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HAND BURNS

HHAANNDD BBUURRNNSSS evere hand BURNS are especially problematic injuries because of theirpropensity for causing long-term disability. Proper treatment of theburned hand may mean that the patient can return to work and anormal , if a large portion of the body is burned, the importance ofthe hands in terms of overall functional outcome is often if not properly treated, BURNS of the hand can result in severe dys-function and significant morbidity. Simple interventions can make ahuge difference in final outcome. This chapter discusses specific interventions for treatment of a handburn. A thorough discussion of the treatment of the whole patient with a burn injury is found in chapter 20, BURNS . IInniittiiaall TTrreeaattmmeenntt Cleanse the burned hand with a gentle soap and cool water. Saline-moistened gauze also may be used for cleansing.

Hand Burns 323 Blisters A blister is a collection of fluid beneath a layer of burned skin. It repre-sents a partial-thickness injury (see discussion of depth of burn on the

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Transcription of HAND BURNS

1 HHAANNDD BBUURRNNSSS evere hand BURNS are especially problematic injuries because of theirpropensity for causing long-term disability. Proper treatment of theburned hand may mean that the patient can return to work and anormal , if a large portion of the body is burned, the importance ofthe hands in terms of overall functional outcome is often if not properly treated, BURNS of the hand can result in severe dys-function and significant morbidity. Simple interventions can make ahuge difference in final outcome. This chapter discusses specific interventions for treatment of a handburn. A thorough discussion of the treatment of the whole patient with a burn injury is found in chapter 20, BURNS . IInniittiiaall TTrreeaattmmeenntt Cleanse the burned hand with a gentle soap and cool water. Saline-moistened gauze also may be used for cleansing.

2 Remove any clothingor other material attached to the burned tissues. Grease embedded in burned tissues often can be removed by gentlywiping with a petrolatum ointment. If tar is stuck onto the skin, leaveit alone; it will separate as the tissues heal. If you pull the tar off, youprobably will remove healthy skin, making the injury worse than itneeded to be. Make sure that the patient s tetanus immunizations are up to date. Pain medication is important; intravenous administration of mor-phine is the most useful 34 KKEEYY FFIIGGUURREESS::Neglected handEscharotomy322 Practical Plastic Surgery for Nonsurgeons Apply an antibiotic ointment, such as silver sulfadiazine, to theburned areas, and cover lightly with gauze. Gentle cleansing with saline and application of antibiotic ointmentoptimally should be done twice each day, but daily is acceptable.

3 The hand should be kept elevated (on a pillow or folded sheet) tominimize swelling. Oral or intravenous antibiotics should be used onlyif signs of infec-tion are burned hand of a child who did not receive proper care. The hand isessentially nonfunctional and will not grow properly. A, Dorsal , BURNS 323 BlistersA blister is a collection of fluid beneath a layer of burned skin. It repre-sents a partial-thickness injury (see discussion of depth of burn on thefollowing page). In general, a blister serves as a useful biologic dress-ing because it allows the deeper tissues to remain in a sterile environ-ment. Blisters promote healing and decrease the blister alone is often the best initial treatment. However,some blisters become very tight, to the point that blood flow to the handis diminished. Ischemia can lead to further, unnecessary tissue blisters also interfere with hand and finger motion.

4 Therefore,when a blister feels very tight, it should be opened and the outer skinlayer should be removed. The top skin layer also should be removedfrom blisters that have burst or look as if they are about to to Debride a BlisterDebridement of blisters is not a painful procedure if done properly:1. Clean the area with Betadine or some other cleansing Use a knife or scissors to make an opening in the outer layer of theblister. 3. Remove the outer layer of the blister by cutting it off a few millime-ters from the point where it attaches to the surrounding nonblis-tered The fluid in the blister has a high protein content and may be almostgelatinous. Completely remove the fluid and gel-like material, andgently wipe the area with saline-moistened Apply antibiotic ointment to the area, and cover with of a Stiff and Useless HandA severe burn to the hand poses significant risk for long-term morbid-ity.

5 The injured hand tends to assume a flexed posture, which can leadto stiffness of the interphalangeal (IP) and metacarpophalangeal(MCP) joint ligaments. Without aggressive treatment during the timerequired for the burn to heal, the hand may become permanently stiffwith limited function. Occupational therapyis a vital component in the treatment of severehand BURNS . If a therapist is available, make the referral. Encourage the patient to move his or her hands and fingers often,especially at dressing changes. The nurse or family can move the fin-gers and hand for the patient if the patient is unable to do so. Activeand passive range-of-motion exercises should be Practical Plastic Surgery for Nonsurgeons Pain controlis important because movement hurts. Place the hand in a splint to prevent it from assuming the flexed po-sition that ultimately may limit function.

6 The splint should keep thewrist in 20 of extension, the MCP joints in 70 of flexion, and the IPjoints as straight as possible. The padding for the splint should bechanged if it becomes soiled. At a minimum, the patient should wearthe splint at night; critically injured patients should wear the splint atall times until the BURNS have healed. Careful tangential excision of the burn and split-thickness skingraftingshould be done relatively early (within days of the injury ifpossible) for full-thickness BURNS . This will prevent the development oftight scars, which can lead to severe movement limitations. Only healthcare providers with surgical expertise should undertake these proce-dures. See the discussion of surgical treatments for more DDeepptthh ooff BBuurrnnAs explained in chapter 20, BURNS , it is often difficult to determinethe severity of the burn at the first examination.

7 Reevaluate the burnonce it has been cleansed and regularly thereafter. BURNS are describedas first degree (superficial), second degree (partial thickness), and thirddegree (full thickness).The skin of the hand has a wide range of thickness. The skin over thedorsum of the hand is much thinner than the skin over the palmar sur-face. A more severe burn injury is required to cause a full-thicknessburn to the palmar vs. the dorsal surface. Because the extensor tendonsare so close to the surface, full-thickness BURNS to the dorsal surface ofthe hand can be especially problematic. TTaabbllee WWoouunndd CCllaassssiiffiiccaattiioonn*Partial-thi ckness BURNS can be superficial or deep. A superficial partial-thickness burn may have athin blister, and the skin will be soft and pink. A deep partial-thickness burn appears white and feelssofter than a full-thickness burn ; some hair follicles are still attached.

8 A deep partial-thickness burnoften behaves like a full-thickness DDeepptthhAAppppeeaarraanncceePPaaiinnSS eennssaattiioonnSuperficial (first-degree)Erythema+YesPartial thickness* (second Blisters, hairs (if present) stay+++Yesdegree)attachedFull thickness (thirdThick, leathery feel0 Nodegree)Pale colorHairs (if present) do not stayattachedThombosed veins may be seenHand BURNS 325 Estimating the depth of the burn is important to approximate time tohealing. First- and superficial second-degree BURNS should heal within2 weeks, whereas deep second- and third-degree BURNS can take 3 4weeks or longer to the BURNS do not show significant evidence of healing after 7 10 daysor if a full-thickness burn occurs in an area where tight scarring islikely, consideration should be given to early surgical intervention (seeTangential Excision).

9 SSuurrggiiccaall TTrreeaattmmeennttssEscharotomySevere, circumferential full-thickness BURNS of the hand and fingersrequire extra precautions. The burned skin becomes leathery and losesall elasticity. As the underlying tissues swell (from a combination ofthe burn injury and from the fluid that the patient receives), theburned skin cannot give, and pressure builds up in the build-up can lead to decreased circulation, which can resultin further loss of all patients with severe BURNS , check for palpable pulses at the they are not present, blood circulation to the tissues probably is inad-equate because of the tightness of the burned tissues. An escharotomymust be done emergently to prevent further tissue the placing of incisions into the burned tissues to releasethe tightness. Do not extend the incisions into the deeper tissues; cutthrough the burned tissue only.

10 Incisions must be placed with care to pre-vent injury to the important underlying nerves, tendons, and can be done at the bedside. Caution:Escharotomy can bea bloody procedure. Be sure that blood is available, along with gauze,clamps, and an electrocautery the eschar itself has no sensation, the procedure can be quitepainful. Intravenous morphine or intravenous sedation/general anes-thesia is Treat the FingersAn incision is made along the side of the finger. Usually only one inci-sion is needed on each finger. Try to avoid placing the incisions on theradial borders of the fingers. Placing the incisions along the ulnar sur-faces of the fingers will prevent future problems with scar sensitivitywhen the patient attempts to grasp Practical Plastic Surgery for NonsurgeonsTo Treat the Hand Four dorsal, longitudinal incisions should be made between the meta-carpal bones.


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