Pedido-120530145, i] Usui ope Carrera VE1.1 — EMali:mayor2409@gmaitcom =| VE1,1 Mall: mayor2408@gmaiLcom r WMD seuna or rau Pec 120600%146 597019 paga 148-62 Earle Delayed deine reeonaructon the burned René ev pubmed)” | Jou of Trauma 17010 page 149-152 Earle Colayes define Fane de reterecia pubmed ‘ecanarucon ofthe bued hare ev [pubmed ‘Obervagbes Soto por Sana Mayor Local 8R.1 ‘Opgdes:BR.1 / CMT-EXT(ALC) — " Atondido Paginas: 1 Biblioteca Humberto Garcia Arocha Rejetado Motive: | Fundacién Sistema Nacional de \" ) ay Decumentacién e Informacién Instituto de Medicina Experimental / Facultad de Medicina 40 piso ~ Ciudad Universitaria 4 1050 - Caracas VENEZUELADelayed Definitive Reconstruction of the Burned Hand: Evolution of a Program of Care A SCOTT BAREA, MD, aNo RICHARD 1. FRATIANNE, MD. igen 16 441) [Szperience gained in treating patents with hand burns admitted to ‘Regional Barn Center hes resulted inthe developrnent of tive ie biphasic approsch rreconatactive surge! procedures ‘Tis schedule permite ate definitive surgery on healed functioning handy and ‘accomplisea ina single operation in most euaes ‘This biphaste approach has led to beter results our iattution interme of ‘hand function and appearance ad to Secreae in toa numberof surged procedures, Reports of others using alternative methods and schedule, tsa ‘nth statutory results are discussed. [A number of surgical developments during the past four decades have contributed to improved care of burs ingoneral snd of the burned hand in particule. ‘These includes 1) improved methods of skin coverage dating fam Brown and McDowell's now clase contributions (9,2) the experience guined in centers for hand injuries stablshed during World War IL (9), and 3) the recent tendency to teat all major burns in burn centers (1,5) ‘Tis tendency has enabled sorgeons to pin experience with relatively large numbers of burn-veated injuries Walle providing aleve of care above that sly possible incommunity hoeptas ‘Articles published in recent years demonstrate that a ‘varity of approaches can lead to good end reslls in lating burns of the hand, Barly total excision and immediate grafting (2 15), delayed early excision and rafting (®), sequential tangential excision and grafting (@ 7, 1, 18, 18), “conservative” treatment to permit =yoitaneous healing with grafting reserved only for the ‘deepest burt (12) and various monieatons ofthese ‘ie good result ci The present paper describes « program which has ‘solved gradually over the past 5 years onthe Burn and ‘Phtic Surgical Services of the Cleveland Metropolitan ‘General Hospital where we are. now using a planned phasic approach for the care of the more severely ‘burned hand, Barly coverage is gained by program of aggressive surgical debriderment based on individual ‘ed followed by application of thin skin grafts, Parca: ‘Hhekness burs are’ permitted Co heal spontaneously tae W'S Stan Rod, ‘conan O11 #00 Most important, during the initial being phase, joint function agaresively maintained by ative and passive ‘exercises, Bvaluation and planning for reconatractive procedures are delayed until the reactive changes inthe healed areas have subsided completely and then reco stration performer electvely during single operative ‘session whenever posible, CLINICAL MATERIAL AND TREATMENT METHODS. During the period between 1 July 972 and 31 June 107, a total of B57 patents were admated to our Bur Service for hee priary eat. Of poup, 753 patients survived thet injury, for an overall sural o 8%. Our ‘cords inleste that approsimately 2 (26 patent) Ihave had signcant burns of one ofboth hae of fever worthy of mention in charting the een ofthe burn. OF the 225 significant hand bur 744% (17 pa ‘nt equred no further reconstruten afer he la naling phase. Of the remaining 51 pains, 18 had major ume of Sion to the Plate Sarpeal Service for arter definitive Fecantrctve surgery. OF Uneae 68 exes, aint had rns loc to the dorsi, and ofthe rex, thane were of the pliaraurace and about third toh hand surfaces ad burns severe eon to require Inte reconstructive surgery (Table ‘Our second-phase reconstrctivetedniques and the Aiming of surgery hve undergone considerable eoliton tnd modification ding the 5 years sire our burn nit tres establhed. Our operative statics reflect theve Shanges. Italy, our patent population include. pu tne fered ate ctr course ih exiled bun contrac of rary ont inctading sre with he all Shown clewed. hand so charcerste ofthe mgiected turned hand Some of oor own ently patents ala devel160 TheJournal of Trauma oped contractures before we recognized the need for intensive early passive and active therapy to maintain Joint mebiity, Betablshed ura contractures require & ‘numberof reconstructive procedures which may’ OF my fot be sicensul in retoring normal function. ‘Thus, ‘luring oat fist yer, seven ofthe eight patients undergo ing late reconstruction required two oF more operations ‘Daring the last year ofthis study, however only three of 20 patients required more than one late reconstructive ‘urseal procedure (Table I). The numberof operations ‘er patint has declined each year since the activation of ‘he Cleveland Area Burn Unit In al, 171 late reconstructive operations were carried ‘out on 68 ured hands (Table ITD. Scar resection or lease with appropriate coverage with thick split oF full thicants skin grafts was performed 91 times on 52 fxttemitco during the S-year period covered by this Feport. Distant skin flaps were required for nine extrem “ember f portions per patty yeaa: ear experience peapastonn, vr 2 peste 2 Tesora i ge hg) 3 Pie ne ger ‘ir eprtons pera om male gt ave as stud soe esta wn cued ut arg» ein (in nar core og in onal ae be March 1979 ites (eight patients). A variety of other operations were flso performed, more commonly in the past than at resent, including rp arthrodeses, mp capsulotomies,Z Dlastee, intrinsic releases, and tendon reconstruction. ‘Amputatons were occasionally indicated for severely ‘Contracted ite gers. One burn! and shortened index finger was policed with good rel ‘Our present protocol for treating burns of the hand is as fllows: Therapy during the fir, oF healing, paso is directed to obtaining a healed wound with fully fane- tional joints. Sequential tangential excision and debride- ‘ment are sed for deep dermal burns with coverage provided by thin splicthicknet gate, We do not hes tate to ute mesh grafts on the hends when the extent tind severity of the burns makes expansion of skin nec: ‘soar, Resident staff, nurs, and therapists ar ured to trainin full active and passive motion of burned hands flurng debridement procedures and dressing changes a2 ‘well ae during the therapist iit: Immobilization ater trating ie mainiained for only 3 18 days ‘Spline are useful adjuncts in seating bums of the hand, but we fel that their importance has been over ‘emphasized, Splints reduce immobility and shoul, we Delve, be zed only a night. To ely’ on splinting isto invite contractre in the splinted position (some of our ‘early mp joints required vole capsulotomies to correct the contractures which fllowed over-dependence on hay-raker” spina. Progresive los of joint motion secondary to searing is an indication for early suegca itervention; but #0 Tong asthe small joints retain their fonction reconstruc tion ean safely be postponed. We do not balieve that ‘sablisnent of searing nthe healing wound influences tnd results wo long as normal joint motion is maintained. Tn this regard, tthould be pointed out that individual joints should be evaluated with neighboring joints in full sve extension, Hand funtion asa whole for example, ‘he ability to "make fist") may be arkedly impaired yet the small joints examined individually may be flly functional So long asthe individual small joints vetain normal excursion second: phase reconstruction can be ‘succesfully earied out. ‘Our Inte recontructive procedures are carid out ‘under either general or rgional axilary) block anesthe tia. We no longer ase tourniquet control for reconstruc tive surgery of the burned hand. Rather, a dilate Lido- ‘caineepinephrine slution* is injcted generously along the interface between the sca athe underlying normal tie for ease in inaction and to minimize Bleeding. Blevation ofthe hand during surgery aso seems to reduce: bleeding. Although we have not made quantitative stud jes, we believe that blood loss using this technique is only ‘small faction of that encountered during the reactive eee ae unas SareeaVol 19, No.3 hyperemia that follows tourniquet release, In burns of the dorsal surface the scare removed by scissors disec- tion with the tips of the scars held ily against the Underside ofthe scarred tsnve, “Darts” ee incised gen “rously long skin creases atthe margin ofthe graft nd the normal tiewe, Thumb and interdgital webs are in- ‘coed far onto the volar surface, thas preventing later ‘web contractures, Established principles of coverage ate followed (3 10,1, 17,18). We use thick spit grate (18 to 20 1/1000 of ah inch) taken whenever possible as « "ng shot wth an oversized 88" Padgett dermatonne fora Watson knife. The skin gratis sutured into place ‘vith fine runing absorbable sutures of 4 or 5-0 catgut Re total hemostasis has been achieved, Dorel skin ‘ras are maintained in position with pressure dresings Applied very femly for 4 days ‘Sans of the palm arv also excised Volar contractures fof the fingers can often be trested with simple scar Felease placed botween the Nexion creases in order to prevent exposure of tendons. Fither fre fall thickest {rafts or thick epit-thickness grafts aroused for coverage Preccure dressings again are used on the volar surface to maintain positon of lage grafs for 8 to 7 days, Tie-over dressings are frequenlysed for smaller patch grafts on the volar surfaces ofthe fingers. We do not hesitate to perform eapsulotomies, intrinale relenies, or arthrodesee Of i-p joints as part of the definitive reconstructive op tration although, as mentioned, these anllary proce ‘dures are indieated les frequently than previously 'By carving out the enite definitive recontroction in ‘one sage, multiple periods of postoperative immobile tion are avoided: In the past, sngle-saged reconstructive operations of this type frequently were quite lengthy. With continuing experince, however, operating times have grown increasingly shorter. When secondary pro- ‘cedures ar indicated, an attempt i made, usualy suc- ‘esflly, co complete the reconstruction during this sec fond operation. Secondary surgery ually consists of “touch-up” procedures Methiciin is routinely administered intravenously «uring the operation beentve staphylococcus infection ab lemonstrated by eulture was found in the past to be a Significant caus for loss of skin grafts on our unt. We have not had a single grat fall becase of infection in ‘ur reconstructive patients since methiclin has became routine. Patient are ually retumed tothe operating room on the fourth postoperative day and the entre Aressng removed under sedation. Small hematomas are ‘occasionally encountered; these are evacuated and the raft replaced Cultures are not routinely obtained at this time Joint motion is checked during this fis dressing ‘change. Three days later the dressing i again changed ‘and setiv and passive therapy is then begun. DISCUSSION tisdiicl to evaluate and quantitate ou own results ‘except in a descriptive sense, Bach burned hand 1 & e $8 nat w7e Delayed Reconstruction ofthe Burned Had 151 unique injury. There are variations in the locations of the ‘burs and of the extent in both total area and depth ‘Burn seventy in our patents has Varied from total lose of an extremity (four patents have lost five extremities ta result of electrical bums during the study period), to Subtotal lows requiring major reconstructive efforts, to. localized injures that requze only skin grafting oF Z: last, to patil thicknes burns that heal spontaneously With satisfactory function and appearance, o superficial Frat and second-degree burns that require lite teat "The overall condition of the burned patient also inl: ‘ences the outeome, Some of our surviving patients were baieved to be moribund on admiason. Many had major fluid derangements, or pulmonary and CRS damage Under such circumstances, al efforts go to achioving patient survival and early therapy to the burned hand ‘ay understandably be delayed: Significant burn con: Uinctures are rarely seen today: when they occur ft usually in such severely injured patients, Patient mot- vation sa final variable that alo greatly affect outcome, Considerable time and eflort are expended by the mett- bere of the burn team in an attempt to motivate and ‘encourage our patients during thei rebiltaton: good. ‘evults ae diffielt to achieve without patient coopera- tion. Given the above litations, evaluation ofthe end renuls in series of burned hands necessarily has tobe based on the surgeons” judgment and on his appraisal arrived a as objectively a possible ‘We believe that we ar providing increasingly better areas our methods of treating the burned hand evolve. uphasis on earlier debridement, earlier grating, de- creased dependence on splinting, and especially an in ‘creasing emphasis on maintaining active and passive joint mobility has resulted in hands whose late recon ‘struction consists chiefly in achieving satifactory cov. ‘rage. Early nour experience, before the evolution of ‘our present methods, bots funetional mobility and cov: ‘erage had tobe provided surgically ‘There are numerous advantages vo «biphasic approach tothe treatment ofthe bumed hand as we have described {tO patients have been discharged frm thet initial ‘admission tothe Burn Service with healed wounds and frequently with hands tha have exsentilly normal joint function. Readmisson and delayed definitive surgery on ‘the Plastic Surgical Servce then permit completion of reconstruction, usually during a single admission. During {hissecond admission, iti posible to operate along well tstablied sear interfaces in hand that i completely healed without open burs eschar or granulations. Intec tion has not been a problem and graft take has been excellent. ‘The period of immobilization is usually lose ‘han 1 week and full rage of motion therapy may be started with the fret of tecond dressing change, We ae convinced thatthe cosmetic appearance of the burned hhand treated with delayed reconstruction is better than that achieved when definive grafting is attempted early182 "The Journal of Trauma Sn the postburn petiod since thick spll- or fee fall. Uekines grafts cane used with ite risk of failure "The biphasic approach to the reconstruction ofthe Ipurned hand has worked well in our clinical setting, We recognize very well, however, Unat excellent results have been and are bing achieved in many bare centers, by ‘ngeons, sng other schedules and methods. AS fn example, we were intrigued reenly by the compar of three sere of bur hands reported from Fae following the late Sinai war, The burns in Useae seies apparently were comparable, yet they were treated by ‘ite diferent methods. ln two series aggremve debride tent and grating were performed (14,19) Inthe other the burns wete permitted to heal spontaneously while Inaintaning aggresive therapy to prevent the los of Joint function diring the healing period (12). The end Fesuls even theugh the patients were treated by dispar ‘ne metho, seem be similar” What, then, is the fommon denominator? ‘urns of the hand in children suggest the answer to this question. Regards of the extent of serving in thilren, we see no joint contractures (unless Use jinte have been direaly burned) after the hand has been set free by aca resection and grating. In children there Is fo problem in providing joint function for it was never Toe I adult, towever function mat be maintained at al levels of treatment including that provided by occ ‘ational and physical therapist, When is possible thus {tomuintain joint mobility during che healing proces, the tiring and techniques of reconstruction become of 3c- ‘ondary importance. ‘Acknowledgment We wih to exes our appreciation to Avra I Frimson, IMD. for his intrest an mugetione for the care af out ‘tosh tr a hea Merch 1979 “Am Coll Soweto TE eae sat "epi Suet "hf td the Moers “Seen ie ating Ans Bur ofthe Upper Extremity "THE SECOND ANNUAL EMERGENCY MEDICINE SYMPOSIUM. ‘Safari Resort & Convention Conter ‘Scottdale, Arion Jormstin from: Chery! Wiliams, Symposium Coordinator, Arizona Syoteme Ince 0, Hox 13900, Phoonis, AZ 49015, Phone 602+2642748,