Comprehensive Management of the Burned Hand

Question 1

Fat grafting for chronic pain and pruritus

Answer 1

T

Question 2

the surgeon should proceed directly to fasciotomies,
especially if the patient has diminished or absent Doppler signals,
sensory changes, or clinical evidence of impending compartment
syndrome.

Answer 2

T

Question 3

areas that must be released

Answer 3

the carpal tunnel, Guyon canal, hypothenar and thenar muscle groups, interosseous muscles accessed through the dorsal hand, the radial vessels
in the distal forearm, the volar and dorsal compartments of the
forearm, the cubital tunnel at the elbow. and the brachia! vessels in the arm

Question 4

Patients with electrical injury represent
a special category because the pronator quadratus must also be decompressed, deep to the flexor tendons of the distal volar forearm

Answer 4

T

Question 5

elevation ofthe extremity,
splinting in an intrinsic plus position

Answer 5

T

Question 6

Second-degree burns superficial partial thickness of the hand topical bacitracin or mupirocin (if nasal swab is positive for methicillin-resistant staphylococcus aureus), covered with xeroform or Vaseline gauze,consideration of early xenograft placement without the need for
wound excision

Answer 6

T

Question 7

Second-degree burns, indeterminate or intermediate

Answer 7

Collagenase for 24 hours, followed by laser Doppler imaging to determine burn wound perfusion: if adequate, the wound should heal by secondary re-epithelialization; if not, the wound needs to be excised and autografted

Question 8

Managment of scald burne

Answer 8

a cost-effective option, which improves pain control and decreases length of stay, is superficial debridement of the wound with a soft scrub brush and xenografting, which permits the wound to heal by secondary re-epithelialization

Question 9

routinely use tourniquets for excision of hand burns

Answer 9

F because the
surgeon must identify the level at which the tissues exhibit fine,
punctate, capillary bleeding

Question 10

xenografting ( <36 hours after injury) permits rapid discharge from the hospital

Answer 10

T

Question 11

the digits are grafted with the metacarpophalangeal joints
in flexion and the distal interphalangeal joint (DIPJ) and proximal interphalangeal joint (PIPJ) in extension

Answer 11

T

Question 12

For patients
who have an evolving burn wound or whose depth and viability
are uncertain at the time of excision, meshed allograft is indicated

Answer 12

T

Question 13

Scar management, from the early to late phases ofwound healing,
remains the focus ofrehabilitation

Answer 13

T

Question 14

Initially, successful edema management can yield impressive gains, as the patient transitions from the
use ofcompressive dressings to compression garments

Answer 14

T

Question 15

When I can start laser therapy for the burned patients

Answer 15

By 6 months, patients may be candidates for laser remodeling of burned skin, grafted areas, and donor site

Question 16

where I should use PDL laser ?

Answer 16

two or three rounds of pulsed dye laser photothermolysis first,
targeting areas of persistent inflammation and increased vascularity of hypertrophic scars

Question 17

and when should stop using PDL ?

Answer 17

The end points are reduction oferythema, with
improvement ofsymptoms such as pruritus and pain.

Question 18

When cam start using co2 laserr

Answer 18

attention
is then turned toward resurfacing with fractional CO2 laser, targeting the thickness of the new scars, which have immature collagen

Question 19

Although significant improvements can be achieved after one session, several rounds can yield dramatic gains in pliability

Answer 19

T

Question 20

Nearly all patients in our practice receive a maximum ofKenalog 1 mg/kg topically, applied in the
operating theater after laser resurfacing

Answer 20

T

Question 21

Occupational therapy should begin immediately, although compression garments should be restarted only after these channels close, within 6 to 24 hours.

Answer 21

T

Question 22

occupational therapy, which may last weeks to months
to years

Answer 22

T

Question 23

The chronic pain in burne can be manage with laser

Answer 23

T laser surfacing to modulate components of neuropathic
pain, which may occur because of aberrant reinnervation of sensory nerves with damaged or absent sensory receptors within the burned of grafted skin

Question 24

Causes of chronic pain in burned patients

Answer 24

Neuropathic pain or nerve compression.or neuroma

Question 25

For patients who still have neuropathic pain, but require pharmacologic control, what you can do as an adjunct treatment

Answer 25

fat grafting can be considered as an adjunct and has had increasing success in our practice

Question 26

Chronic pain management options ?

Answer 26

Medical
laser
Decompression
Fat injection

Question 27

take rates higher than 90%. with fat injection

Answer 27

T

Question 28

MOA of FAT

Answer 28

■ Mechanical cushioning effects between the scar and underlying
structures
■ Disruption of aberrant innervation between sensory nerves and
scar
■ Release of growth factors and other cytokines from stem cells
present in the mesenchymal stromal vascular fraction of adipose
tissue

Question 29

W-plasties can increase the length of the scar

Answer 29

W-plasties do not add length
to the original scar but can improve form, despite no gains in function.

Question 30

In case of development of common hand condition what is the plan of incision

Answer 30

In general, normal incisions can be made through burn scars but we need to take in consideration the following
- surrounding tissue is not extensively undermined
- perforators from major vessels are preserved when encountered
- Wound healing may not be as robust as in unburned
skin, so closure often requires multiple layers
- sutures that are left in place for 10 to 14 days.

Question 31

In first web contracture we need to release the abductor policies muscle

Answer 31

fasciotomies of the adductor pollicis and first dorsal interosseous muscles

Question 32

Severe first web space contractures may even require placement of a
full-thickness skin graft and skeletal fixation of the thumb metacarpal
in abduction, with Kirschner wires for I to 2 weeks

Answer 32

T

Question 33

Patients with focal
contractures of the second through fourth web spaces how you can treat the contracture?

Answer 33

STARplasty, is a technique that permits transverse, longitudinal, and oblique release, and utilize a robust local flap, with central blood supply, to correct the angle of inclination and resurface the web space

Question 34

In almost all cases, the surgeon can identify
the location and extent of nerve injury

Answer 34

T

Question 35

Nerve conduction
studies, with electromyography, should be done for all burned patients with suspected nerve injury

Answer 35

F is only obtained if the patient’s history
and examination are not consistent,
occult compression is suspected in another location,
or if there are medicolegal concerns or requirements
for preauthorization

Question 36

digital neurolysis is performed in almost
all volar finger contractures to ensure integrity ofthe digital nerves

Answer 36

T

Question 37

patients with unstable, painful joints
that do not respond to the above interventions, arthrodesis can be performed

Answer 37

T

Question 38

Damage to the germinal matrix is irreversible

Answer 38

T

Question 39

if symptomatic
with nail fragmentation or splitting, is best treated with excision and/ or destruction ofthe germinal matrix itself, to effect nail plate ablation

Answer 39

T

Question 40

patients with significant fingertip abnormalities
may benefit from revision amputation that excises the nail apparatus and distal phalanx remnant, with closure using a volarly-based, innervated fillet flap over the distal portion of the middle phalanx

Answer 40

T