NC DHSR OEMS: Comprehensive Management of Hand Burns

Comprehensive Management of Hand Burns

Comprehensive Management Comprehensive Management of Hand Burnsof Hand Burns

C. Scott Hultman, MD, MBA, FACSChief and Program Director, Division of Plastic Surgery

Associate Director, NC Jaycee Burn CenterUniversity of North Carolina, Chapel Hill

May 2010

University of North Carolina Jaycee Burn Center

University of North Carolina University of North Carolina Jaycee Burn CenterJaycee Burn Center

• Regional Burn Center (6 states)– North Carolina: 9.5 million people

• 22 ICU beds, 20 floor beds• 900 admissions per year• 30 nurses, therapists• Out-patient clinic• 4 surgeons

Overview of Hand BurnsOverview of Hand BurnsOverview of Hand Burns

• Resuscitation 0-3 days• Resurfacing 1-3 weeks• Reconstruction 3 months - ?• Rehabilitation months• Reintegration years

RehabilitationReconstruction

of function Restoration of body image

Burn Injury

Resuscitation

Resurfacing

Recovery

Presenter

Presentation Notes

As a plastic surgeon who is committed to the care of burn patients, I would like to provide the full spectrum of care to people with this injury, which includes not only resuscitation and resurfacing, but also rehab, recon, and restoration of image. Too often, however, patients do not have access to cosmetic services, through lack of education, little financial resources, denial by insurance companies, or no available providers. With the recent closure of several burn centers in the Southeast, this problem will only get worse over time.

Hand Burns: Mechanism

Hand Burns:Hand Burns: MechanismMechanism

• Scald hot water, soup, microwave

• Flame house fire

• Abrasions motor vehicle collisions

• Electrical low voltage

• Chemical IV contrast, chemotherapy

• Infections meningococcemia, TENS/SJS

• Cold frostbite (rare)

Hand Burns: Resuscitation Hand Burns:Hand Burns:

ResuscitationResuscitation

• History: Mechanism

• Physical Examination: Wound Characteristics

• Restoration of Perfusion• Damage Control• Wound Care• Occupational Therapy• Systemic Issues

Hand Burns: Resurfacing Hand Burns:Hand Burns: ResurfacingResurfacing

• Excision• Temporary Coverage• Grafting• Flaps• Amputation

DermabrasionWeck scalpel bladeVersajet (water pick)Tangential Fascial

DermabrasionWeck scalpel bladeVersajet (water pick)Tangential Fascial



Biobrane (nylon netting)

Integra (synthetic collagen)

Xenograft (pigskin)Allograft (cadaver skin)VAC (negative pressure

sponge dressing)

Biobrane (nylon netting)

Integra (synthetic collagen)

Xenograft (pigskin)Allograft (cadaver skin)VAC (negative pressure

sponge dressing)



Split-thickness sheet graft

Split-thickness meshed graft (1/4:1)

Full-thickness skin graftCultured skin -- never

Split-thickness sheet graft

Split-thickness meshed graft (1/4:1)

Full-thickness skin graftCultured skin -- never



Random dorsal handLocal “Kite” from digitRegional reverse forearmDistant pedicled groinFree transfer latissimus muscle

Random dorsal handLocal “Kite” from digitRegional reverse forearmDistant pedicled groinFree transfer latissimus muscle

Hand Burns: Reconstruction

Hand Burns:Hand Burns: ReconstructionReconstruction

• Stiffness• Swan Neck Deformity• Tendon Adhesions• Boutonniere Deformity• Mallet Finger• Claw Hand• Nail Plate Abnormalities• Hypertrophic Scar

• Palmar/digital Contractures• Web Space Deformities• Axillary Contractures• Elbow Dysfunction• Amputation Deformity• Thumb Loss• Chronic Pain• Nerve Compression

Syndromes

dorsaldorsal

volarvolar

Web Space ReconstructionWeb Space ReconstructionTechniquesTechniques

ZZ--plastyplasty

hourhour--glass flapglass flap

YVYV--plastyplasty transposition flaptransposition flap

VMVM--plastyplastyjumping man Zjumping man Z--plastyplasty

dorsaldorsal

volarvolar

Presenter

Presentation Notes

. . .a variety of local tissue flaps. Many of these techniques, however, do not permit complete release of the web space and depend upon scarred, burned tissue for reconstruction.

aa bb

aa bb cc

cc’’

dorsaldorsal

volarvolar

bb’’aa’’ cc’’

aa’’ bb’’

cc

STARplastySTARplastyTechniqueTechnique

HultmanHultman CS, CS, Ann Ann PlastPlast SurgSurg, 2005, 2005

Presenter

Presentation Notes

It occurred to me that many of these techniques did not take full advantage of the relatively uninjured, supple skin of the volar surface of the web. Secondly, none combined longitudinal and oblique releases. The STARplasty was developed to utilize tissue from the digital sidewalls and permit the maximum lengthening and widening of the web space.

Hand Burns: Recovery

Hand Burns:Hand Burns: RecoveryRecovery

• Rehabilitation – Occupational Therapy– Physical Therapy– Skin Care: Garments, Sunscreen, Moisturizers– Scar Management: Message, Silicone, Lasers (PDL, CO2 )

• Reintegration– Neuro-psychiatric Support– Functional Capacity Evaluation– Vocational Rehabilitation– Return to Work

Hot Press Hand Injuries:A Paradigm for Multidisciplinary Management

C. Scott Hultman, MD, MBA, FACS

SESPRSPuerto RicoJune 2009

UNCUNC

||

PlasticPlastic

||

SurgerySurgeryLeading through Innovation, Serving with CompassionLeading through Innovation, Serving with Compassion

Presenter

Presentation Notes

•• crush and thermal crush and thermal component component

•• wide range of wide range of morbidity morbidity

•• limited number of limited number of published reportspublished reports

•• longlong--term outcome term outcome unknownunknown

IntroductionIntroductionHotHot--Press Hand InjuriesPress Hand Injuries

Presenter

Presentation Notes

Hot-press hand injuries include both a crush and thermal component and can cause a wide range of morbidity. There exists a limited number of published reports, and the long-term outcomes are unknown

HotHot--Press Hand Burn Treatment, Press Hand Burn Treatment, AchauerAchauer et al,et al, J Burn Care J Burn Care RehabilRehabil 1998, 19;1281998, 19;128--130130

•• n=17, 1994n=17, 1994--19961996

•• nonnon--op (41%), STSG (47%), flap (12%)op (41%), STSG (47%), flap (12%)

•• ““normal hand function,normal hand function,”” ““goodgood”” cosmesiscosmesis

•• one complication (minor graft loss)one complication (minor graft loss)

•• no secondary reconstruction performedno secondary reconstruction performed

IntroductionIntroductionHotHot--Press Hand InjuriesPress Hand Injuries

Presenter

Presentation Notes

Previous work . . .

•• to provide a comprehensive, longitudinal, to provide a comprehensive, longitudinal, institutional review of hotinstitutional review of hot--press hand injuriespress hand injuries

•• to assess functional morbidity, need for to assess functional morbidity, need for secondary reconstruction, and vocational secondary reconstruction, and vocational rehabilitationrehabilitation

•• to propose recommendations for managementto propose recommendations for management

PurposePurposeHotHot--Press Hand InjuriesPress Hand Injuries

Presenter

Presentation Notes

The purpose of this study is to provide a comprehensive, longitudinal, institutional review of hot-press hand injuries, assessing functional morbidity, need for secondary reconstruction, and vocational rehabilitation, and to propose recommendations for management.

•• Prospectively assembled database Prospectively assembled database

•• N=56 patients N=56 patients

•• December 1994 to December 2008 December 1994 to December 2008

•• North Carolina Jaycee Burn CenterNorth Carolina Jaycee Burn Center

•• MultiMulti--disciplinary team of surgeons, hand disciplinary team of surgeons, hand therapists, rehabilitation counselors, social therapists, rehabilitation counselors, social workers, psychologists, and chaplainsworkers, psychologists, and chaplains

MethodsMethodsHotHot--Press Hand InjuriesPress Hand Injuries

Presenter

Presentation Notes

Using a prospective database, we identified 56 patients with hot-press hand injuries who were treated from 1994-2008, at an accredited regional burn center, by a multi-disciplinary team of surgeons, hand therapists, rehabilitation counselors, and chronic pain specialists.

HotHot--Press Hand InjuriesPress Hand InjuriesDistribution of Cases by Year, n=56Distribution of Cases by Year, n=56

Presenter

Presentation Notes

This slide demonstrates distribution of cases by year, showing a rapid rise in cases in the late 90’s.

•• ageage: : 37.0 years (range 1837.0 years (range 18--62)62)

•• gendergender: 41 female patients: 41 female patients

15 male patients15 male patients

•• languagelanguage: Spanish: Spanish--speaking 26/56 (47%)speaking 26/56 (47%)

ResultsResultsHotHot--Press Hand InjuriesPress Hand Injuries

Presenter

Presentation Notes

The majority of patients were young and female, with 47% who did not speak English as their primary language.

Mechanism of Injury

drydry--cleaning press cleaning press (39)(39)steam presssteam press (3)(3)industrial press industrial press (11)(11)home appliance home appliance (3)(3)


Presenter

Presentation Notes

Mechanism of injury was predominately dry-cleaning press, but also steam press, industrial press, and home appliance

•• time to presentationtime to presentation: : mode: 0 days median: 3 days mean: 8.8 days range: 0-120 days

•• admissionsadmissions: 39/56 patients (70%): 39/56 patients (70%)

•• length of staylength of stay: 10.4 days (range 2: 10.4 days (range 2--40) 40)

•• length of followlength of follow--upup: 17.5 months (range 1: 17.5 months (range 1--45)45)


Presenter

Presentation Notes

Although patients most commonly presented immediately after their injury, many patients had a significant delay in treatment, with a mean of 8.8 days. 70% of patients required admission, for a length of stay of 10.4 days. Mean length of f/u was 17.5 months, with a range of 1-45 months.

Burn Wound Characteristicstotal surface area: 118 cm2 (range 4-400 cm2)location: dorsal >> volar

hand and forearmleft (32), right (21), bilateral (3)

depth: superficial partial thickness (5)deep partial thickness (8)full thickness (43)


Presenter

Presentation Notes

Regarding burn wound characteristics, mean total surface area was 118 cm2. Most burns occurred on the dorsal surface of the non-dominant hand and were full-thickness in depth.

Surgical Managementoperative intervention: 48/56 pts (85.7%)

damage control: fasciotomy/CTR (4), amputation (4), fracture reduction/fixation (3)

staged excision: 17/48 pts (35%)acute coverage: STSG (35), FTSG (5), groin flap (7),

completion amputation (1)secondary coverage: posterior interosseous flap,

DMCA flap, radial forearm adipofascial turnover flap, free lateral arm flap, free serratus flap


Presenter

Presentation Notes

In terms of surgical management, 39/44 patients required operative intervention. Damage control procedures included fasciotomy in 4 pts, digital amputation in 4 pts, and reduction of fracture in 3 pts. 16/39 patients underwent staged excision. Acute coverage was accomplished via STSG in 26 pts, FTSG in 5 pts, groin flap in 7 pts, and completion amp in 1 pt. Flaps required for secondary coverage included an adipofascial turnover flap, a DMCA flap, a posterior interosseous flap, a free lateral arm flap, and a free serratus flap.

Functional Morbidity 38/56 pts (67.9%)chronic painchronic pain 1414compressive neuropathycompressive neuropathy 1111contracture (dorsal, contracture (dorsal, volarvolar, web), web) 1111nail plate abnormalities nail plate abnormalities 55boutonniere deformity boutonniere deformity 55stenosingstenosing tenosynovitistenosynovitis 4 4 mallet fingermallet finger 22intrinsic tightnessintrinsic tightness 22late flexor tendon rupturelate flexor tendon rupture 11unstable thumb IP jointunstable thumb IP joint 11


Presenter

Presentation Notes

In terms of functional morbidity, 68% of patients sustained complications or adverse sequela. This included chronic pain in 14 patients, compressive neuropathy in 11 patients, and soft tissue contractures in 11 patients. Other morbidity included nail plate abnormalities, tenosynovitis, boutonniere deformity, mallet finger, flexor tendon rupture, and unstable joint.

Secondary Reconstruction 28/56 (50%)nerve decompression 11

CTR (8), digital (4), Guyon’s canal (2), cubital tunnel (2), ulnar dorsal sensory (1), digital nerve graft (1)

contracture release 11tendon reconstruction 11

tenolysis (5), tendon repair (4), transfer (2), tenotomy (2), central slip recon (2)

joint reconstruction 5 capsulotomy (3), arthrodesis (3)


Presenter

Presentation Notes

Secondary reconstruction was performed in 50% of patients and included nerve decompression in 11 patients, contracture release in 11 patients, tendon reconstruction in 11 patients, and joint reconstruction in 5 patients.

Neuro-Psychiatric Sequelaenerve compression syndrome 11chronic pain syndrome 10reflex sympathetic dystrophy 4seizure disorder 2substance abuse 2post-traumatic stress disorder 9mood disorder 20

Critical support from Anesthesia, Physical Medicine, Neurology, Psychiatry, Alternative Medicine


Presenter

Presentation Notes

Regarding long-term outcome, function was limited by the following neuro-psychiatric sequelae: nerve compression syndrome in 11 patients, chronic pain in 10 patients, RSD in 4 patients, seizure disorder in 2 patients, PTSD in 9 patients, and mood disorder in 20 patients. Of note, patients received critical support from Anesthesia, Physical Medicine, Neurology, Psychiatry, Clinical Psychology, and Alternative Medicine.

•• all patients compliant with OT/PT all patients compliant with OT/PT

•• final impairment rating: 22.2% (8final impairment rating: 22.2% (8--84%), n=3184%), n=31

•• return to employmentreturn to employment full-time 14 (25%) restricted/modified 22 (39%) retired 1 (2%) disabled 4 (7%) lost to

follow-up 10 (18%) pending (need FCE, VR) 5 (9%)


Presenter

Presentation Notes

All patients were compliant with occupational and physical therapy. Mean final impairment rating was 22%, with a range of 8-84%. Despite this impairment, 64% of patients have returned to full-time or restricted/modified work. 4 patients are disabled 2ary to PTSD, and 10 patients were lost to f/u. 5 cases are still open and dependent upon the results of functional capacity evaluation and vocational rehabilitation testing.

•• potentially devastating injurypotentially devastating injury

•• significant longsignificant long--term morbidityterm morbidity

•• early and late complicationsearly and late complications

•• limitations in functional recoverylimitations in functional recovery

•• return to work can occur with return to work can occur with considerable rehabilitationconsiderable rehabilitation

SummarySummaryHotHot--Press Hand InjuriesPress Hand Injuries

Presenter

Presentation Notes

In summary, hot press hand injuries are potentially devastating with significant long-term morbidity. Despite early and late complications and limitations in functional recovery, return to work can occur but requires considerable rehabilitation

Successful rehabilitation dependent uponSuccessful rehabilitation dependent upon::•• Timely referral to an accredited Burn CenterTimely referral to an accredited Burn Center

•• Aggressive Aggressive periperi--operative hand therapyoperative hand therapy

•• Early excision and staged coverage Early excision and staged coverage (groin flap)(groin flap)

•• Secondary reconstruction Secondary reconstruction (nerve decompression)(nerve decompression)

•• Psychosocial support Psychosocial support

•• Multidisciplinary approachMultidisciplinary approach

ConclusionsConclusionsHotHot--Press Hand InjuriesPress Hand Injuries

Presenter

Presentation Notes

Success of rehabilitation appears to be dependent upon Timely referral to an accredited Burn Center, 2)Aggressive peri-operative hand therapy, 3)Early excision and staged coverage, 4)Secondary reconstruction, 5)Psychosocial support, 6)Multidisciplinary approach Plastic surgeons are uniquely positioned to facilitate the recovery and rehabilitation of these patients.

NC DHSR OEMS: Comprehensive Management of Hand Burns

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