The Effective Management and Outcome of Hand Burns

Burns is a common public health problem and these injuries can be accidental, suicidal or even homicidal in nature. Hands being the most active part of the body, are often involved in burns. Hand burns represent three percent of body surface area, and are involved in more than 80% of all severe burns. Hand burns predominantly affect young adults and therefore have serious social and financial implications. The hand is one of the most frequent sites of burns scar contracture deformity. The deformities and contractures result in lifelong physical problems and affects the normal functioning of the person.

Correction of Hand Deformities after Burn

Hand burns can lead to deformities even after successful primary healing. They are the most common cause of skin contractures involving the hand. This review article discusses ways to correct claw deformity, flexion contracture in palm and finger, and web space contracture, which are post-burn hand deformities commonly encountered in clinical practice. Loss of skin is the end result in many causes of hand deformities after burn. Therefore, reinforcing the lost skin is the principle of corrective surgery. Even if the skin is thicker than the full-thickness skin, it will engraft if damage to the tissue and blood vessels of the recipient is minimized. The thicker the skin, the less is the re-contraction and growth. The foot is an ideal donor site for skin graft on the hand. In particular, the instep or the area below the malleolar is a very good donor site. First web space of the hand is very important for hand function, and it must be reconstructed with Z-plasty, skin graft, and free flap step by step according to the degree of contraction.

Outcomes For Hand Burns Treated With Autologous Skin Cell Suspension In 20% Tbsa And Smaller Injuries

Hypothesis In order to address the confounder of TBSA on burn outcomes, we sought to analyze our experience with the use of autologous skin cell suspensions (ASCS) in a cohort of subjects with hand burns whose TBSA totaled 20% or less. We hypothesized that the use of ASCS in conjunction with 2:1 meshed autograft for the treatment of hand burn injuries would provide comparable outcomes to hand burns treated with sheet or minimally meshed autograft alone. Methods A retrospective review was conducted for all deep partial and full thickness hand burns treated with split thickness autograft (STAG) at our urban verified burn center between April, 2018 to September, 2020. Exclusion criterion was a TBSA greater than 20%. The cohorts were those subjects treated with ASCS in combination with STAG (ASCS(+)) versus those treated with STAG alone (ASCS(-)). All ASCS(+) subjects were treated with 2:1 meshed STAG and ASCS overspray while all ASCS(-) subjects had 1:1, piecrust, or unmeshed sheet graft alone. Outcomes measured included demographics, time to wound closure, proportion returning to work (RTW), and length of time to RTW. Mann-Whitney U test was used for comparisons of continuous variables, and Fishers Exact test for categorical variables. Values are reported as medians and 25 th and 75 th interquartile ranges. Results Fifty-one subjects fit the study criteria (ASCS(+) n=31, ASCS(-) n=20). The ASCS(+) group was significantly older than the ASCS(-) cohort (44 yrs [32, 54] vs 32 [27.5, 37], p=0.009) with larger %TBSA burns (15% [9.5, 17] vs 2% [1, 4], p <0.0001), and larger size hand burns (190 cm2 [120, 349.5] vs 126 cm2 [73.5, 182], p=0.015). Comparable results were seen between ASCS(+) and ASCS(-), respectively, for time to wound closure (9 days [7, 13] vs 11.5 [6.75, 14], p=0.63), proportion RTW (61% vs 70%, p=0.56), and days for RTW among those returning (35 [28.5, 57] vs 33 [20.25, 59], p=0.52). The ASCS(+) group had two graft infections with no reoperations, while ASCS(-) had one infection with one reoperation. No subjects in either group had a dermal substitute placed. Conclusion Despite being significantly older, having larger hand wounds, and larger overall wounds within the parameters of the study criteria, patients with 20% TBSA burns or smaller whose hand burns were treated with 2:1 mesh and ASCS overspray had comparable time to wound closure, proportion of returning to work, and time to return to work as subjects treated with 1:1 or pie-crust meshed STAG. Our group plans to follow this work with scar assessments for a more granular picture of pliability and reconstructive needs.

Adherence of Burn Outpatient Clinic Referrals to ABA Criteria in a Tertiary Centre: Creating Unnecessary Referrals?

Initial assessment and triage of burns is guided by the American Burn Association criteria for referral to a burn centre. These criteria are sensitive but not specific, and can potentially lead to over-triage and “unnecessary” clinic visits. We are a Level 1 trauma centre with burn subspecialty care, and due to the COVID-19 pandemic, referrals to our multidisciplinary outpatient burn clinic required triaging for virtual care appointments. In order to improve the triage process, we retrospectively reviewed our outpatient burn clinic referrals over a 2-year period 2018-2019, for adherence to American Burn Association criteria. We collected data pertaining to patient and burn characteristics, as well as treatment outcome, to characterize referrals not requiring an in-person appointment. Of the 244 patients referred, 73% met the referral criteria, with 45% of these patients being healed at first visit and 14.6% requiring surgical management. Mean time from injury to first visit was 9.7 days (mode 6), and average number of visits was 2. Overall, mean burn size was 2%, with the majority of injuries being partial thickness (71%), located in the hand or extremity (77%). There was fairly equal distribution of contact (36%), flame (21%), and scald (26%) burns. This study highlights the non-specific nature of the American Burn Association referral criteria. We found that paediatric and hand burns in particular were over-triaged and lead to “unnecessary” appointments. This information is useful to help adjust referral criteria and to guide triaging of appointments with the evolution of telehealth and virtual care.

First preliminary Clinical Experiences using Hyperspectral Imaging for Burn Depth Assessment of Hand Burns

The accurate assessment of burn wounds is challenging but crucial for correct diagnosis and following therapy. The most frequent technique to evaluate burn wounds remains the clinical assessment often subjective depending on the experience of the physician. Hyperspectral Imaging is intended to counteract this subjective diagnosis by an accurate and objective analysis of perfusion parameters. The purpose of this study was to analyse the ability of technical burn depth assessment and to investigate a possible link between a certain value to burn depth versus value of healthy skin references. Methods A total of 118 subjects were included in this study between July 2017 and July 2019. 74 images with dorsal hand burns and 44 images of healthy skin on the dorsal hand as control group were analysed. In Hyperspectral Imaging recordings burn wounds were analysed with special interest to wound centre, intermediate zone, and wound margin. Results Significant results were determined for the differentiation between superficial partial burns and healthy skin. Furthermore, the distinction of full thickness burns was significantly possible. Conclusion Currently, it cannot be shown that the use of Hyperspectral Imaging technology significantly assesses the actual burn depth of thermal wounds of the dorsal hand reliably. However, the results show tendencies to improved analysis for differentiations supporting physicians in early objective optimal treatment selection.

Comparative study of Negative Pressure Wound therapy Vs. Local antibiotic cream dressings in acute hand burns second-degree superficial to deep

Background: The hand is one of the most common parts of the body involved in burns, i.e., 80%. Even minor burns in the hand may result in severe limitations of function. Early initiation of physiotherapy, topical antibiotic cream treatment, collagen application, splintage, passive exercise for second-degree superficial burns. Materials and methods: A prospective comparative study was conducted in 10 patients with acute hand burns due to thermal burns (scald, flame). All patients with second-degree superficial to intermediate thickness burns were given Negative pressure wound therapy (indigenous NPWT Kit) to one hand and local antibiotic cream to the other hand or other parts of the body to study clinical profile and outcome. Results: A total of 10 patients were studied. The majority of patients were in 19 to 30 years of age group 6 patients (60%), five females, and one male. Pediatric patients account for 4 patients (40%), two female and two male children. Incidence of burns in females 70% and males’ group 30%. Significant reduction in postburn edema in NPWT hand compared to topical antibiotic cream dressing. Healing is fast in NPWT applied hand/part. Conclusion: Negative Pressure Wound Therapy for Acute second-degree superficial burns showed promising results in wound healing and reduced post-burn edema burn in hand in our study.

657 Bilayer Dermal Substitute in Management of Deep Hand Burns

Introduction Bilayer dermal substitutes, composed of bovine collagen cross-linked with glycosaminoglycan and silicone, have become increasingly integrated into the algorithm for management of complex burns. In complex hand burns, dermal substitutes improve functional and aesthetic outcomes while also allowing early excision in high percentage TBSA burns. We detail the outcomes of 17 patients with 25 cases of complex hand burns managed at our center using a staged procedure of cadaveric allografting followed by dermal substitute placement and early definitive STSG. Methods Between Jan 2018 and Aug 2019, all patients who sustained deep partial/full thickness burns to their hands managed with dermal substitution were identified. Patients less than 18 yo, with additional non-burn trauma to the hands, and with initial operative management at another center prior to transfer were excluded. A retrospective chart review was used to collect data regarding time to operative excision, placement of allografts and substitutes, definitive STSG, and functional outcome. Results 17 patients from 18 and 89 yo presented with 25 deep partial/full thickness hand burns. TBSA varied from 0.75 to 78% (mean 17.7%). On average, patients underwent first excision 5.3 (2–16) days after initial burn or 4.2 days after presentation. Our protocol often uses allografting prior to placement of the dermal substitute, therefore, 22 of 25 burned hands received cadaver allografts at initial excision. Dermal substitute was placed an average of 9.2 days later. 3 of 25 burns had immediate application of dermal substitute at first excision. Following substitute, non-meshed, split-thickness autografts were placed on 18 hands. 5 of the burns did not require STSG and two hands were not further evaluated due to loss of patient follow-up. Of the 25 cases, all had near complete incorporation of the substitute without need for revision. In follow-up, patients who did not require STSG have shown no major limitations in ROM/scarring. Of those who underwent STSG, 6 hands underwent contracture release, with 2 of these progressing to amputation. One hand required repeat autografting due to graft loss. All remaining 18 hands healed well with near complete graft take and minimal scarring or functional limitation. Conclusions Dermal substitutes assist in the closure of complex deep hand burns. Cadaveric allografting prior to placement of the substitute ensures an appropriately excised wound base, allowing for near complete integration without need for reapplication. Autografting following dermal substitution placement may be initiated earlier than previously pursued and occasionally allows for healing without STSG.

113 Long-term Reconstructive Surgery of the Burned Hand: 16-year Experience at a Major Burn Center

Introduction Early excision and grafting for deeper hand burns is important for preservation of long-term hand function. Little information exists on long-term reconstructive and revision operations after acute grafting. Limited quantitative data is available on early predictors of this outcome. This study retrospectively examines a cohort of patients who underwent excision and grafting of acute hand burns and details their reconstructive course in the years after injury. Predictors of future reconstructive hand surgery are examined. Methods A retrospective review was conducted using medical records of patients admitted with acute burn injury to a major regional burn center from February 1999 to October 2015 and who subsequently underwent excision and grafting for closure of the acute wound. Information collected included demographics, burn size and etiology, anatomical involvement, grafting, contracture release, local tissue rearrangement, and regional and distant flaps. Regression analysis assessed for demographic and clinical predictors for future contracture release with grafts and/or local tissue rearrangement surgery. Results A total of 704 hands in 532 adults (71% male, median age 40 years, average burn size 14.9% TBSA) met study criteria (Table 1). Ninety-eight patients underwent at least one reconstructive surgery (122 burned hands). Mean length of follow-up was 1000 days. Multivariable logistic regression analysis showed that male gender was negatively associated (p< 0.001; OR 0.369; 90% CI, 0.233–0.584) with contracture release with graft whereas white race (p=0.030; OR 2.060; 90% CI, 1.192–3.560) and burn size ≥21% TBSA (p< 0.001; OR 3.962; 90% CI, 2.224–7.057) were positively associated. Males had a negative association (p=0.023; OR 0.527; 90% CI, 0.332–0.837) and burn size a positive association with local tissue rearrangement (5–10% TBSA - p=0.041; OR 2.149; 90% CI, 1.161–3.975 and >21% TBSA - p< 0.001; OR 4.230; 90% CI, 7.927). Conclusions Approximately 1 in 6 acutely grafted hands underwent at least one reconstructive surgery of clinically significant contractures, primarily in digits and web spaces. Female gender and burn size were positive predictors of both categories of reconstructive surgery while white race was a positive predictor of release and graft.