Comprehensive Management of the Burned Hand Flashcards
Fat grafting for chronic pain and pruritus
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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.
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areas that must be released
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
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
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elevation ofthe extremity,
splinting in an intrinsic plus position
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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
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Second-degree burns, indeterminate or intermediate
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
Managment of scald burne
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
routinely use tourniquets for excision of hand burns
F because the
surgeon must identify the level at which the tissues exhibit fine,
punctate, capillary bleeding
xenografting ( <36 hours after injury) permits rapid discharge from the hospital
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the digits are grafted with the metacarpophalangeal joints
in flexion and the distal interphalangeal joint (DIPJ) and proximal interphalangeal joint (PIPJ) in extension
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For patients
who have an evolving burn wound or whose depth and viability
are uncertain at the time of excision, meshed allograft is indicated
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Scar management, from the early to late phases ofwound healing,
remains the focus ofrehabilitation
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Initially, successful edema management can yield impressive gains, as the patient transitions from the
use ofcompressive dressings to compression garments
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When I can start laser therapy for the burned patients
By 6 months, patients may be candidates for laser remodeling of burned skin, grafted areas, and donor site
where I should use PDL laser ?
two or three rounds of pulsed dye laser photothermolysis first,
targeting areas of persistent inflammation and increased vascularity of hypertrophic scars
and when should stop using PDL ?
The end points are reduction oferythema, with
improvement ofsymptoms such as pruritus and pain.
When cam start using co2 laserr
attention
is then turned toward resurfacing with fractional CO2 laser, targeting the thickness of the new scars, which have immature collagen
Although significant improvements can be achieved after one session, several rounds can yield dramatic gains in pliability
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Nearly all patients in our practice receive a maximum ofKenalog 1 mg/kg topically, applied in the
operating theater after laser resurfacing
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Occupational therapy should begin immediately, although compression garments should be restarted only after these channels close, within 6 to 24 hours.
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occupational therapy, which may last weeks to months
to years
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The chronic pain in burne can be manage with laser
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
Causes of chronic pain in burned patients
Neuropathic pain or nerve compression.or neuroma
For patients who still have neuropathic pain, but require pharmacologic control, what you can do as an adjunct treatment
fat grafting can be considered as an adjunct and has had increasing success in our practice
Chronic pain management options ?
Medical
laser
Decompression
Fat injection
take rates higher than 90%. with fat injection
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MOA of FAT
■ 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
W-plasties can increase the length of the scar
W-plasties do not add length
to the original scar but can improve form, despite no gains in function.
In case of development of common hand condition what is the plan of incision
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.
In first web contracture we need to release the abductor policies muscle
fasciotomies of the adductor pollicis and first dorsal interosseous muscles
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
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Patients with focal
contractures of the second through fourth web spaces how you can treat the contracture?
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
In almost all cases, the surgeon can identify
the location and extent of nerve injury
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Nerve conduction
studies, with electromyography, should be done for all burned patients with suspected nerve injury
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
digital neurolysis is performed in almost
all volar finger contractures to ensure integrity ofthe digital nerves
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patients with unstable, painful joints
that do not respond to the above interventions, arthrodesis can be performed
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Damage to the germinal matrix is irreversible
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if symptomatic
with nail fragmentation or splitting, is best treated with excision and/ or destruction ofthe germinal matrix itself, to effect nail plate ablation
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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
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