern, the involved arteries and the angiographic findings (classified as normal, sluggish flow, stenosis or occlusion) of the angiography of the upper extremity. We assessed the relationship between the MR imaging findings and the angiographic findings. RESULTS: The signal intensities of affected muscles were isointense or of slightly high signal intensity as compared with the adjacent unaffected skeletal muscle on the T1-weighted MR images. Affected muscles showed heterogenous high signal intensity relative to the adjacent unaffected skeletal muscle on the T2-weighted images. The gadolinium-enhanced T1-weighted images showed diffuse inhomogeneous enhancement or peripheral rim enhancement of the affected muscles. The angiographic findings of the arterial injuries showed complete occlusion in three patients, severe stenosis in two patients and sluggish flow in one patient. Of these, the five patients with complete occlusion or severe stenosis on angiography showed non-perfused and non-viable areas of edematous muscle on MRI. On the other hand, one patient with sluggish flow on angiography showed a perfused and viable area of edematous muscle on MRI. CONCLUSION: Gadolinium-enhanced MRI is a useful non-invasive imaging modality to detect the site and extent of hidden, undetected deep muscle injuries in a group of patients with high-voltage electrical burns of the upper extremities.

Varghese, B. T., S. Thomas, et al. "Accidental radioisotope burns - Management of late sequelae." Indian J Plast Surg 43(Suppl): S88-91. Accidental radioisotope burns are rare. The major components of radiation injury are burns, interstitial pneumonitis, acute bone marrow suppression, acute renal failure and adult respiratory distress syndrome. Radiation burns, though localized in distribution, have systemic effects, and can be extremely difficult to heal, even after multiple surgeries. In a 25 year old male who sustained such trauma by 57

accidental industrial exposure to Iridium192 the early presentation involved recurrent haematemesis, pancytopenia and bone marrow suppression. After three weeks he developed burns in contact areas in the left hand, left side of the chest, abdomen and right inguinal region. All except the inguinal wound healed spontaneously but the former became a non-healing ulcer. Pancytopenia and bone marrow depression followed. He was treated with morphine and NSAIDs, epidural buprinorphine and bupivicaine for pain relief, steroids, antibiotics followed by wound excision and reconstruction with tensor fascia lata(TFL) flap. Patient had breakdown of abdominal scar later and it was excised with 0.5 cm margins up to the underlying muscle and the wound was covered by a latissimis dorsi flap. Further scar break down and recurrent ulcers occurred at different sites including left wrist, left thumb and right heel in the next two years which needed multiple surgical interventions.

5. Chemical Burns of the Hand

Anderson, W. J. and J. R. Anderson (1988). “Hydrofluoric acid burns of the hand: mechanism of injury and treatment.” J Hand Surg [Am] 13(1): 52-7. Hydrofluoric acid is one of the strongest inorganic acids and is used extensively in industry and research. It differs from other acids in that the fluoride ion readily penetrates the skin, causing destruction of deep tissue layers and even bone. Authors have previously described numerous topical treatments. This report describes one method of treatment emphasizing immediate skin cleansing and the application of calcium gluconate gel, which is followed by calcium gluconate subcutaneous injections when necessary. An accurate occupational history and physical examination are important aspects of patient assessment. Prompt treatment resulted in relief of pain and a satisfactory clinical result in all cases. A significant delay in treatment was responsible for permanent impairment in 2 of 14 patients.

Chick, L. R. and G. Borah (1990). “Calcium carbonate gel therapy for hydrofluoric acid burns of the hand.” Plast Reconstr Surg 86(5): 935-40. Hydrofluoric acid is used extensively as an industrial cleaning agent for metals and glass. Many workers are injured by cutaneous contact of the acid with exposed skin surfaces, particularly hands. Hydrofluoric acid burns are characterized by delayed onset of symptomatology with skin ulceration, and severe pain may be of extended duration. Treatment of hydrofluoric acid burns traditionally has consisted of local infiltration or intraarterial injections of calcium solutions. These injections are painful and frequently require retreatment. A new treatment utilizing a topical gel of calcium carbonate is described. Nine patients have been treated for hydrofluoric acid burns of the hand with calcium carbonate gel applied topically and covered with occlusive glove dressings. A gel slurry is compounded from calcium carbonate tablets and K-Y Jelly. Fingernails of the affected fingers are removed if a subungual burn is obvious. The gel is put into a surgeon's glove and placed over the burned hand. The patient replaces the glove and slurry every 4 hours for 24 hours. After the first day, the glove is discontinued unless there is resumption of painful symptoms. Full range of motion is encouraged during this 58 interval. The calcium carbonate gel technique was successfully utilized in nine patients with no further need for injection therapy. In these patients, pain relief was obtained within 4 hours of treatment, with no further progression of skin ulceration. No reconstructive procedures were required in any patient, and only one patient did not return to full-duty work within 1 week. There were no long-term sequelae from burns treated with this topical therapy, except one patient, who presenting 24 hours after the burn, developed a digital tip neuroma that was excised.

Dibbell, D. G., R. E. Iverson, et al. (1970). “Hydrofluoric acid burns of the hand.” J Bone Joint Surg Am 52(5): 931-6.

Kleinert, H. E. and J. L. Bronson (1976). “Hydrofluoric acid burns of the hand.” Med Times 104(12): 75-9.

Wolfort, F. G., D. R. Nevarre, et al. (2000). “Alkali burns to the hand.” Ann Plast Surg 44(3): 346.

Han HH, Kwon BY, Jung SN, Moon SH. Importance of initial management and surgical treatment after hydrofluoric acid burn of the finger. Burns. 2017;43(1):e1-e6. Occupational injuries to digits due to hydrofluoric acid (HFA) are frequently encountered. They have distinctive features, including intense pain, progressive tissue necrosis, and possible bone erosion. To minimize tissue damage, it is of great importance to execute prudent preoperative assessment and determine the correct surgical modality to reconstruct and maintain the function of the hand. However, proper protocols for fingers have not been presented in previous studies. Eight cases with HFA burn to digits were presented to the emergency room. Wounds were immediately irrigated with saline, calcium gluconate was applied topically to block destructive effects of fluoride ions. Blisters that could lead to progressive tissue destruction were debrided. A fish-mouth fasciotomy was performed and prostaglandin was administered intravenously to maintain maximal distal circulation. Wounds were evaluated daily for apparent demarcation for 6 or 7 days. Digits were reconstructed with free sensate second toe pulp-free flap to provide sufficient padding for the fingertip. All patients showed excellent recovery with stable flaps with acceptable external contour, durable soft tissue padding, and full range of motion of affected joints. In conclusion, when a patient is admitted due to HFA exposure to the finger, early treatment including irrigation, topical neutralizers, and fasciotomy are of great importance to minimize tissue damage. In addition, a physician should wait at least 7days until the degree of damage to the tissue can be classified so that the physician can decide whether aggressive debridement should be proceeded. In case of deep layer injuries of weight bearing portions such as finger pulp, reconstruction techniques utilizing durable tissues such as partial second toe pulp free flap should be employed.

5. Therapy for the Burned Hand

Ause-Ellias, K. L., et al. (1994). "The effect of mechanical compression on chronic hand edema after burn injury: a preliminary report." J Burn Care Rehabil 15(1): 29-33.

Chronic hand edema after wound healing is a troublesome condition to treat in patients with burns. Stagnant edema can cause fibrosis, which impedes rehabilitation and may lead to deformity. Although favorable results have been reported with mechanical compression used in acute injuries, no literature was found on the effects of compression for the treatment of chronic hand-burn edema. Five male patients with nine chronically edematous burned hands were subject to mechanical compression at 55 mm Hg pressure. A single-cell unit was used for a 30-minute treatment at 4:1 treatment ratio. Goniometric and volumetric hand measurements were recorded both before and after treatment. Although patients expressed a subjective feeling of improvement, no statistical difference was found in finger joint range of motion nor in hand volume when comparing pretreatment and posttreatment measurements. Many different treatment protocols exist in the literature and are discussed.

Chapman, T. T., et al. (2008). "Military return to duty and civilian return to work factors following burns with focus on the hand and literature review." J Burn Care Res 29(5): 756-762.

Functional recovery and outcome from severe burns is oftentimes judged by the time required for a person to return to work (RTW) in civilian life. The equivalent in military terms is return to active duty. Many factors have been described in the literature as associated with this outcome. Hand function, in particular, is thought to have a great influence on the resumption of preburn activities. The purpose of this investigation was to compare factors associated with civilian RTW with combat injured military personnel. A review of the literature was performed to assimilate the many factors reported as involved with RTW or duty. Additionally, a focus on the influence of hand burns is included. Thirty-four different parameters influencing RTW have been reported inconsistently in the literature. In a military population of combat burns, TBSA burn, length of hospitalization and intensive care and inhalation injury were found as the most significant factors in determining return to duty status. In previous RTW investigations of civilian populations, there exists a scatter of factors reported to influence patient disposition with a mixture of conflicting results. In neither military nor civilian populations was the presence of a hand burn found as a dominant factor. Variety in patient information collected and statistical approaches used to analyze this information were found to influence the results and deter comparisons between patient populations. There is a need 60 for a consensus data set and corresponding statistical approach used to evaluate RTW and duty outcomes after burn injury.

Dewey, W. S., et al. (2007). "The reliability and concurrent validity of the figure-of-eight method of measuring hand edema in patients with burns." J Burn Care Res 28(1): 157- 162.

OBJECTIVE: Water volumetry is considered the "gold standard" for hand edema assessment. This technique requires considerable time, staff, and specialized equipment. The figure-of-eight method for hand edema assessment has been tested only in the orthopedic population. The objective of this study was to test the reliability and concurrent validity of the figure-of-eight method of measuring hand edema in the burn patient population. METHODS: We conducted a prospective blinded study with 20 burned patients (33 edematous hands) admitted from February to May 2005. Two testers performed three separate blinded measurements on each edematous hand, using the figure-of-eight technique. A third tester performed two measurements, using water volumetry. An independent investigator recorded all measurements. Intratester and intertester reliability were analyzed. Concurrent validity was examined and compared with water volumetry measurements. RESULTS: Intraclass correlation coefficients (ICC) for the intratester reliability of the figure-of-eight method were 0.96 for tester 1 and 0.97 for tester 2. The ICC for intertester reliability of the figure-of-eight measurements was 0.94. The intratester ICC for volumetric measurements was 0.99. Correlation coefficient (Pearson's) for tester 1 was 0.83 (P < .01), and for tester 2, 0.89 (P < .01). CONCLUSION: The figure-of-eight technique is a reliable and valid measurement tool for measuring hand edema. This technique is a more clinically feasible tool than water volumetry in the burn patient population.

Dewey, W. S., et al. (2007). "A review of compression glove modifications to enhance functional grip: a case series." J Burn Care Res 28(6): 888-891.

A common complaint among patients with burns is their inability to grasp items while wearing compression gloves. Recent technological innovations permit the addition of grip-enhancing material to garment fabric. The purpose of this case series was to describe the course of development of compression gloves with enhanced grip modifications. Five different types of grip modifications were made during a period of 18 months. Five subjects who were prescribed compression gloves tested each type of glove. The gloves were fabricated with grip-enhancing material on the palmar surface in five ways: 1) rectangular rubber tabs; 2) honeycomb pattern silicone; 3) wave-like pattern silicone; 4) line pattern silicone beads; 5) line pattern silicone beads embedded into the fabric. Each glove was evaluated on a three-point Likert scale (0 = poor, 1 = moderate, 2 = good) for grip-enhancing qualities and durability. All five subjects reported similar experiences with each glove type: 1) the rectangular rubber tabs demonstrated poor grip and moderate durability; 2) the honeycomb pattern provided good grip but poor durability; 3) the wave pattern had good grip and moderate durability; 4) the silicone beads adhered to the fabric had moderate grip but poor durability; 5) the silicone beads embedded into the fabric had moderate grip and good durability. The wave pattern provided the best gripping 61 capability and silicone embedded into the fabric demonstrated the best durability. A wave-like pattern silicone material embedded into the fabric seems to provide the best combination of grip and durability to enhance activities of daily living performance.

Dewey, W. S., et al. (2009). "Opposition splint for partial thumb amputation: a case study measuring disability before and after splint use." J Hand Ther 22(1): 79-86; quiz 87.

STUDY DESIGN: Case report. INTRODUCTION: A combined burn and a partial amputation can be extremely debilitating as the thumb constitutes 40% of the entire hand when evaluating functional impairment. PURPOSE OF THE STUDY: Measure disability with and without opposition splint use after partial thumb amputation due to a burn. METHODS: Impairment and disability measures were completed at discharge from the hospital and subsequently during outpatient follow-up visits while wearing and not wearing a thumb opposition splint at 3, 6, 8, and 15 months. Comparisons between disability and impairment scores were assessed over time. RESULTS: The difference between DASH scores with and without using the splint were 25 at 3 months, 16 at 6 months, 10 at 8 months, and 12 at 15 months. CONCLUSIONS: Splint use in this case demonstrated clinically significant changes over time with minimal changes in impairment indicating enhanced function and improved patient perception of disability. LEVEL OF EVIDENCE: 4.

Dewey, W. S., et al. (2011). "Positioning, splinting, and contracture management." Phys Med Rehabil Clin N Am 22(2): 229-247, v.

Whether a patient with burn injury is an adult or child, contracture management should be the primary focus of burn rehabilitation throughout the continuum of care. Positioning and splinting are crucial components of a comprehensive burn rehabilitation program that emphasizes contracture prevention. The emphasis of these devices throughout the phases of rehabilitation fluctuates to meet the changing needs of patients with burn injury. Early, effective, and consistent use of positioning devices and splints is recommended for successful management of burn scar contracture.

Edgar, D., et al. (2009). "Goniometry and linear assessments to monitor movement outcomes: are they reliable tools in burn survivors?" Burns 35(1): 58-62.

BACKGROUND: Despite common use and theoretical construct validity, goniometry is not reported to be reliable for the measurement of burn-affected joint range of motion. Similarly, a number of simple objective measures commonly used to document hand mobility have eluded this rigour. This study aimed to examine the within sessions of intra-rater and inter-rater reliability of active joint range of motion measurement in patients with burns. METHODS: Intra-rater reliability: One physical therapist (PT) recorded duplicate measurements on each burn-affected joint after a 5-min interval in a subset of patients (n=21). Inter-rater reliability: Four qualified PTs took part in repeated measures testing of 45 patients on the same day. RESULTS: Intra-rater reliability was excellent with intraclass correlation coefficients (ICCs>.99) and 95% confidence intervals (CIs)=.99-1.0. Inter-rater reliability was also excellent with ICCs>.94 (95% 62

CIs=.90-.99). The minimum detectable change using goniometry at the ankle was > or =5 degrees and for all other joints tested was > or =9 degrees. For linear hand measures a change of >1cm and thumb opposition > or =1/2 of one scale point indicated measurable difference. CONCLUSION: This study demonstrated excellent intra-rater and inter-rater reliability and measurement of clinically relevant change for all measurements when applied with a standardised protocol. Therefore, assessing joint range of motion (ROM) with a goniometer or hand movement with linear or scale measurements can provide accurate, objective measures in the burns population.

Gordon, M. D., et al. (2004). "Review of evidenced-based practice for the prevention of pressure sores in burn patients." J Burn Care Rehabil 25(5): 388-410.

Pressure ulcers represent a complex clinical problem, with a reported incidence of 2.7% to 29.5% in hospitalized patients and an etiology that is multifactorial. The prevention of pressure sores in the burn patient population is clearly an area of practice in need of guidelines for care. A multidisciplinary group of advanced burn care professionals have compiled, critiqued, and summarized herein the current evidence of practice in nursing, nutrition, and rehabilitation as it pertains to the prevention of pressure sores after burn injuries. A broad overview of risk factors and assessment scales is described, and current intervention practices and recommendations for care are provided based, whenever possible, on research findings. In addition, research questions are generated in an attempt to move the specialty of burns toward the formal investigation of pressure sores with the ultimate goal being the development of evidence-based practice guidelines.

Goverman, J., et al. (2017). "Adult Contractures in Burn Injury: A Burn Model System National Database Study." J Burn Care Res 38(1): e328-e336.

As the overall survival rate for burn injury has improved, increased emphasis is placed on postburn morbidity and the optimization of functional and cosmetic outcomes. One major cause of morbidity and functional deficits is that of joint contractures. The true incidence of postburn contractures and their associated risk factors remains unknown. This study examines the incidence and severity of contractures in a large, multicenter, burn population. The associated risk factors for the development of contractures are determined. Data from the National Institute on Disability and Rehabilitation Research Burn Model System database, for adult burn survivors from 1994 to 2003, were analyzed. Demographic and medical data were collected on each subject. The primary outcome measures included the presence of contractures, number of contractures per patient, and severity of contractures at each of nine locations (shoulder, elbow, hip, knee, ankle, wrist, neck, lumbar spine, and thoracic spine) at time of hospital discharge. Regression analysis was performed to determine predictors of the presence, severity, and numbers of contractures, with P < .05 used for statistical significance. Of the 1865 study patients, 620 (33%) developed at least 1 contracture at hospital discharge. Among those with at least one contracture, the mean is three (3.38) contractures per person. The shoulder was the most frequently contracted joint (23.0%), followed by the elbow (19.9%), wrist (17.3%), ankle (13.6%), and knee (13.4%). Most contractures were mild (47.2%) or moderate (32.9%) in severity. Statistically significant predictors of contracture development were 63 male sex, black race, Hispanic ethnicity, medical problems, neuropathy, TBSA grafted, and TBSA burned. Predictors of the severity of contracture included male sex, black race, medical problems, neuropathy, TBSA grafted, and TBSA burned. Predictors of the number of contractures included male sex, medical problems, flash burn, neuropathy, TBSA burned, and TBSA grafted. Similar to a previous single-center study on postburn contractures, approximately one third of the patients with an eligible burn injury requiring autografting developed a contracture at hospital discharge. It is likely that these contractures develop despite early therapeutic interventions such as positioning and splinting; therefore, the challenge to the burn community remains, to identify new and better prevention strategies.

Goverman, J., et al. (2017). "Pediatric Contractures in Burn Injury: A Burn Model System National Database Study." J Burn Care Res 38(1): e192-e199.

Joint contractures are a major cause of morbidity and functional deficit. The incidence of postburn contractures and their associated risk factors in the pediatric population has not yet been reported. This study examines the incidence and severity of contractures in a large, multicenter, pediatric burn population. Associated risk factors for the development of contractures are determined. Data from the National Institute on Disability and Rehabilitation Research Burn Model System database, for pediatric (younger than 18 years) burn survivors from 1994 to 2003, were analyzed. Demographic and medical data were collected on each subject. The primary outcome measures included the presence of contractures, number of contractures per patient, and severity of contractures at each of nine locations (shoulder, elbow, hip, knee, ankle, wrist, neck, lumbar, and thoracic) at time of hospital discharge. Regression analysis was performed to determine predictors of the presence, severity, and numbers of contractures, with P < .05 used for statistical significance. Of the 1031 study patients, 237 (23%) developed at least 1 contracture at hospital discharge. Among those with at least one contracture, the mean was three (3.3) contractures per person. The shoulder was the most frequently contracted joint (27.9%), followed by the elbow (17.6%), wrist (14.2%), knee (13.3%), and ankle (11.9%). Most contractures were mild (38.5%) or moderate (36.3%) in severity. The statistically significant predictors of contracture development were age and intensive care unit (ICU) length of stay. The statistically significant predictors of severity of contracture were age, ICU length of stay, presence of amputation, and black race. Predictors of the number of contractures included total age, length of stay, length of ICU stay, presence of amputation, TBSA burned, and TBSA grafted. This is the first study to report the epidemiology of postburn contractures in the pediatric population. Approximately one quarter of children with a major burn injury developed a contracture at hospital discharge, and this could potentially increase as the child grows. Contractures develop despite early therapeutic interventions such as positioning and splinting; therefore, it is essential that we identify novel and more effective prevention strategies. 64

Korp, K., et al. (2015). "Refining the idiom "functional range of motion" related to burn recovery." J Burn Care Res 36(3): e136-145.

The term "functional" in burn rehabilitation has gained widespread use to describe a patient's recovery after burn injury. But what truly is "functional" when applied to a patient recovering from burn injury? A literature search was performed for information defining "functional" range of motion (ROM). Maximum upper and lower ROM values to perform a variety of daily activities were abstracted and compared with published outcomes of patient groups recovered from burn injury. Seventy references were reviewed leading to categorizing 11 activities and 26 joint motions. Seven burn outcome articles were found that classified patient scar contracture severity based on ROM. In comparing the results, many burn survivors with severe burn scar contractures could be considered "functional." Refinement of the term "functional" is needed related to burn outcomes. Functional ROM of a particular joint to perform one specific task may be insufficient to perform a variety of other tasks when all planes of motion are considered. Use of the term "functional" to describe a patient's outcome should be used in a guarded manner.

Lester, M. E., et al. (2013). "Influence of upper extremity positioning on pain, paresthesia, and tolerance: advancing current practice." J Burn Care Res 34(6): e342-350.

Loss of upper extremity motion caused by axillary burn scar contracture is a major complication of burn injury. Positioning acutely injured patients with axillary burns in positions above 90 degrees of shoulder abduction may improve shoulder motion and minimize scar contracture. However, these positions may increase injury risk to the nerves of the brachial plexus. This study evaluated the occurrence of paresthesias, pain, and positional intolerance in four shoulder abduction positions in healthy adults. Sixty men and women were placed in four randomly assigned shoulder abduction positions for up to 2 hours: 1) 90 degrees with elbow extension (90 ABD); 2) 130 degrees with elbow flexion at 110 degrees (130 ABD); 3) 150 degrees with elbow extension (150 ABD); and 4) 170 degrees with elbow extension (170 ABD). Outcome measures were assessed at baseline and every 30 minutes and included the occurrence of upper extremity paresthesias, position comfort/tolerance, and pain. Transient paresthesias, lasting less than 3 minutes, occurred in all test positions in 10 to 37% of the cases. Significantly fewer subjects reported paresthesias in the 90 ABD position compared with the other positions (P < .01). Pain was reported more frequently in the 170 degrees position (68%) compared with the other positions (P < .01). Positioning with the elbow flexed or in terminal extension is not recommended, regardless of the degree of shoulder abduction. Positioning patients in a position of 150 degrees of shoulder abduction was shown to be safe and well tolerated. Consideration of positions above this range should be undertaken cautiously and only with strict monitoring in alert and oriented patients for short time periods.

Moore, M. L., et al. (2009). "Rehabilitation of the burned hand." Hand Clin 25(4): 529- 541. 65

Successful outcomes following hand burn injury require an understanding of the rehabilitation needs of the patient. Rehabilitation of hand burns begins on admission, and each patient requires a specific plan for range of motion and/or immobilization, functional activities, and modalities. The rehabilitation care plan typically evolves during the acute care period and during the months following injury.

Parry, I., et al. (2010). "Methods and tools used for the measurement of burn scar contracture." J Burn Care Res 31(6): 888-903.

After burn injury, scar contracture can cause significant impairment and functional deficit. Many studies have investigated the treatment and prevention of burn scar contracture, but few studies have focused on the methods for measuring contracture. The purpose of this study was to determine whether consistent and objective methods of measurement are used to quantify scar contracture in the clinical evaluation of burn patients and in burn research. A survey was administered to 407 burn therapists to determine the methods and tools used clinically to measure scar contracture, while a review of recent burn literature was conducted to determine the methods and tools used in burn research. The results of the survey indicate that there is a lack of consensus in the methods and tools used for the measurement of scar contracture, both clinically and in research. Instead, a variety of measurement methods was reported, each with varying degrees of objectivity. Clinically, the methods are rarely checked for reliability or performance competency. In burn research, the methods and tools vary, and contracture data obtained are often reported in an inconsistent manner. If the measurement of scar contracture is not done objectively and consistently, then it is difficult to determine reliability, validity, and responsiveness of the measurement methods. Development of standard protocols with reliable measures of scar contracture would improve the quality of burn care and research.

Richard, R. (1999). "Assessment and diagnosis of burn wounds." Adv Wound Care 12(9): 468-471.

Richard, R. (2014). "Burn therapist contributions to the American Burn Association and the Journal of Burn Care and Research: a 45th anniversary review." J Burn Care Res 35(6): 465-469.

The year 2013 marked the 45th anniversary of American Burn Association (ABA) annual meetings. At this significant juncture, a review of contributions of its members is appropriate to celebrate this milestone. Since the first ABA annual meeting and the initiation of the Journal of Burn Care and Research (JBCR), burn therapists, including both occupational and physical therapists, have grown to become integral members of the ABA, and their contributions among all members are highlighted. A systematic manual review of both ABA annual meeting proceedings and the JBCR was performed. The contributions of burn therapists to the ABA as a whole were classified, cataloged, and hand counted. Areas included: 1) quantifying ABA abstract and JBCR articles on authorship and subject matter, 2) representation on ABA committees; 3) participation in special activities; and 4) other recognitions. Burn therapists comprise 9.7% of ABA 66 members overall. During the course of the first 44 ABA meetings, 8381 abstracts have been presented. Of this number, 634 (7.6%) have been delivered by burn therapists as lead authors. Through the end of 2011, no less than 3207 publications by all disciplines have appeared in JBCR. The vast majority of articles have been written by physicians, followed by doctorate-trained professionals. One hundred-forty therapists have 249 publications (7.8%) to their credit. For both abstracts and articles, the top three subject matter topics have been: scarring, splints and casts, and outcomes. Numerous burn therapists have served as faculty and moderators at ABA annual meetings and on ABA committees including JBCR. Burn therapists have made significant contributions to the JBCR and in support of the ABA and its annual meetings over the past 45 years from the clinical, scientific, and Association perspectives.

Richard, R., et al. (2009). "Burn rehabilitation and research: proceedings of a consensus summit." J Burn Care Res 30(4): 543-573.

Burn rehabilitation is an essential component of successful patient care. In May 2008, a group of burn rehabilitation clinicians met to discuss the status and future needs of burn rehabilitation. Fifteen topic areas pertinent to clinical burn rehabilitation were addressed. Consensus positions and suggested future research directions regarding the physical aspects of burn rehabilitation are shared.

Richard, R., et al. (2008). "Burns." Burns 34(2): 295-296.

Richard, R. and R. M. Johnson (2002). "Managing superficial burn wounds." Adv Skin Wound Care 15(5): 246-247.

Richard, R., et al. (2015). "Hierarchical decomposition of burn body diagram based on cutaneous functional units and its utility." J Burn Care Res 36(1): 33-43.

A burn body diagram (BBD) is a common feature used in the delivery of burn care for estimating the TBSA burn as well as calculating fluid resuscitation and nutritional requirements, wound healing, and rehabilitation intervention. However, little change has occurred for over seven decades in the configuration of the BBD. The purpose of this project was to develop a computerized model using hierarchical decomposition (HD) to more precisely determine the percentage burn within a BBD based on cutaneous functional units (CFUs). HD is a process by which a system is degraded into smaller parts that are more precise in their use. CFUs were previously identified fields of the skin involved in the range of motion. A standard Lund/Browder (LB) BBD template was used as the starting point to apply the CFU segments. LB body divisions were parceled down into smaller body area divisions through a HD process based on the CFU concept. A numerical pattern schema was used to label the various segments in a cephalo/caudal, anterior/posterior, medial/lateral manner. Hand/fingers were divided based on anatomical landmarks and known cutaneokinematic function. The face was considered using aesthetic units. Computer code was written to apply the numeric hierarchical schema to CFUs and applied within the context of the surface area graphic evaluation BBD program. Each segmented CFU was coded to express 100% of itself. The CFU/HD 67 method refined the standard LB diagram from 13 body segments and 33 subdivisions into 182 isolated CFUs. Associated CFUs were reconstituted into 219 various surface area combinations totaling 401 possible surface segments. The CFU/HD schema of the body surface mapping is applicable to measuring and calculating percent wound healing in a more precise manner. It eliminates subjective assessment of the percentage wound healing and the need for additional devices such as planimetry. The development of CFU/HD body mapping schema has rendered a technologically advanced system to depict body burns. The process has led to a more precise estimation of the segmented body areas while preserving the overall TBSA information. Clinical application to date has demonstrated its worthwhile utility.

Richard, R., et al. (2000). "Multimodal versus progressive treatment techniques to correct burn scar contractures." J Burn Care Rehabil 21(6): 506-512.

The treatment of burn scar contractures is a major emphasis in the rehabilitation of patients with burn injuries. Many treatment techniques have been used successfully but without a critical investigation of the best practice of care. In this study, we compared the outcomes for pediatric and adult patients treated with a multimodal therapy approach to treatment techniques that are considered to be progressive to determine if differences existed in the techniques. The medical records of 52 patients with documented burn scar contractures were reviewed for patient and rehabilitation treatment parameters. Included were population demographic information and type of treatment intervention used to correct the scar contracture. In particular, the postburn day when the contracture appeared, the percentage of range of motion deficit, the day when definitive treatment that eventually corrected the contracture was begun, and the days required to correct the contracture were noted. With equal range-of-motion deficits identified, the burn scar contractures of patients in the progressive treatment group were corrected in less than half the time of the burn scar contractures of the patients in the multimodal treatment group. This result occurred despite scar contractures that appeared significantly earlier and later initiation of definitive treatment.

Richard, R., et al. (2017). "Burn Hand or Finger Goniometric Measurements: Sum of the Isolated Parts and the Composite Whole." J Burn Care Res 38(6): e960-e965.

Accurate assessment of hand function following a burn is important for patient impairment determination. Goniometric measurement of hand or finger range of motion (ROM) is typically done measuring individual finger joints with the adjacent joint in extension (isolated) or measuring the joints in a fist position (composite). The purpose of this study was to compare if the total flexion motion of the summed angles of the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints in burned hands were equal when performed in an isolated vs a composite manner. Passive flexion ROM angles were collected prospectively and measured at the 68 metacarpophalangeal, proximal interphalangeal, and distal interphalangeal with the adjacent joints extended to measure isolated angles and with the adjacent joints fully flexed for composite angles. Thumb joints were excluded. ROM for isolated and composite positions of eight fingers was compared individually and as an aggregate. Finger measurements from 145 adult patients were compared. The study population was predominately male (69%) with a mean age of 41 +/- 16.6 years. Mean total burn size was 14.2 +/- 13.2%. A total of 739 fingers contributed 2217 joint ROM comparisons. Aggregate analysis of isolated ROM was 235.5 degrees +/- 52.1 degrees compared with composite ROM of 226.8 degrees +/- 53.2 degrees (P < .0001). Individual fingers showed significant differences between the two measurement methods as well (P

Richard, R. and A. R. Santos-Lozada (2017). "Burn Patient Acuity Demographics, Scar Contractures, and Rehabilitation Treatment Time Related to Patient Outcomes: The ACT Study." J Burn Care Res 38(4): 230-242.

In 2008, the U.S. Department of Defense funded a rehabilitation study through the American Burn Association titled "Burn patient acuity demographics, scar contractures, and rehabilitation treatment time related to patient outcomes," commonly known at the ACT study. The ACT was a multi-institutional, prospective, observational, and quasirandomized investigation of the acute hospital course of 307 patients. The ACT specifically emphasized the capture of factors that may impact the physical outcome of patients with burn injury including burn severity, daily rehabilitation interventions such as mobility and splinting, and detailed skin grafting episodes. In particular, the effect that the amount of daily rehabilitation time patients received as it related to range of motion measured at the time of acute hospital discharge of areas affected by the burn injury was analyzed. The information contained herein is intended to give the interested reader an overview of the extent and breadth of the ACT dataset in terms of parameters available for further investigation. This information is also intended to be used as a basic reference for conduct of the ACT study in future reports.

In 2008, the U.S. Department of Defense funded a rehabilitation study through the American Burn Association titled "Burn patient acuity demographics, scar contractures, and rehabilitation treatment time related to patient outcomes," commonly known at the ACT study. The ACT was a multi-institutional, prospective, observational, and quasirandomized investigation of the acute hospital course of 307 patients. The ACT specifically emphasized the capture of factors that may impact the physical outcome of patients with burn injury including burn severity, daily rehabilitation interventions such as mobility and splinting, and detailed skin grafting episodes. In particular, the effect that 69 the amount of daily rehabilitation time patients received as it related to range of motion measured at the time of acute hospital discharge of areas affected by the burn injury was analyzed. The information contained herein is intended to give the interested reader an overview of the extent and breadth of the ACT dataset in terms of parameters available for further investigation. This information is also intended to be used as a basic reference for conduct of the ACT study in future reports.

Richard, R., et al. (2017). "Profile of Patients Without Burn Scar Contracture Development." J Burn Care Res 38(1): e62-e69.

Burn scar contractures (BSCs) are a frequently recognized problem for survivors of burn injury. In the burn literature, many reports focus on the frequency and factors associated with the BSC development. To the contrary, few burn rehabilitation publications report on patients who are able to successfully avoid developing BSC. From a prospective, multicenter study, data were extracted and reviewed on a group of 56 adult burn survivors who were discharged from their acute hospitalization without any measured BSCs. Forty-three variables with a recognized or presumed association with the development of BSCs were analyzed and are reported. Highlighted features of the noncontracted group included being an adult male with an educated background and few associated physical, medical, or social problems. The group had relatively small burn sizes that nonetheless required hospitalization. Despite the overall TBSA, the majority of the burn areas required skin grafting, although this area also represented a small area. The patient group had a longer than expected hospital stay. Rehabilitation was provided to patients on 80% of their hospital days. In addition, patients received sufficient rehabilitation treatment based on the number of cutaneous functional units involved in the burn injury. Patients were judged to have a high pain tolerance and compliant with rehabilitation. The results of this study document the clinical circumstances that patients with burn injury can be discharged from their acute hospitalization with the development of BSC. This study challenges the rehabilitation personnel to expand the upper limit of burn severity that can result in similar positive outcomes.

Richard, R., et al. (1994). "Hand burn splint fabrication: correction for bandage thickness." J Burn Care Rehabil 15(4): 369-371.

Richard, R., et al. (1994). "The wide variety of designs for dorsal hand burn splints." J Burn Care Rehabil 15(3): 275-280.

A search of the burn literature to find standard dimensions for fabrication of a typical splint to use with patients with a dorsal hand and finger burn is an elusive endeavor. The original impetus for such a search stemmed from a discussion with a student therapist on how to properly splint a burned hand. An ongoing interest was sustained when no one set of universal dimensions for a hand splint design was found to exist. In fact, the literature is replete with numerous individual recommendations on the dimensions to make such a hand splint. In general, dorsal hand burn splints can be classified either as position of function or antideformity splints. However, there is little agreement among authors about how to make these splints. The purpose of this investigation was to document the wide 70 range and variable designs among splints for dorsal hand burns and present the findings for use as a resource guide when making decisions about their fabrication.

Richard, R., et al. (1996). "Mathematic model to estimate change in burn scar length required for joint range of motion." J Burn Care Rehabil 17(5): 436-443; discussion 435.

Burn scar contracture results from an insufficient amount of extensible tissue to permit complete range of motion. The purpose of this study was to develop a mathematic model to estimate additional tissue length required for full range of motion in the presence of a scar contracture. Seven areas with a known predilection for burn scar contracture were assessed. Twenty-five volunteers with normal range of motion had the length of their limbs measured at predetermined angles. Changes in limb length through range of motion were documented. On the basis of these changes, a mathematic model was developed to estimate the additional amount of tissue length required to complete range of motion for each area. This information may be useful to determine burn patient rehabilitation potential or need for reconstructive surgery.

Richard, R. L. (1986). "Use of the Dynasplint to correct elbow flexion burn contracture: a case report." J Burn Care Rehabil 7(2): 151-152.

Richard, R. L. (2005). "Documenting changes in burn scars over time." J Burn Care Rehabil 26(3): 272.

Richard, R. L., et al. (2008). "A clarion to recommit and reaffirm burn rehabilitation." J Burn Care Res 29(3): 425-432.

Burn rehabilitation has been a part of burn care and treatment for many years. Yet, despite of its longevity, the rehabilitation outcome of patients with severe burns is less than optimal and appears to have leveled off. Patient survival from burn injury is at an all-time high. Burn rehabilitation must progress to the point where physical outcomes parallel survival statistics in terms of improved patient well-being. This position article is a treatise on burn rehabilitation and the state of burn rehabilitation patient outcomes. It describes burn rehabilitation interventions in brief and why a need is felt to bring this issue to the forefront. The article discusses areas for change and the challenges facing burn rehabilitation. Finally, the relegation and acceptance of this responsibility are addressed.

Richard, R. L., et al. (2009). "Identification of cutaneous functional units related to burn scar contracture development." J Burn Care Res 30(4): 625-631.

The development of burn scar contractures is due in part to the replacement of naturally pliable skin with an inadequate quantity and quality of extensible scar tissue. Predilected skin surface areas associated with limb range of motion (ROM) have a tendency to develop burn scar contractures that prevent full joint ROM leading to deformity, impairment, and disability. Previous study has documented forearm skin movement associated with wrist extension. The purpose of this study was to expand the 71 identification of skin movement associated with ROM to all joint surface areas that have a tendency to develop burn scar contractures. Twenty male subjects without burns had anthropometric measurements recorded and skin marks placed on their torsos and dominant extremities. Each subject performed ranges of motion of nine common burn scar contracture sites with the markers photographed at the beginning and end of motion. The area of skin movement associated with joint ROM was recorded, normalized, and quantified as a percentage of total area. On average, subjects recruited 83% of available skin from a prescribed area to complete movement across all joints of interest (range, 18- 100%). Recruitment of skin during wrist flexion demonstrated the greatest amount of variability between subjects, whereas recruitment of skin during knee extension demonstrated the most consistency. No association of skin movement was found related to percent body fat or body mass index. Skin recruitment was positively correlated with joint ROM. Fields of skin associated with normal ROM were identified and subsequently labeled as cutaneous functional units. The amount of skin involved in joint movement extended far beyond the immediate proximity of the joint skin creases themselves. This information may impact the design of rehabilitation programs for patients with severe burns.

Ryan, C. M., et al. (2017). "Functional Outcomes Following Burn Injury." J Burn Care Res 38(3): e614-e617.

Major advances in functional recovery following burn injury over the last ten years include the development of conceptual framework for disability assessment and its application burn recovery, the description of the long-term outcomes in the burn population, and progress in basic science research leading to new treatments that improve long-term functional outcomes. Future tasks and challenges include the development of common data elements and standards for burn recovery in order to measure and optimize the path toward functional recovery. The development of patient-reported outcome measures with benchmarks for recovery over time has the potential to improve patient- provider communication and quality of patient-centered care. The study of burn recovery should include an examination of resiliency along with the study of disabilities following burn injury. Better understanding of the mechanisms, impact and modulation of hypermetabolism and inflammation following burn injury is essential to improve functional recovery. Continued basic science and clinical research must focus on scar modulation and skin replacements and address recalcitriant problems such as heterotopic ossification. Health tracking technologies should be leveraged to understand and optimize physical therapy interventions.

Schneider, J. C., et al. (2006). "Contractures in burn injury: defining the problem." J Burn Care Res 27(4): 508-514.

This study prospectively examined the incidence and severity of large joint contractures after burn injury and determined predictors of contracture development. Data were collected prospectively from 1993 to 2002 for consecutive adult burn survivors admitted to a regional burn center. Demographic and medical data were collected on each subject. The primary outcome measures included the presence of contractures, number of 72 contractures per patient, and severity of contractures at each of four joints (shoulder, elbow, hip, knee) at time of hospital discharge. Logistic regression analysis was performed to determine predictors of the presence and severity of contractures and a negative binomial regression was performed to determine predictors of the number of contractures. Of the 985 study patients, 381 (38.7%) developed at least one contracture at hospital discharge. Among those with at least one contracture, the mean is three contractures per person. The shoulder was the most frequently contracted joint (38%), followed by the elbow (34%) and knee (22%). Most contractures were mild (60%) or moderate (32%) in severity. Statistically significant predictors of contracture development were length of stay (P < .005) and extent of burn (P = .033) and graft (P < .005). Predictors of the severity of contracture include graft size (P < .005), amputation (P = .034), and inhalation injury (P = .036). More than one third of the patients with a major burn injury developed a contracture at hospital discharge, which highlights the importance of therapeutic positioning and intensive therapy intervention during acute hospitalization. Furthermore, this challenges the burn care community to find new and better ways of preventing contractures after burn injury.

Schneider, J. C., et al. (2008). "Contractures in burn injury part II: investigating joints of the hand." J Burn Care Res 29(4): 606-613.

This study prospectively examines the incidence and severity of hand contractures after burn injury and determines predictors of contracture development. Data were collected prospectively from 1993 to 2002 for adult burn survivors admitted to a regional burn center. Demographic and medical data were collected on each subject. Primary outcome measures include presence of contractures, number of contractures, and the severity of contractures at each of the hand joints at hospital discharge. The metacarpal-phalangeal, proximal inter-phalangeal (PIP), and distal inter-phalangeal joints of all digits and the wrist joints are included in this study. Regression analysis was performed to determine predictors of the presence, severity, and number of contractures. Of the 985 study patients, 23% demonstrated at least one hand contracture at hospital discharge. Those with a contracture averaged ten contractures per person. Most contractures were mild (48%) or moderate (41%) in severity. The wrist was the most frequently affected joint (22%). Statistically significant predictors of contracture development include concomitant medical problems, total body surface area grafted and presence of hand burn and hand grafting (P < .05). Predictors of the number of contractures include length of stay, concomitant medical problems, burn size and presence of hand burn and grafting (P < .05). Contractures of the hand are a significant complication of burn injury. Clinicians can use the contracture predictors to help target interventions for those patients most at risk of developing hand contractures. Given the functional importance of the hand in daily living, the burn care community is challenged to find new ways of preventing and treating hand contractures.

Serghiou, M. A., et al. (2016). "Clinical practice recommendations for positioning of the burn patient." Burns 42(2): 267-275. 73

The objective of this review was to systematically examine whether there is clinical evidence to support recommendations for positioning patients with acute burn. Review of the literature revealed minimal evidence-based practice regarding the positioning of burn patients in the acute and intermediate phases of recovery. This manuscript describes recommendations based on the limited evidence found in the literature as well as the expert opinion of burn rehabilitation specialists. These positioning recommendations are designed to guide those rehabilitation professionals who treat burn survivors during their acute hospitalization and are intended to assist in the understanding and development of effective positioning regimens.

Staley, M. and R. Richard (1997). "Management of the acute burn wound: an overview." Adv Wound Care 10(2): 39-44.

Goals for managing an acute burn wound are similar to those of other wounds such that infection and scar formation are minimized, a moist wound environment is provided, and the surrounding tissue is protected from trauma. A variety of cleansing techniques are used with burn wounds, including local wound care and nonsubmersion and immersion hydrotherapy. Topical agents have significantly decreased the development of burn wound sepsis since the 1960s, and now various experimental agents are being investigated to improve wound healing. The choice of dressings depends on many patient and wound-related factors, and synthetic, biologic, and biosynthetic dressings are used to treat the different depths of burn wounds. However, skin grafts and the newer cultured skin substitutes remain the mainstay for healing a full-thickness burn wound.

Staley, M., et al. (1996). "Functional outcomes for the patient with burn injuries." J Burn Care Rehabil 17(4): 362-368.

In health care, outcome measures have become important tools to assist with monitoring the efficacy of therapeutic interventions. This article defines functional outcomes and describes why therapists should begin monitoring the care of patients with burn injuries in terms of function. Suggestions are provided on the identification and documentation of functional outcomes for patients with burn injuries.

Staley, M. J. and R. L. Richard (1997). "Use of pressure to treat hypertrophic burn scars." Adv Wound Care 10(3): 44-46.

Pressure has been used since the early 1970s by burn care provides to help minimize the formation of hypertrophic scars. Although the exact mechanism of action is unknown, pressure appears clinically to enhance the scar maturation process. Bandages that can be wrapped and unwrapped or are made of a soft material are used in early scar management. Custom-made pressure garments generally are used for definitive scar management. Inserts are placed in concavities to aid in compression. Whatever intervention is used for scar management, patient and family should be educated about the realistic, potential outcome. 74

Young, A. W., et al. (2019). "Rehabilitation of Burn Injuries: An Update." Phys Med Rehabil Clin N Am 30(1): 111-132.

A major burn is a severe injury with a global impact. Our system of medical evacuation has led to the survival of many severely injured service members. Burn rehabilitation is a complex and dynamic process and will not be linear. Recovery requires a comprehensive, interdisciplinary team-based approach, individually designed to maximize function, minimize disability, promote self-acceptance, and facilitate survivor and family reintegration into the community.

Mohammadi, A. A. and A. Bakhshaeekia (2011) "Suture fixation of the fingers": an effective method for positioning burned and contracted fingers using a pulley system as a guide." Burns 37(2): 351-3. Preserving function of the hand is the aim of treatment in burned hands; appropriate splinting is one of the important measures during acute and chronic treatment. We introduce an effective safe method for positioning of fingers without violating the joints; In this method before performing skin graft for palmar finger burn or contracture release we suture tip of finger with silk 2-0 and fix it to dorsum of hand while extending the finger and for preventing slipping we insert some pulley like circles tied with silk 2-0 fixing over dorsum of mid phalanx.

Hwang, Y. F., M. J. Chen-Sea, et al. (2009). "Factors Related to Return to Work and Job Modification After a Hand Burn." J Burn Care Res. Occupational therapy aims to help patients resume their occupations. Therefore, we must know their work status after our intervention. We collected demographic and burn-related data from patient charts and analyzed it to determine the work status of former patients with burned hands and what influenced their returning to work. From 284 former patients with burns, we screened 159 with burned hands, 108 of whom were interviewed through the telephone about their work status. We used logistic regression analysis to analyze factors for having work, returning to work, the length of time required to return to work, and job modifications. We found that 1) having preburn employment increased the likelihood of having postburn employment; 2) being the primary wage earner in a family increased the likelihood of having work and of a return to work postburn; 3) a stay in the hospital, and burn injuries on both hands and trunk increased the time required to return to work; and 4) being older and having a smaller percentage of total body burn area decreased the likelihood of returning to a job modified because of a burn injury. Returning to work was affected not only by general demographic and employment factors but also by burn-related factors. We urge occupational therapy departments to include a return-to-work program in their routine services to improve the chances of patients with hand burns to return to work. We strongly recommend that a multicenter prospective study of hand-burn injuries should be performed.

Ripper, S., B. Renneberg, et al. (2009). "Adherence to pressure garment therapy in adult burn patients." Burns 35(5): 657-64. 75

Pressure garment therapy (PGT) is a generally accepted procedure to prevent hypertrophic scarring after severe burns. Wearing pressure garments is uncomfortable and challenging for the patient and, consequently adherence is low. In order to improve adherence, precise knowledge about the advantages and disadvantages of PGT is necessary. In this study we investigated specific aspects which inhibit or reinforce the application of PGT on the patients' part. Twenty-one patients participated in a semi- structured interview concerning their experiences with PGT. The complaints most frequently mentioned were 'physical and functional limitations' caused by the garments, 'additional effort' created by the need to care for garments and 'perceived deficiencies' of the treatment. At the same time, most of the patients reported coping strategies used to persevere with the therapy. Coping can be categorised into 'behavioural' and 'cognitive coping strategies'. Besides the 'expectation of success', 'emotional' as well as 'practical support' and experiencing 'good outcome' were motivating factors for the patients. Based on the analyses of limitations and resources, recommendations for future interventions enhancing adherence are outlined.

Anzarut, A., J. Olson, et al. (2009). "The effectiveness of pressure garment therapy for the prevention of abnormal scarring after burn injury: a meta-analysis." J Plast Reconstr Aesthet Surg 62(1): 77-84. OBJECTIVES: This study had three objectives. First, to conduct a systematic review to identify the available evidence for the use of pressure garment therapy (PGT); second, to assess the quality of the available evidence; and third, to conduct a meta- analysis to quantify the effectiveness of PGT for the prevention of abnormal scarring after burn injury. BACKGROUND: Standard care for the prevention of abnormal scarring after burn injury includes pressure garment therapy (PGT); however, it is associated with potential patient morbidity and high costs. We hypothesise that an assessment of the available evidence supporting the use of pressure garment therapy will aid in directing clinical care and future research. METHODS: Randomised control trials were identified from CINHAL, EMBASE, MEDLINE, CENTRAL, the 'grey literature' and hand searching of the Proceedings of the American Burn Association. Primary authors and pressure garment manufacturers were contacted to identify eligible trials. Bibliographies from included studies and reviews were searched. Study results were pooled to yield weighted mean differences or standardised mean difference and reported using 95% confidence intervals. RESULTS: The review incorporated six unique trials involving 316 patients. Original data from one unpublished trial were included. Overall, studies were considered to be of high methodological quality. The meta-analysis was unable to demonstrate a difference between global assessments of PGT-treated scars and control scars [weighted mean differences (WMD): -0.46; 95% confidence interval (CI): - 1.07 to 0.16]. The meta-analysis for scar height showed a small, but statistically significant, decrease in height for the PGT-treated group standardised mean differences (SMD): -0.31; 95% CI: -0.63, 0.00. Results of meta-analyses of secondary outcome measures of scar vascularity, pliability and colour failed to demonstrate a difference between groups. CONCLUSIONS: PGT does not appear to alter global scar scores. It does appear to improve scar height, although this difference is small and of questionable clinical importance. The beneficial effects of PGT remain unproven, while the potential 76 morbidity and cost are not insignificant. Given current evidence, additional research is required to examine the effectiveness, risks and costs of PGT.

Ansell, B. M., J. G. Williams, et al. (1972). “Farnham Park modular splint system.” Rheumatol Phys Med 11(7): 334-6.

Bach, J., B. Draslov, et al. (1984). “Positioning, splinting and pressure management of the burned hand: a method.” Scand J Plast Reconstr Surg 18(1): 145-7. A splinting procedure to avoid hand and finger deformities in deep dermal and subdermal burns of the hand is presented. The same splint may be used in the healing phase as well as in the rehabilitation period. The method is characterized by a combination of simple materials, active exercises and a teamwork involving the patient and the staff.

Barillo, D. J., K. D. Harvey, et al. (1997). “Prospective outcome analysis of a protocol for the surgical and rehabilitative management of burns to the hands.” Plast Reconstr Surg 100(6): 1442-51. Treatment protocols for the management of burned hands are essential for integrating team efforts and achieving optimal functional results. Standard protocols are especially useful during mass casualty incidents, when the admission of multiple patients with large burns and/or associated injuries may reduce the priority usually accorded the hands. We prospectively evaluated a surgical and rehabilitative treatment protocol for burned hands during a mass casualty incident, after which 43 burn patients with 82 burned hands were admitted to one burn center. Soft-tissue management was individualized to achieve, if possible, wound closure within 14 days, and included the use of topical antimicrobials, cutaneous debridement and/or tangential excision, biologic dressings, and split-thickness autografts. Range of motion therapy was based on daily measurement of active motion of the metacarpophalangealjoints. Static splinting alternating with continuous passive motion every 4 hours was utilized for sedated patients. Continuous passive motion alternating with active ranging and night splinting was utilized for metacarpophalangeal flexion or =70 degrees. Sixty-four hands required excision and grafting, with 89 percent having at least one autografting procedure completed by postburn day 16. Total active motion of the hands treated averaged 220.6 degrees on discharge and 229.9 degrees at 3 months after injury. Mean hand grip strength was 60.8 pounds at discharge and 66.0 pounds at 3 months after injury. Adherence to a standard hand burn protocol resulted in timely wound coverage and recovery of hand function for a large group of patients treated at a single burn facility after a mass casualty incident.

Boswick, J. A., Jr. (1974). “Rehabilitation of the burned hand.” Clin Orthop 0(104): 162- 74.

Boswick, J. A., Jr. (1983). “Rehabilitation after burn injury.” Ann Acad Med Singapore 12(3): 443-8. 77

Optimal rehabilitation of patients after burn injury requires the organised application of sound, recognised principles. The basic concerns are the prevention of loss of joint motion, loss of muscle mass, and the prevention of anatomical deformities. Important considerations are starting the rehabilitative programme as early as possible after injury and avoiding techniques which unduly immobilise the patient or parts of the body. The use of early active motion to the patient and all movable joints, along with appropriate positioning while at rest, is crucial to a successful programme. Passive exercising along with the use of restraints and splints are necessary in certain patients.

Buchan, N. G. (1975). “Experience with thermoplastic splints in the post-burn hand.” Br J Plast Surg 28(3): 8193-7.

Cheng, J. C. (1991). “Dynamic pressure therapy for scars in the finger web spaces.” J Hand Surg [Am] 16(1): 176-7.

Coenen, L. (1984). “A new splint for the functional immobilization of the burned hand.” Plast Reconstr Surg 73(2): 330.

Covey, M. H., K. Dutcher, et al. (1987). “Return of hand function following major burns.” J Burn Care Rehabil 8(3): 224-6.

Covey, M. H., K. Dutcher, et al. (1988). “Efficacy of continuous passive motion (CPM) devices with hand burns.” J Burn Care Rehabil 9(4): 397-400. Ten patients with bilateral (deep second-degree and/or third-degree) hand burns requiring excision and grafting were included in a prospective randomized study to evaluate the efficacy of continuous passive motion (CPM) with burned hands. The purpose of the study was to evaluate: 1) if CPM is a useful alternative to supervised OT/PT for burned hands; 2) which patient populations benefit from CPM intervention; 3) if CPM use has deleterious effects on new grafts; and 4) what effect CPM has on hand pain. Eight hands in the control group and eight hands in the experimental group regained normal total active motion (TAMs) in an average of nine days (range three to 22 days). Two hands with tendon involvement in each group remained impaired at discharge. No patients suffered graft loss attributable to range of motion. Both groups reported only minimal pain during exercise.

Fishwick, G. M. and D. G. Tobin (1978). “Splinting the burned hand with primary excision and early grafting.” Am J Occup Ther 32(3): 182-3.

Helm, P. A., M. D. Head, et al. (1978). “Burn rehabilitation-a team approach.” Surg Clin North Am 58(6): 1263-78. The team concept in the treatment of burned patients is an effective approach in caring for the physical, psychological, and social needs of the patient. Through the initiation of early rehabilitation services, long-term problems can be prevented and a quicker return to a meaningful life style is possible.

Helm, P. A., S. C. Walker, et al. (1986). “Return to work following hand burns.” Arch Phys Med Rehabil 67(5): 297-8. Time to return to work following hand burns was studied in 70 patients in relation to several variables: 1. total body surface area (TBSA) burned; 2. hand burned; 3. grafting; 4. patient age; 5. occupational category. Return to work data were also compared by meta-analysis to data in prior reports on return to work in nonburn hand injuries. Patients were evaluated during their hospital stay on all independent variables, and at 8 months following discharge as to the date of return to work. Of the 70 patients selected for the study, 52 (74%) had returned to work at the 8-month assessment. The best predictor of time to return to work was TBSA burned, followed by "grafting" and "hand burned." No significant differences or predictors were found for patient age, occupational category, or between nonburn hand trauma patients in prior reports. Conclusions are drawn concerning the usefulness of these results in terms of case management and economic impact in hand-burn injuries.

Johnson, C. J. and W. P. Graham, 3rd (1969). “Use of thermoplastic splints in the treatment of burned hands.” Plast Reconstr Surg 44(4): 399-400.

Kealey, G. P. and K. T. Jensen (1988). “Aggressive approach to physical therapy management of the burned hand. A clinical report.” Phys Ther 68(5): 683-5. Hand burn care requires physical therapy involvement from the earliest stage of wound management. Hand burns may cause loss of sensation, decreased range of motion, loss of tissue and digits, or a combination of these conditions. The initial evaluation must include careful analysis of the extent and depth of the hand burn and concomitant injuries. Proper-positioning splints and active and passive range-of- motion exercises are vital to the preservation and restoration of function of the burned hand. This clinical report describes an aggressive physical therapy hand burn management program that is initiated early in patient care and continued throughout patient hospitalization and outpatient follow-up.

Koepke, G. H. (1970). “The role of physical medicine in the treatment of burns.” Surg Clin North Am 50(6): 1385-99.

Lavore, J. S. and J. H. Marshall (1972). “Expedient splinting of the burned patient.” Phys Ther 52(10): 1036-42.

Le Coultre, C. and A. Graber (1985). “The use of plastic face mask and silicone gloves and boots as alternative to compression suits for treating hypertrophic scars.” Z Kinderchir 40(4): 221-3. Prevention and treatment of hypertrophic scars and contractures is usually obtained by the use of compression suits. The compression hood for the burned face is unaesthetical and often refused by the child. A better compression can be obtained by the use of a clear transparent plastic mask. It offers a better view and looks better, thus increasing the cooperation of the patient. Compression gloves and stockings are difficult to adapt to. It is easier to make mittens and boots out of silicone. These two techniques 79 meet the criteria of efficiency: early application of compression, good tolerance, splint support, individually moulded splints for optimum pressure and cooperation.

Leman, C. J. (1992). “Splints and accessories following burn reconstruction.” Clin Plast Surg 19(3): 721-31. Splints, exercise, traction, and compression garments are commonly accepted methods to minimize disabling scar formation. Although burn rehabilitation treatment has improved over the past 10 years, there is still no overnight cure for scars and contracture. The extent and depth of the burn injury, emotional strength and patience of the burn victim, and support systems available play an important role in scar treatment. Scar contracture is a frustrating complication for the recovering patient and burn team. Surgical reconstruction to correct functional impairment is often needed before wound maturation is complete. Splints are usually part of the postoperative treatment plan. When this is the case, patient understanding, compliance, motivation, and comfort are important to assure splint effectiveness. The treatments reviewed are specific for scar contracture limiting function of the upper body. Although they were presented as treatment of neck, mouth, axilla, and hand contractures, many of the principles and materials can be used after burn reconstruction of the lower extremities. Regardless of the area treated, assessment of patients is important to determine their specific needs in splint design.

Malick, M. H. and J. A. Carr (1980). “Flexible elastomer molds in burn scar control.” Am J Occup Ther 34(9): 603-8. Burn scar hypertrophies and contractures have responded well to pressure techniques with pressure gradient burn garments except over soft tissue areas and concave body areas such as the axilla, hand, clavicle, neck, and face. Although these areas represent only 20 percent of the body area, when scarred from burns they pose perplexing functional and esthetic problems. Rigid splints and face masks have been used but their rigidity makes them uncomfortable for long-term wear. Silastic Medical Elastomer molds have proved highly successful in these areas when worn under pressure garments. They are flexible and of definite shape. The elastomer molds fill the concave gapping so that consistent definitive pressure can be maintained and scar hypertrophies prevented.

Miller, J., S. B. Hardy, et al. (1967). “Silicone in the treatment of burns of the hand.” J Occup Med 9(4): 183-4.

Ngim, R. C., S. T. Lee, et al. (1983). “Rehabilitation of burns of the upper limb.” Ann Acad Med Singapore 12(3): 350-7. The authors wish to document the experience of the Burns Unit, Singapore General Hospital in the management of burns of the upper limb. Fifty-six patients with post-burn deformity of the upper limb seen during a five year period (July 1978-July 1983) were reviewed. The cases were analysed and there were no significant differences in age, sex and race distribution. There were 8 axillary contractures, 9 elbow contractures, 10 wrist deformities and 56 hand deformities. Anterior axillary skin fold contracture was the commonest deformity occurring at the shoulder, whilst cubital contractures were mainly found on the lateral aspect of the elbow. The elbow was the 80 commonest site for periarticular heterotopic calcification. Wrist deformities included hypertrophic scars and contractures and they were frequently found on the dorsum of the wrist. A classification of post-burn hand deformity has been described and this was based on the site of the original injury. Burns involving the dorsum of the hand/fingers were subclassified into two groups depending on whether the extensor tendon was involved. The prognosis was good when there was no tendon injury, but when the extensor tendons were involved, poorer hand function resulted and this was reflected by the number of secondary operative procedures required. Flexion contractures were the commonest deformity found on volar burns. When both surfaces were burned the prognosis depended upon the burns depth. Digital burns treated surgically had fewer residual contractures. The role of occupational therapy, scar control, splinting and secondary surgery in relation to the rehabilitation of the burned upper limb is discussed in some detail.(ABSTRACT TRUNCATED AT 250 WORDS)

Parry, C. B. (1970). “Problems in rehabilitation of the burnt hand.” Hand 2(2): 140-4.

Puddicombe, B. E. and M. A. Nardone (1990). “Rehabilitation of the burned hand.” Hand Clin 6(2): 281-92. This paper presents a comprehensive overview of the rehabilitation and management of hand burns. The therapist, as an integral member of the burn team, significantly contributes to the successful outcome of this treatment.

Richard, R., S. Schall, et al. (1994). “Hand burn splint fabrication: correction for bandage thickness.” J Burn Care Rehabil 15(4): 369-71.

Richard, R., M. Staley, et al. (1994). “The wide variety of designs for dorsal hand burn splints.” J Burn Care Rehabil 15(3): 275-80. A search of the burn literature to find standard dimensions for fabrication of a typical splint to use with patients with a dorsal hand and finger burn is an elusive endeavor. The original impetus for such a search stemmed from a discussion with a student therapist on how to properly splint a burned hand. An ongoing interest was sustained when no one set of universal dimensions for a hand splint design was found to exist. In fact, the literature is replete with numerous individual recommendations on the dimensions to make such a hand splint. In general, dorsal hand burn splints can be classified either as position of function or antideformity splints. However, there is little agreement among authors about how to make these splints. The purpose of this investigation was to document the wide range and variable designs among splints for dorsal hand burns and present the findings for use as a resource guide when making decisions about their fabrication.

Salisbury, R. E. and L. Palm (1973). “Dynamic splinting for dorsal burns of the hand.” Plast Reconstr Surg 51(2): 226-8.

Tanigawa, M. C., O. K. O'Donnell, et al. (1974). “The burned hand: a physical therapy protocol.” Phys Ther 54(9): 953-8.

Tilley, W., S. McMahon, et al. (2000). “Rehabilitation of the burned upper extremity.” Hand Clin 16(2): 303-18. With the advancement in medical technology and more effective life- sustaining measures, the rehabilitation therapist is faced with the immense task of effectively restoring functional ROM, strength, and mobility and producing a cosmetic result acceptable to the patient. Rehabilitation therapists have a very significant role to play in achieving these goals. The patients and their families come to rely very heavily on the therapists for advice, support, and information both in the acute phase of burn management and, potentially, for years to follow. A concerted team approach is necessary for a satisfactory functional outcome following burn injury. van Straten, O. (1986). “The use of games in occupational therapy of hand burns.” Burns Incl Therm Inj 12(7): 521-5. The need for active range of motion in hand burns is obvious and through adapted games the patient's interest is aroused and provides an incentive for active participation in his/her therapeutic programme. All the games are for individual players, on different intellectual levels, and provide different active ranges of motion: for fingers, wrist, elbow and shoulder. Most of the games were made by a former patient, now retired, copied from games in the collection of the occupational therapist, and some of the games are of Israeli idea and manufacture. All the games can be gas autoclaved and therefore be used from patient to patient. The games also provide a much needed outlet for intellectual stimuli and distraction from the burns unit and all it signifies. van Straten, O., P. Ben-Meir, et al. (1987). “New ideas in splinting of burns.” Burns Incl Therm Inj 13(1): 66-8. Splinting in burns is by no means a new subject, but this paper tries to demonstrate a new approach using new materials and sometimes humour. Conventional burn splints, dynamic and static, have been described in the past. All the following splints are made either with Mediplast, a new Israeli product, or Hexcelite.

Van Straten, O. and A. Sagi (2000). “"Supersplint": a new dynamic combination splint for the burned hand.” J Burn Care Rehabil 21(1 Pt 1): 71-3; discussion 70. Dynamic splinting for the burned hand is used worldwide. We previously presented a home hand therapy program. This program included a series of dynamic splints made by the occupational therapist for daily use by the patient. The "supersplint" evolved from the need to reduce the time required to manufacture the splints for the home therapy program; it also reduced patient-therapist sessions in the occupational therapy unit. The supersplint provides active-resistive movements of the fingers and thumb. As range of motion progresses, resistance can be increased to strengthen muscles and tendons. The supersplint provides tendon gliding, helps control edema, prevents muscle disuse, prevents skin and capsular contracture, minimizes complications, and helps prevent deformities. The patient uses the supersplint daily as part of an occupational 82 therapy program that includes activities of daily living, prevention of shoulder hand syndrome, and scar therapy (including pressure garments).

Von Prince, K. M., P. W. Curreri, et al. (1970). “Application of fingernail hooks in splinting of burned hands.” Am J Occup Ther 24(8): 556-9.

Yotsuyanagi, T., K. Yokoi, et al. (1994). “A simple and compressive splint for palmar skin grafting in young children with burns.” Burns 20(1): 55-7. A simple, compressive, and easily applied splint which is suitable even for fearful and uncooperative patients after skin grafting for paediatric deep palmar burns is described. The hand, including the wrist and the forearm, is inserted between the palmar and dorsal plates of the splint and thus compression and immobilization act to decrease flexion contracture and dysfunction of the digits. Compression can be easily controlled by the use of leather bands.

Sudhakar G, Le Blanc M. Alternate splint for flexion contracture in children with burns. J Hand Ther. 2011;24(3):277-9.

Splinting children and ensuring that children wear the splint can be challenging tasks for both the therapist and the caregiver. Sometimes creativity is needed to create a pediatric splint that is easy to don and stays in place. These authors describe their challenge with pediatric burn patients either not wearing or losing their splint and how they now combine the splint directly into the pressure garment to ensure better patient compliance

Nam HS, Seo CH, Joo SY, Kim DH, Park DS. The Application of Three-Dimensional Printed Finger Splints for Post Hand Burn Patients: A Case Series Investigation. Ann Rehabil Med. 2018;42(4):634-8.

The application of three-dimensional (3D) printing is growing explosively in the medical field, and is especially widespread in the clinical use of fabricating upper limb orthosis and prosthesis. Advantages of 3D-printed orthosis compared to conventional ones include its lower cost, easier modification, and faster fabrication. Hands are the most common body parts involved with burn victims and one of the main complications of hand burns are finger joint contractures. Applying orthotic devices such as finger splints are a well-established essential element of burn care. In spite of the rapid evolution of the clinical use of 3D printing, to our knowledge, its application to hand burn patients has not yet been reported. In this study, the authors present a series of patients with hand burn injuries whose orthotic needs were fulfilled with the application of 3D-printed finger splints.

Dewey WS, Richard RL, Parry IS. Positioning, splinting, and contracture management. Phys Med Rehabil Clin N Am. 2011;22(2):229-47, v.

8/7/2020

Reconstruction of the Burned Hand

G.Germann

ETHIANUM

Clinic for Plastic & Reconstructive Surgery, Aesthetic and Preventive Medicne Partner Hospital of the University of Heidelberg

except

2017

1 8/7/2020

The hands are involved in 80% of all major burns Predominantly the dorsum of the hands

Burns of the Upper Extremity Classification (Achauer) A. Claw Deformity 1. Complete 2. Incomplete

B. Palmar Contracture

C. Web Space Deformity 1. Web Space Contracture 2. Adduction Contracture 3. Syndactylism

D. Hypertropic scar/contracture bands

E. Amputation deformity

F. Nail bed deformity

Severe bilateral contracture

2 8/7/2020

After release

After groin flap

3 8/7/2020

Reconstruction with a radial forearm flap

Burns of the Upper Extremity Classification (Achauer) A. Claw Deformity 1. Complete 2. Incomplete

B. Palmar Contracture

C. Web Space Deformity 1. Web Space Contracture 2. Adduction Contracture 3. Syndactylism

D. Hypertropic scar/contracture bands

E. Amputation deformity

F. Nail bed deformity

4 8/7/2020

Palmar contracture

Full thickness skin graft

5 8/7/2020

Final result

Burns of the Upper Extremity Classification (Achauer) A. Claw Deformity 1. Complete 2. Incomplete

B. Palmar Contracture

C. Web Space Deformity 1. Web Space Contracture 2. Adduction Contracture 3. Syndactylism

D. Hypertropic scar/contracture bands

E. Amputation deformity

F. Nail bed deformity

6 8/7/2020

Nailbed correction with local flap

7 8/7/2020

Burns of the Upper Extremity Classification (Achauer) A. Claw Deformity 1. Complete 2. Incomplete

B. Palmar Contracture

C. Web Space Deformity 1. Web Space Contracture 2. Adduction Contracture 3. Syndactylism

D. Hypertropic scar/contracture bands

E. Amputation deformity

F. Nail bed deformity

8 8/7/2020

❤️

9 8/7/2020

Five flap Z-plasty

10 8/7/2020

Posterior interosseus flap for scar release of the web space and the radial aspect of the forearm

Further corrections necessary, but main problem is solved

Released sever contracture of the 1st Radial forearm flap raised web space

11 8/7/2020

Final result

Severe contracture after primary conservative treatment

Free lateral arm flap

12 8/7/2020

Burns of the Upper Extremity Classification (Achauer) A. Claw Deformity 1. Complete 2. Incomplete

B. Palmar Contracture

C. Web Space Deformity 1. Web Space Contracture 2. Adduction Contracture 3. Syndactylism

D. Hypertropic scar/contracture bands

E. Amputation deformity

F. Nail bed deformity

Deep contact burn

13 8/7/2020

14 8/7/2020

No toe transfer possible

Contracture release

Creation of a rudimentary grip option

15 8/7/2020

Double toe transfer in combination with a groin flap to create a helper hand

4 year old boy Primary treatment in Pediatric Surgery Defect coverage with STSG Loss of all fingers– extension contracture of the wrist

16 8/7/2020

Free parascapular flap to both hands

Pollizisation of MC II to MC I and deepening of the web space

DMCA Flaps

PIP joints are frequently exposed in deeper dorsal burns

The Fate of the Dorsal Metacarpal Arterial System Following Thermal Injury to the Dorsal Hand: A Doppler Sonographic Study Germann G, Funk H, Bickert B.J Hand Surg Am. 2000 Sep;25(5):962-8.

17 8/7/2020

Donor site

Recipient site

Fig. 4a

Fig. 4b

18 8/7/2020

Fig.4c

Kite flap (1. DMCA) (Hilgenfeld 1952, Paneva-Holevich 1968, Foucher 1976)

HF - Burn - Necrosis of the germinal and sterile matrix

Pedicle includes fascia of Donor site after 4 months dorsal interosseus muscle

19 8/7/2020

Lipofilling

Unstable adherent scar and painful stump

20 8/7/2020

Some rare cases

Exposed extensor tendons in cases of deep burn with unsuccessful skin grafting T P F

21 8/7/2020

Flap anastomosed to priceps pollicis artery and subcutaneous vein

Syndactyly

Very acceptable contour and function

22 8/7/2020

Exposed joints and tendons

Serratus fascia flap

23 8/7/2020

24 8/7/2020

Excellent aesthetic and fucntional result

12 year old girl burned 4 years ago and treated in her home country (Usbekistan)

Arthrolysis – Tenolysis – Tendon Reconstruction

25 8/7/2020

Temporary wrist fusion with K-Wires Free myo-cutaneous Latissimus

6 weeks postop - 6 months ago

No need to be desperate. There is always a solution