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SURGICAL TECHNIQUE

Acute Surgical Management of Hand Burns
Winston T. Richards, MD, Edward Vergara, Dawood G. Dalaly, DO,
Loretta Coady-Fariborzian, MD, David W. Mozingo, MD

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makes it
vulnerable to burn injuries that have a high
potential for morbidity. In addition, differences in the natural history of second- and third-degree
burns are important in their surgical management.
Second-degree burns heal with minimal scarring
whereas deeper wounds develop thick restrictive scars
if not treated surgically. Excision and grafting of burn
wounds also has the potential to create restrictive
scars. Surgical intervention on a superficial burn may
create a poor result where observation would not. This
AND EXPOSURE TO THE ENVIRONMENT

From the Department of Acute Care Surgery, Department of Surgical Critical Care, and the
Department of Plastic and Reconstructive Surgery, University of Florida at Shands Medical
Center; and the Department of Physical and Occupational Therapy, Shands Medical Center,
Gainesville, FL.
Received for publication June 13, 2014; accepted in revised form July 22, 2014.
No benefits in any form have been received or will be received related directly or
indirectly to the subject of this article.
Corresponding author: Winston T. Richards, MD, Department of Acute Care Surgery,
University of Florida at Shands Medical Center, 1600 SW Archer Rd., Gainesville, FL 32608;
e-mail: Winston.richards@surgery.ufl.edu.
0363-5023/14/3910-0035$36.00/0
http://dx.doi.org/10.1016/j.jhsa.2014.07.032

Surgical Technique

A hand represents 3% of the total body surface area. The hands are involved in close to 80%
of all burns. The potential morbidity associated with hand burns can be substantial. Imagine a
patient carrying a pan of flaming cooking oil to the doorway or someone lighting a room-sized
pile of leaves and branches doused with gasoline. It is clear how the hands are at risk in these
common scenarios. Not all burn injuries will require surgical intervention. Recognizing the
need for surgery is paramount to achieving good functional outcomes for the burned hand.
The gray area between second- and third-degree burns tests the skill and experience of every
burn/hand surgeon. Skin anatomy and the size of injury dictate the surgical technique used to
close the burn wound. In addition to meticulous surgical technique, preoperative and postoperative hand therapy for the burned hand is essential for a good functional outcome.
Recognizing the burn depth is paramount to developing the appropriate treatment plan for any
burn injury. This skill requires experience and practice. In this article, we present an approach
to second- and third-degree hand burns. (J Hand Surg Am. 2014;39(10):2075e2085.
Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.)
Key words Burn, injury, hand, acute, surgery.

difference in the healing process highlights the need
for accurate recognition of second- and third-degree
burns, a skill that requires clinical experience.1
A large burn is life-threatening and the hands assume lower priority during treatment. Preserving
hand function in these situations requires hand therapy during the resuscitation and burn wound
debridement phases and the use of skin substitutes or
allograft to cover the wounds until donor sites have
healed. Edema management through limb elevation,
orthosis fabrication, and dressings is an important
adjunct in this process. This highlights the critical
function of the occupational therapy service in the
management of hand burns.2e4
SURGICAL ANATOMY
Skin has 2 distinct layers: the epidermis and the
dermis. These layers measure 0.05 to 1.5 mm for the
epidermis and 0.3 to 3.0 mm for the dermis. Hair
follicles are present in varying concentrations, their
base is in the deep dermis, and they have an epithelial
lining. Sebaceous glands and sweat glands lined with
epithelium reside in the dermal layer also. Glabrous

Ó 2014 ASSH

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Published by Elsevier, Inc. All rights reserved.

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FIGURE 1: A cartoon representing the structure of intact skin. Notice the dermal capillary bed and nerve endings, which figure prominently in differentiating second- and third-degree burns. Also note the epithelial lining of the hair follicles and sweat glands, which allow
for rapid healing of superficial burns. (Reprinted with permission from Duffy BJ, McLaughlin PM, Eichelberger MR. Assessment, triage,
and early management of burns in children. Clinical Pediatric Emergency Medicine. 7(2):82e93. Copyright Ó 2006 Elsevier, Inc.)

FIGURE 2: A superficial second-degree hand burn. A The wound bed is moist and painful and blanches when compressed. B The
blisters have been removed and the wound bed is bleeding after minor debridement.

skin is naturally hairless and covers the palms and
soles (Fig. 1).
Recognition of burn depth is exceptionally difficult. Unevenness in burn injuries, skin pigmentation,
discoloration from soot, adherent clothing, blisters,
J Hand Surg Am.

dressings, and topical treatments all change the
appearance of burn wounds, confounding the accurate identification of burn depth. In addition, burn
wounds tend to progress and demarcate over 24 to
48 hours, adding uncertainty to the initial evaluation.
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FIGURE 3: Examples of deep second-degree burns. A A step-off is present between the wound bed and the unburned skin. B, C A thick
sloughing serum and cream cover a pale wound bed with hemorrhage in the dermis.

FIGURE 4: Third- and fourth-degree burns on a hand. A The skin is leathery, discolored, and dry. Escharotomies (arrow) released the
constricting circumferential burn. B The repose of the resting fingers suggests burn injury with rupture of the underlying tendons
(transverse arrow, fingers extended) and coagulation of the forearm muscles (oblique arrow, fingers flexed) in this electrical injury.

Accurate diagnosis involves serial examinations over
the first 48 hours and early wound debridement
removing loose detritus material under sedation.
Burn wounds involve the epidermis, dermis, and
even subcutaneous structures. Superficial second-degree burns involve the epidermis and superficial
dermis. They are typically blistered and moist. The
nerve endings are intact, making them painful to light
touch and the dermal capillary beds are present,
blanching on palpation. Routinely, they heal in 2 to 3
weeks when epithelial cells surrounding the dermal
appendages (hair, sebaceous glands, and sweat
glands) proliferate and fill in the burned area.
Second-degree burns involving the deep dermis
have few epithelial structures intact. They take longer
than 2 to 3 weeks to heal and have an increased risk for
J Hand Surg Am.

hypertrophic scarring. Topical antimicrobial dressings applied to deep second-degree burns allow us
to determine their depth and time to heal. Subsequently, they may require skin grafting. Thirddegree burns involve the skin’s full thickness,
destroying the dermal appendages and leaving no
nests of epidermal cells to proliferate. Dermal vessels and superficial veins may be thrombosed and
visible, and the skin is leathery, dry, desiccated, or
carbonized. Tangential excision and grafting or
excision and primary closure are the treatments of
choice for these burns (Figs. 2e4).
INDICATIONS AND CONTRAINDICATIONS
Burn depth, size, and time to heal drive the indications
for surgical intervention. Superficial second-degree
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FIGURE 5: A Weck knife (Teleflex Medical, Research Triangle Park, NY) used at our institution. This knife has a straight razor blade
and multiple fixed guards ranging from 0.004 to 0.012 inch in depth. A Blade and knife handle separate. B Blade inserted into handle
and guard in place for right-handed use.

Surgical Technique
FIGURE 6: A deep-second and third-degree burn wound before A and after B surgical debridement. Note the pink moist wound bed with
punctate hemorrhage. Arrows show hemorrhage. Electrocautery was used on the larger bleeding capillaries prior to applying an STSG.
Arrows also show sites to cauterize.

burns that heal with time and topical antimicrobials
avoid a donor site and the scarring associated with
tangential excision and grafting. The indications for
surgical excision are deep dermal burns that have not
healed in 2 weeks and third- or fourth-degree burns.
A relative contraindication to burn wound excision
on the hand occurs in patients with a large total body
surface area (TBSA) burn. Survival depends on
excising and grafting the largest burn areas first. Once
those donor sites have healed, one can then harvest a
split-thickness skin graft (STSG) to cover the hands.
Temporizing approaches available in this situation
include enzymatic debridement, dermal substitutes,
allograft, and cultured cells allowing coverage of the
hand burns while treating the larger burn wound.
Several articles report no difference in the outcome of
J Hand Surg Am.

late versus early excision of hand burns provided one
continues therapy by means of judicious functional
orthosis fabrication and maintaining range of motion
(ROM) to wrist and fingers.5,6
Optimum timing for excision and grafting of burn
wounds on the hands is a complex problem often
complicated by extensive burns. Shortly after the patient is resuscitated and the wounds are well demarcated, one may excise third- and fourth-degree
burn injuries. Observation of second-degree burns
while using topical antimicrobial creams or dressings
allows time to determine the depth of injury. We then
excise and graft large wounds that granulate or remain
open after 2 weeks. In addition, aggressive hand
therapy routines before and after surgery improve
hand function.1
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FIGURE 7: A deep second-degree burn after 2 weeks under Xenograft (pigskin; Brennen Medical, LLC, St. Paul, MN). The wound had
not completely healed and required excision and grafting. A Before debridement. B After debridement with the Versajet and hemostasis
with electrocautery. We removed small nests of epithelial cells (arrow in A shows small healed area that was removed for uniform
coverage) from the center of the wound to provide a uniform wound bed for grafting (arrow in B shows uniform wound bed).

FIGURE 8: This superficial second-degree burn was debrided and then covered with Xenograft. The proximal graft was secured with
staples, and the distal graft on the fingers was secured with Dermabond (Ethicon/Johnson & Johnson, Somerville, NJ) skin adhesive. A
After debridement. B Xenograft in place.

SURGICAL TECHNIQUE
A major advance in the treatment of burn wounds
was the introduction of tangential excision and
grafting. This involves serial excision of thin layers
of burned skin exposing healthy tissue, followed by
closing the wound with a skin graft.
J Hand Surg Am.

Weck knives, used for excision, have a fixed guard
from 0.004 to 0.012 inch in depth. Multiple passes of
the knife used in a sawing fashion at a slight angle to the
surface uncovers healthy tissue. A useful excision
technique involves holding traction and countertraction
on the wound while passing the knife over the burn.

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FIGURE 9: A This third-degree burn wound was excised and covered with allograft. Notice the difference in pigmentation. B We
covered the larger surface area on the forearm and upper arm with an STSG in a 2:1 mesh pattern during this operation. We removed the
allograft in 2 weeks when the patient’s donor sites had healed.

A moist glistening surface identifies successful
debridement. A healthy dermal capillary bed reveals
punctate bleeding when unroofed. As the excision
progresses in depth, the space between capillaries
becomes wider. When determining the adequacy of
debridement, the presence of thrombosed vessels and
tissue hemorrhage suggest further excision. Normalappearing fat has a yellow wet appearance to it, and
healthy muscles, once exposed, will contract when
stimulated. Tourniquet use during this process makes
identifying the level of debridement more difficult but
reduces blood loss (Figs. 6, 7).
Tourniquet use allows more time to debride a
complex wound area on the hand and fingers. Elevating
the limb for 2 minutes prior to inflation instead of
exsanguinating with an Esmarch bandage leaves
enough residual blood in the capillaries to evaluate the
depth of excision. When using an Esmarch bandage
prior to debridement, partial deflation of the tourniquet
may reveal areas that need further excision. Finally, if
the depth of excision is uncertain, apply allograft to the
wound as a test. If this graft becomes adherent, then
there is potential for successful autograft application;
otherwise repeat the debridement in several days.
Grafting may be performed with xenograft (animal
skin, most often pigskin), allograft (cadaver skin
obtained through a tissue bank), or autograft, the
patient’s own skin. Each of these biological coverings
has a specific place in the acute management of
hand burns. In addition, skin substitutes and burn
woundespecific dressings may be used.

FIGURE 10: A Third-degree hand burn wound. B STSG sheet
graft with hash marks (arrow). A 1:1 mesh pattern in the STSG
and limited separation of the interstices produces the same effect.

In addition to the standard knives, the Versajet
(Smith & Nephew Wound Management, Hull, UK) is
a recently developed adjunct. This system uses a
high-pressure jet of water to remove thin layers of
tissue with each pass. Used in conjunction with sharp
debridement, it smoothens out the wound surface and
is useful on complicated contours in the burn wound
(Fig. 5).
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FIGURE 11: Example of the use of a dermal substitute. A At this stage, the Integra (Integra Life Sciences, Plainsboro, NJ) has engrafted
on the wound bed as evidenced by the red color of the material. B After removing the silicone layer and light debridement of the wound,
we applied an STSG.

TABLE 1. Dermal Substitutes and Burn-Specific Wound Dressings With a Description of Their Components,
Primary Uses, and Company Information
Skin
Substitute

Components

Primary Use

Company Information

Xenograft

Porcine Skin

Superficial second-degree burns
temporary covering

Brennen Medical, LLC, 1290 Hammond
Rd., St. Paul, MN 55110-5959

Biobrane

Nylon mesh, silicone, and
type 1 porcine collagen

Superficial second-degree burns
temporary covering

Smith & Nephew Wound Management,
PO Box 81, 101 Hessle Rd., Hull,
HU3 2BN, UK

Allograft

Full-thickness
cadaver skin

Deep second- and third-degree burns
temporary covering

AlloSource, 6278 South Troy Circle,
Centennial, CO 80111

AlloDerm

Cadaver dermis

Third-degree burns combined with
thin STSG. Wound closure

LifeCell Corporation, 95 Corporate Dr.,
Bridgewater, NY 08807

Integra

Silicone, collagen,
chondroitin-6-sulfate

Third-degree burns combined with
thin STSG. Wound closure.
Two-stage procedure

Integra Life Sciences, 311 Enterprise Dr.,
Plainsboro, NJ 08536

Matriderm

Collagen, elastin

Third-degree burns combined with
thin STSG. Wound closure

Dr. Oto Suwelack Skin and Health
Care AG, Josef-Suwelack-Strasse 48727
Billerbeck, Germany

Oasis

Porcine small intestinal
submucosa

Second degree burns as a dressing.
Wound closure

Smith & Nephew Wound Management,
3909 Hulen St., Fort Worth, TX 76107

Primatrix

Fetal bovine dermis

Second- and third-degree burns,
may be combined
with STSG. Wound closure

TEI Biosciences, 100 Winter St., Waltham,
MA 02451

Xenograft (pigskin) (Brennen Medical, LLC, St.
Paul, MN) covers superficial second-degree burns. It
seals the wound from the environment, allowing it to
epithelialize. Allograft, cadaver skin (AlloSource,
Centennial, CO), is useful in the management of large
J Hand Surg Am.

burn injuries. We excise the hand burn as soon as
possible and use allograft as a temporary biological
dressing. Allograft adheres to the excised wound in a
fashion similar to that of autografted skin. In 3 weeks,
the cadaver skin separates from the wound bed
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FIGURE 12: Example of the dressing process used for hand burns after grafting. A Xenograft applied to a second-degree burn wound. B
Nonstick layer of wound veil applied over the grafts. C Fingers wrapped individually with gauze for a secure dressing with some
flexibility for the patient to participate in therapy activities.

from areas covered by clothing. The thighs, buttocks,
and flanks are good donor sites for covering the
hands, fingers, and wrists with sheet grafts. Smooth
out bony prominences in a donor site with clysis (ie,
infiltration of saline or dilute epinephrine solution to
level out the donor surface to facilitate dermatome
use). Using the widest dermatome guard limits the
number of graft-to-graft seams. A sheet graft or 1:1
meshed graft offers good cosmetic results. Meshed
skin grafts are useful in extensive burn injuries where
donor sites are limited. When using a meshed graft on
the hand, limited stretching of the interstices will
limit the “waffled” appearance of the healed grafts.
STSG, harvested at a thickness of 0.012 inch, provide well-healing donor sites and a flexible graft with
minimal scar contracture. Increasing the thickness of
the donated skin increases the flexibility of the healed
graft, reduces contracture at the grafted site, but increases the time to donor site healing. Full-thickness
skin grafts (FTSG) provide the most flexible grafting
material for a full-thickness burn wound on the hand.
They also require primary closure or skin graft closure
of the donor site. A prospective randomized controlled
trial of STSG thicknesses of 0.015 inch or 0.025 inch
did not show a significant difference in function once
the wounds healed7 (Fig. 10).
Dermal substitutes are available for use in deep
burns. Integra is a bilayer material of silicone and
collagen/chondroitin-6-sulfate. This material provides a moisture- preserving covering and a neodermal
layer. Small capillary vessels invade the collagen
layer, engrafting the material. Once the layer is
adequately vascularized, at around 21 days, remove
the silicone layer, prepare the surface, and cover it

FIGURE 13: Picture highlights the obvious difference between
the palmar glabrous skin and the FTSG used to revise scar
contractures on this palm.

secondary to inflammation. If the allograft initially
adheres to the wound bed, then the wound is well
vascularized and bacterial colonization is minimal.
When appropriate donor sites become available to
harvest, remove the allograft and replace it with a
skin graft (Figs. 8, 9).
Harvest autograft from nonburned areas for the
treatment of acute burn injuries. Choose donor sites
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FIGURE 14: A Hypertrophic scarring on the dorsal hand involving the eponychial folds. B Scarring in the first webspace, which limits
thumb function. The hypertrophic scarring noted in these 2 cases represents a complication of hand burns that may occur despite
adequate debridement and skin grafting. Scar excision and repeat grafting or grafting with dermal substitutes are effective treatments for
this problem.

FIGURE 15: Web space syndactyly is another hand burn complication encountered when treating hand burns. The first case A represents a low-grade syndactyly. B Markings for a planned Z-Plasty to release the second web space. C This patient has an almost
complete syndactyly. D Intraoperative picture of the dorsal skin flap resurfacing the web space. E Completed closure of the repair with
FTSGs secured with absorbable sutures.

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FIGURE 16: A Before debridement and postgrafting case pictures for the patient presented in the video. B The graft is being trimmed
and secured.

PERIOPERATIVE MANAGEMENT
Functional recovery of the burned hand is achieved
through early and ongoing intervention both before
and after surgery. Many of the anticipated issues in
the postoperative recovery process are the same as
those in the acute phase of injury: pain, edema, skin
and joint contracture, joint and sensory impairments,
loss of skin integrity, and impaired functional hand
use. The burn therapist must have a thorough understanding of the effects of burn injury on anatomical structures and the rehabilitation implications of
both pre- and postsurgical intervention. Ongoing
communication and collaboration within the burn
team is essential to the successful management of the
burned hand (Appendix A, available on the Journal’s
Web site at www.jhandsurg.org).

with a thin STSG (0.008 inch). This 2-part process,
which creates a neodermal layer covered by epithelium, results in a thick pliable covering over the
wound with limited scarring. Dermal substitutes are
useful in the management of large burn wounds
where donor sites are limited, on the dorsum of the
hand for deep burns involving the subcutaneous tissue, and for scar revision surgery. They are difficult
to use because the wound bed must be absolutely
clean and well debrided with minimal bacterial
colonization. Integra may be meshed in a 1:1 Brennen mesher (Brennen Medical, LLC, St. Paul, MN)
and secured in place with a wound VAC negativepressure system (Kinetic Concepts, Inc., San Antonio, TX) to control egress of fluids from the wound
and enhance the apposition of the graft to the wound
surface8,9 (Fig. 11; Table 1).
The final critical piece of surgical management of
a burn wound is the dressing. This process secures
the grafts in position and protects them from minor
trauma. Appropriate dressing techniques allow for
control of fluids leaking from the wound and decrease
local edema. Wrapping the fingers individually and
providing some flexibility in the dressing will allow
the patient to begin early therapy. Our current practice is to apply wound veil (DeRoyal, Powell, TN), a
nonstick dressing, to the grafts and wrap them with
Kling (Johnson & Johnson, New Brunswick, NJ)
gauze. Our nursing staff applies 5% sulfamylon solution to the gauze every 8 hours. Once the grafts
have become adherent to the wound bed, we then
switch the dressing to wound veil with bacitracin or
mupirocin (Bactroban) ointments (Fig. 12).
J Hand Surg Am.

PEARLS AND PITFALLS
Recognizing second-degree burns that will heal
without scarring is key to achieving good outcomes for
hand burns. Waiting 2 to 3 weeks while the wound
heals and the patient performs therapy helps in these
difficult to assess injuries. Adding donor site morbidity
and graft scarring to a wound that might have
healed well is a major pitfall. Accurate and thorough
debridement of appropriate wounds is another important point to achieving good wound healing.
Glabrous skin is the smooth hairless skin on the
palms of the hands and soles of the feet. An STSG
harvested from the instep of the foot makes a suitable
graft for a small injury on the palm of the hand. A
small graft from the thenar or hypothenar eminence
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1. Tredget EE, Nedelec B, Scott PG, Ghahary A. Hypertrophic scars,
keloids, and contractures. The cellular and molecular basis for therapy. Surg Clin North Am. 1997;77(3):701e730.
2. Petro JA, Salisbury RE. Rehabilitation of the burn patient. Clin Plast
Surg. 1986;13(1):145e149.
3. Sheridan RL, Hurley J, Smith MA, et al. The acutely burned hand:
management and outcome based on a ten-year experience with 1047
acute hand burns. J Trauma. 1995;38(3):406e411.
4. Barillo DJ, Harvey KD, Hobbs CL, Mozingo DW, Cioffi WG,
Pruitt BA. Prospective outcome analysis of a protocol for the surgical
and rehabilitative management of burns to the hands. Plast Reconstr
Surg. 1997;100(6):1442e1451.
5. Omar MT, Hassan AA. Evaluation of hand function after early
excision and skin grafting of burns versus delayed skin grafting: a
randomized clinical trial. Burns. 2011;37(4):707e713.
6. Mohammadi AA, Bakhshaeekia AR, Marzban S, et al. Early excision
and skin grafting versus delayed skin grafting in deep hand burns (a
randomized clinical controlled trial). Burns. 2011;37(1):36e41.
7. Mann R, Gibran NS, Engrav LH, et al. Prospective trial of thick vs
standard split-thickness skin grafts in burns of the hand. J Burn Care
Rehabil. 2001;22(6):390e392.
8. Lou RB, Hickerson WL. The use of skin substitutes in hand burns.
Hand Clin. 2009;25(4):497e509.
9. Ryssel H, Germann G, Kloeters O, Gazyakan E, Radu CA. Dermal
substitution with Matriderm(Ò) in burns on the dorsum of the hand.
Burns. 2010;36(8):1248e1253.
10. Moore ML, William DS, Richard RL. Rehabilitation of the burned
hand. In: Klein MB, ed. Hand Clinics: Hand Burns. Vol. 25, no. 4.
Philadelphia: WB Saunders; 2009:529e554.
11. Kowalske K. Outcome assessment after hand burns. In: Klein MB,
ed. Hand Clinics: Hand Burns. Vol. 25, no. 4. Philadelphia: WB
Saunders; 2009:557e561.
12. Smith MA, Munster AM, Spence RJ. Burns of the hand and upper
limb—a review. Burns. 1998;24(6):493e505.
13. Nakamura DY. Occupational therapy principles for the burn patient.
In: Sood R, ed. Achauer and Sood’s Burn Surgery, Reconstruction
and Rehabilitation. Philadelphia: Elsevier; 2006:370e387.
14. Macintyre L, Baird M. Pressure garments for use in the treatment of
hypertrophic scars—a review of the problems associated with their
use. Burns. 2006;32(1):10e15.

COMPLICATIONS
Graft failure, web space syndactyly, flexion or extension contractures secondary to scarring, epithelial
shelves, pits, and sinuses all represent complications of
burn injuries to the hands. In addition, mallet and
boutonniere deformities may represent a complication
of the severity of the wound or aggressive debridement
of the burn wound from either damage to tendons or
stretch attenuation. There are multiple approaches for
their treatment (Figs. 14, 15).
CASE ILLUSTRATION
A 44-year-old woman with history of right breast
cancer and lumpectomy sustained burns to her right
arm, right hand, and left arm after a grease fire 4 days
prior to presentation. She initially received silver sulfadiazine (Silvadene) cream and pain medicine at an
outside hospital. However, she returned to that hospital
with purulent drainage, fevers, nausea, and vomiting.
After antibiotic treatment, she transferred to our facility for definitive management of her burns. The
following videos highlight her treatment (Fig. 16;
Videos 1, 2 [available on the Journal’s Web site at
www.jhandsurg.org]).

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REFERENCES

can cover a small area on the palmar surface of the
fingers. An advantage of this technique is to supply
skin with similar characteristics to the wound and
avoid pigment differences and the possibility of hair
growth on the palm (Fig. 13).

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APPENDIX A. PERIOPERATIVE MANAGEMENT
Functional recovery of the burned hand is achieved
through early and ongoing intervention both before
and after surgery. Many of the anticipated issues in
the postoperative recovery process are the same as
those in the acute phase of injury: pain, edema, skin
and joint contracture, joint and sensory impairments,
loss of skin integrity, and impaired functional hand
use. The burn therapist must have a thorough understanding of the effects of burn injury on anatomical
structures and the rehabilitation implications of both
pre- and postoperative intervention to joint, tendon,
and soft tissue structures.10 Ongoing communication
and collaboration between the occupational therapist
and the burn team is essential to the successful
management of the burned hand.
Surgical Technique

Dressings
After surgery, dressings provide protection while
facilitating edema reduction. Dressings should not
hinder primary goals for proper positioning and
orthosis fabrication. As the wounds heal, dressings
should be decreased as much as possible to allow for
the most effective positioning and orthosis fabrication
as well as to allow for greater active and passive ROM
of the hand. If possible, remove dressings during
stretching, exercise, and ROM sessions to achieve and
record true ROM limits. Removing and reapplying
dressings with rehabilitation treatment also serves to
ensure that wounds are evaluated frequently so that
any negative changes are found early on.
Positioning and orthosis fabrication
Positioning and orthosis fabrication of the hand is
instrumental throughout all phases of the burn process.11,12 The goal of ongoing postoperative positioning and orthosis fabrication is to protect and
optimize healing. Individualized plans for positioning
and orthosis fabrication need constant management to
accommodate for changes throughout the healing
process.11 Elevating the distal extremity above the
heart coupled with extension of the elbow facilitates
promotion of increased venous return, reducing
vascular pressures in the extremity and allowing for
greater freedom of ROM and protection of structures
in the acute postoperative phase. Proper positioning
and orthosis fabrication also promotes elongation
forces on healing tissues to prevent contracture and
improve functional hand outcomes. It is generally
accepted that for any burned body part, allowing the
position of comfort allows for position of contracture.10 There are many approaches to orthosis fabrication of the hand by therapists, but the principles for
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preserving joint and tendon function along with preventing scar contracture deformity are the same. When
fabricating an orthosis for dorsal hand burns, the
antideformity position is generally accepted. The
orthosis is fabricated with the hand in the intrinsic plus
position, placing the wrist in extension, the metacarpophalaneal (MCP) joints in flexion, the proximal
interphalangeal (PIP) and distal interphalangeal (DIP)
joints in extension, and the thumb in palmar abduction
to preserve the web space. With palmar hand burns,
the goal is to preserve finger extension at the MCP,
PIP, and DIP joints along with thumb radial abduction. Circumferential hand burns require managing
dorsal and volar positioning and orthosis fabrication
techniques that will allow for the best functional
outcomes.10 Positioning and orthosis fabrication goals
may change as the hand undergoes the healing process, and continual management is necessary to promote the best postoperative outcomes.
Active and passive ROM
Treatment plans for hand burns must incorporate
ROM techniques to promote skin elongation, joint
function, and muscle and tissue strengthening. Active
ROM is generally preferred over passive ROM;
however, a combination of both active ROM, active
assisted ROM, and passive ROM is often needed for
achieving full potential of recovery.11,12 Tissue
elongation, pliability, and joint articulation are
necessary to prevent scar contracture and achieve
maximal hand function. Because scar contraction is a
constant 24-hour process, exercise should be done
frequently throughout the day and multiple exercise
sessions are preferred over a singular intense session.
The patient should be taught ROM and strengthening
exercises as soon as possible. Patients actively
engaged in their own ROM and exercise programs
will have increased success in the overall return of
function.13 Between exercise sessions, positioning
and orthosis fabrication plans must continue. Evaluation of orthosis fabrication and positioning should
occur frequently to help maintain and/or facilitate
ROM programs. Dynamic components to orthosis
fabrication may provide low load stress and elongation of tissues over time, promoting increases in hand
ROM. Ultimately, the therapist must progress the
patient to be an active and compliant participant in the
rehabilitation process. No prescribed treatment plan
will be successful if the patient participates only when
the therapist is present.13 The patient must continue to
perform stretching, exercise, and ROM between
therapy sessions to achieve the greatest functional
outcome.
Vol. 39, October 2014

Several methods are used to assess hand function
and include individual joint active ROM, passive
ROM, total active motion, total passive motion,
pinch and grip strength, sensation, and dexterity.
Whereas all of these are important to assess hand
function, no single assessment can comprehensively
predict functional outcome in the long term.11 At
present, the correlation between these objective
measurements and hand function has not been
clearly defined. Another measure of hand function is
more qualitative in nature but may provide a more
meaningful measure of “function.” The patient’s
own self-report of activities of daily living independence and ability to return to work should be
explored by the occupational therapist and be a
driving factor in setting goals in the rehabilitation
process. The occupational therapist is instrumental
not only in optimizing hand function after surgery
but also in the reintegration of the patient to the
community and return to work. Incorporating both
objective and qualitative measures of hand function
will facilitate the best outcomes.13

the hand to tolerate pressure. This early process can
also serve to normalize the concept of compression
for the patient as a vital part of the healing process.10
Typically, compression for the purpose of scar control starts when a majority of wounds are healed and
the skin is at a point that can tolerate the wearing of
garments. Scar compression garments are typically in
the pressure range of 25 to 30 mm Hg and can be
both commercially available and custom fabricated to
therapist measurements.14 The compression garment
may fail to provide even pressure owing to its
inability to completely conform to the hand. Most
often, these areas are in the web spaces between
digits, in the palm, and at the volar and dorsal wrist. It
may be necessary to apply inserts to keep pressure as
even as possible in all areas.10 Manufacturers of
custom compression garments can often incorporate
foam or silicon inserts to selected areas. Garments are
typically prescribed with a wear schedule of at least
23 h/d.10,14 Garments are replaced periodically
throughout the 12- to 18-month scar maturation
phase. The prescription of constant wear damages the
garment’s integrity and compromises the initial
pressures needed to affect scar tissue. Assessing the
hand measurements regularly ensures proper garment
fitting with anticipated changes in edema, skin
integrity, ROM, and development of hypertrophic
scar.14

Compression garments
Compression is often introduced early in the acute
phase of the burn to control edema and this continues
after surgery. The amount of compression will vary
depending on the skin integrity and overall ability of

J Hand Surg Am.

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Vol. 39, October 2014

Surgical Technique

ACUTE SURGICAL MANAGEMENT OF HAND BURNS