Primary operative management of hand burns
- Samuel P Mandell, MD, MPH, FACS
Samuel P Mandell, MD, MPH, FACS
- Assistant Professor of Surgery, Department of Surgery
- Harborview Medical Center
- University of Washington
- Matthew B Klein, MD, MS, FACS
Matthew B Klein, MD, MS, FACS
- Clinical Associate Professor
- Stanford University Division of Plastic Surgery
- Section Editors
- Marc G Jeschke, MD, PhD
Marc G Jeschke, MD, PhD
- Section Editor — Burn Surgery
- Director Ross Tilley Burn Centre
- Sunnybrook Health Sciences Centre
- Professor, Department of Surgery and Plastic Surgery
- University of Toronto
- Charles E Butler, MD, FACS
Charles E Butler, MD, FACS
- Section Editor — Plastic and Reconstructive Surgery
- The University of Texas, MD Anderson Cancer Center
Over 80 percent of severe burn injuries involve the hand and thus have a tremendous impact on daily function and quality of life . Effective treatment of hand burns requires a multifaceted and interdisciplinary approach that includes burn surgeons, plastic surgeons, rehabilitation physicians, and physical therapists.
The initial surgical approach to the patient with a burned hand, including the primary and secondary assessment and primary operative management, are discussed here. Surgical techniques used for primary coverage of burns (eg, skin grafts, free flaps) are also used for reconstruction of burns. The principles of reconstruction and operative procedures for secondary or delayed reconstruction of burns to the hands are reviewed elsewhere. (See "Principles of burn reconstruction: Extremities and regional nodal basins", section on 'Hand'.)
INITIAL EVALUATION AND MANAGEMENT
The initial evaluation of the patient with a hand burn begins with a thorough history and physical examination. Information about the mechanism of injury and the circumstances surrounding the injury may provide insight into the potential depth of the burn and healing capacity. The patient's hand dominance, occupation, and prior hand injuries should also be ascertained.
The focus of the physical examination is to estimate the severity and depth of injury as well as the viability of the hand and digits. Adequate hand perfusion is present if the radial and ulnar pulses are palpable; Doppler assessment should be done if pulses are not palpable. Each digit should be evaluated separately for perfusion by Doppler . Patients at greatest risk for loss of perfusion are those who have full thickness burns, circumferential burns, or associated crush injuries and lacerations.
Signs of poor perfusion include [2-6]:
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- INITIAL EVALUATION AND MANAGEMENT
- SECONDARY MANAGEMENT
- Neurovascular compromise
- - Escharotomy
- - Fasciotomy
- - Peripheral nerve release
- - Amputation
- Tissue loss
- - Excision and skin grafting
- - Tissue flaps
- SURGICAL ANATOMY
- OPERATIVE MANAGEMENT
- SURGICAL PROCEDURES
- Excision and grafting
- Dermal regeneration templates
- Tissue flaps
- Biobrane glove
- Vacuum-assisted closure
- POSTOPERATIVE CARE
- Physical therapy
- Edema management
- FOLLOW-UP CARE
- SUMMARY AND RECOMMENDATIONS