Annals of Burns and Fire Disasters - vol. XIII - n. 2 - June 2000

INTERDIGITAL BRIDGING FOR TREATMENT OF THE BURNED HAND

Ullmann Y.,Lerner A.,Shtein H.,Peled I.J. - Israel

Departments of Plastic Surgery and Orthopaedics W, Rambarn Medical Centre and the Faculty of Medicine, Technion, Haifa, Israel

RESUME. A simple method is presented for bridging between burned fingers in order to keep the webs open during and after surgery. This "trick" can be tried when Kirschner wires are used during surgery for stabilization of the interphalangeal and metacarpophalangeal joints. Horizontal wires are connected to the free ends of the intradigital wires by means of bone cement. Stabilization of the skin grafts is easier, fewer bandages are needed, and good preservation of the webs can be achieved. Our experience is based on the patient described and on four others, in whom the method was used to treat burned hands.

Dealing with the deeply burned hand is a great challenge for the reconstructive surgeon. Deformation of the fingers due to scar contracture is a common consequence. Contracture of the fingers sometimes occurs in spite of early skin grafting, good splinfing, and vigorous exercises, and early treatment of the problem may prevent long-term disability. We suggest the use of internal splinting for a limited period, after release of the contracted scar and skin grafting.The use of internal fixation stabilizes the interphalangeal and the metacarpophalangeal joints, and this allows good positioning of the fingers and immobilization until the grafts take.In this paper we describe a "trick" to maintain good separation of the fingers while internal splints are being used, with a view to reducing the common phenomenon of web space contracture.

Case history

A 20-yr-old soldier was admitted to our burn unit with a 50% TBSA deep burn caused during a military operation. The patient underwent early excision of the eschar on the third day post-burn. About 20% of the bare areas, including the neck, hands, and elbows, were covered by splitthickness autografts. Cryopreserved homografts were used to cover the remaining excised areas. During the third week post-burn the patient was taken back to the operating room, where the homografts were exchanged for autografts. Owing to the deep hand burns, which were complicated by the delay in healing, and in spite of early surgery, meticulous splinting, and vigorous exercises, the patient developed scar contracture. This affected the metacarpophalangeal and interdigital joints of both hands.
When the scar contracture limited the extension of the finger to the point that exercise could not remedy it, the patient was taken once again to the operating room. The scars in the right hand were opened and covered with fullthickness skin grafts, and Kirschner wires were inserted from the tips of the fingers through the interdigital and the metacarpophalangeal joints into the metacarpal bones, in order to keep the fingers extended. To keep the fingers apart, we constructed an interdigital bridging, placing horizontal wires between the free ends of the intradigital wires. We used bone cement (CMM Depuy International Ltd., Blackpool, England) to fix these horizontal wires. This cement is widely used by orthopaedic surgeons to fix endoprostheses to the bone. It is necessary to wait five minutes for stabilization of the cement.
The bridging technique made it possible to keep the fingers widely separated, ensuring better healing of the web areas (Fig. 1). Minimal dressing was needed over the grafts, and complete healing of the fingers was achieved after two weeks, when the wires were taken out and intensive physiotherapy was started. Thermoplastic splints were used at night, and pressure garments were used 23 h a day. The fingers remained nicely separated and functional one year after the last surgery (Fig. 2), with only the second left web space requiring further separation. The same procedure was applied to the left hand, three months after surgery in the right hand, with satisfactory results.

Fig. 1a - Interdigital bridging using K wires and bone wax two weeks after surgery. Palmar view. Fig. 1b - Dorsal view of right hand.   Fig. 2 - Hands of same patient one year later. The right third-finger distal phalanx could not be straightened and was later amputated.

Discussion

It is well known that in some patients with deep hand burns, the scars - despite excellent splinting and physiotherapy - begin to contract and form secondary deformities. These cases should be treated early, in order to prevent badly positioned autofusion.The use of Kirschner wires for the positioning of joints is well described. It helps to overcome the malpositioning of the joints, facilitates stabilization of the skin graft, and eliminates the need for bolster dressing.
Web contracture is a common consequence of burns involving the hands. It can take the mild form of dorsal hooding over the web space, or syndactyly.
Many techniques have been described for reconstruction of these areas, including Z-plasties, local flaps, and grafting.
We believe that the "trick" we describe can help in this problematic area, both during initial care and later on when further reconstruction is needed. We have used this method in four other patients during the last year, and we have found local treatment easier and the end results more satisfactory than those obtained with conventional methods.
The necessary materials are available in every operating theatre and are not expensive. No special skill is needed for this simple extra splint.

RESUME. Les Auteurs présentent une méthode simple pour créer un pont entre les doigts brûlés afin de maintenir ouvertes les toiles pendant et après l'intervention chirurgicale. Ce "truc" peut  être employé quand le chirurgien emploie les broches de Kirschner pour stabiliser les jointures interphalangiennes et métacarpophalangiennes. Moyennant des fils horizontaux il faut attaquer lesextrémités libres des broches interdigitales avec du ciment osseux. La stabilisation des greffes cutanées devient plus facile, on emploie une quantité mineure de pansements, et on obtient une bonne conservation des toiles. L'expérience des Auteurs se base sur les résultats obtenus dans le cas qu'ils présentent et sur quatre autre cas oû la méthode a été employée pour des mains brûlées.

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