Roje ZŠ.,¹ PetricŠevic´ T.,² Roje ZŠ.,³ Karanovic´ N.^2
1 Division of Plastic Surgery and Burns, Department of Surgery, University Hospital, Split School of Medicine, Split, Croatia
² Division of Anaesthesiology and Reanimation, University Hospital, Split School of Medicine
³ University Hospital, Split School of Medicine

SUMMARY. Aim: To evaluate preferences and the quality of non-fully expanded mesh skin grafts compared with sheet skin grafts in the surgical treatment of deep hand burns. Method: Forty patients in the Division of Plastic Surgery and Burns in Split, Croatia, with clinically manifest deep hand burns of various aetiology were surgically treated during the period 1989-1997. The patients were divided into two subgroups. The first group (20 patients) was treated with early tangential excision and mesh non-expanded skin grafts. The second group (also 20 patients) was treated with early tangential excision and sheet skin grafts. All the patients were treated according to standard management protocol for the pre-, peri-, and post-operative period. The results of the treatment were estimated and the advantages and quality of non-fully expanded mesh skin grafts were compared with those of sheet skin graft for the same purpose. Results: The evaluation of the results was based on functional results, morbidity, appearance and manifestation of burn wound infection, type of skin graft, graft lyses, post-operative range of movement in small joints, scarring and contracture, aesthetic results, and quality of life. Detailed results are given. The main criteria for treatment success were the total number of operations until full healing of skin grafts, the percentage of healing in sheet and mesh non-expanded skin grafts, range of movement in small joints, occurrence of hypertrophic scars and post-burn contractures, web contractures, artificial syndactyly, and aesthetic appearance. In the follow-up period (5 years), all the patients were treated with pressure garments, plus individual physical and occupational therapy. Conclusion: The method of early tangential excision and skin grafting with non-expanded mesh graft in deep hand burns gave good functional and aesthetic results. Mesh non-expanded skin graft was used in cases of poor general health, manifest burn wound infection, and high percentage of total body surface area burned. The higher healing rate, reduced formation of haematoma and seroma, reduced burn wound infection, and good functional and aesthetic outcome showed that mesh non-expanded skin graft had many advantages over sheet skin graft. Early physical and occupational therapy and the use of pressure garments reduced the formation of scars and contractures, chronic joint stiffness, and other functional limitations.

Introduction

Hand function evolves and improves continuously, and work and practice affect the way in which hand functionality develops (there is a big difference, for example, between a violinist’s hand and that of a manual worker).

In the overall number of body burns, hand and wrist burns account for some 39%, usually being part of a larger burned surface or a self-standing local injury. They fall into the category of “functional burns”. Recent analytical studies concerning injuries have established that the hand and wrist are affected in 35.8% of cases.1 An analysis by the US Army Institute of Surgical Research shows that hand and wrist burns were present in 89% of 568 burns analysed.2,3 The clinical manifestation of hand burns is directly related to the aetiology of the burn (thermal, electrical, chemical and radiation).

Hand burns can either be located only on the hand or be part of a larger burned body surface. Each clinical type requires a specific therapy until full recovery. The dispute between early surgical treatment, including early tangential excision and skin grafting, and late tangential excision and skin grafting after eschar demarcation is still going on.^3,6-11

There are two main clinical types of hand burn:

1. exposed - burns mainly on the dorsal side;
2. contact - burns mainly on the volar side.

Dorsum hand burns are usually in both hands. The hand by reflex action clenches and covers the face. The back of the hand cannot however be protected by the mechanism of clenching. Dorsum skin is thin, has less subcutaneous tissue, and is therefore liable to deeper burns. The burn usually affects tendons, muscles, bones, and joints. Digital adhesion and joint stiffness are the consequence of burn depth, long-lasting oedema, and local bacterial infection, causing connective tissue proliferation, stiffness, and contractures, with various hand deformations.

Palmar burns are usually isolated injuries in one hand only, and are rarely part of a larger burned surface. In most cases these are deep burns affecting deep functional structures. Generally speaking, they are not life-threatening, but their total treatment is complicated and complex.

In addition to heat as an aetiological burn factor, in everyday life we encounter other causes such as electric current and chemical agencies. Electric current produces specific tissue damage as a result of the combined action of various factors: voltage, amperage, resistance, current pathway and type, current flow duration, and the point of contact with the current. The damage is greater than can be seen directly on the injured surface. These burns are usually accompanied by other injuries, e.g. fractures and internal injuries due to the fall and fractures with tetanic contraction. Subfascial oedema develops because of damage to muscles, blood vessels, and nerves, accompanied by circulation and sensibility disturbances. In such cases it is necessary to perform decompression, using either escharotomy or fasciotomy.

Chemical agencies (acid and alkaline) also produce specific tissue damage. Complete neutralization using the appropriate antidote is required in such cases. The onset of burn necrosis is a sign that the agent has not been completely neutralized. In practice we encounter burns caused by NaOH, ammonium, nitrous, sulphuric, and hydrofluoric acid, and phosphorus.

From the surgical point of view, deep dermal and subdermal hand burns are especially important. Deep dermal burns present a pale surface and a waxy appearance. The blisters are less clearly expressed, while paraesthesia together and other changes in sensibility are more manifest. Post-burn oedema can cause the Esmarch effect. Intravenous coagulation causes eventual redness. The coagulation zone involves most of the dermal layer. The remaining dermis can be considered a zone of injury with a high risk of conversion. Oedema is widespread throughout the burn, and the necrotic tissue remains adherent, requiring either necrolysis or surgical debridement for removal.

Subdermal burns destroy the entire epidermis and dermis, leaving no space for residual epidermal cells to repopulate. Vascular burn tissue is waxy-white in colour and painless. If the burn produces charring or extends into the fat, it is leathery brown or black, with surface coagulation veins. Subdermal fat tissue and other deep structures are affected and require special treatment methods.

The main rule in hand burn treatment, whatever the aetiological factor and the age of the patient, is to ensure primary healing of the burn injury and prevent anatomical deformities and loss of hand functionality.

All burns in which the subpapillary capillary plexus is damaged are considered deep. After 48 h it is possible to make a clinical differentiation between superficial and deep burns. An accurate estimate of burn depth, on which the correct choice of skin grafting depends, can be made only during excision. The depth is established by assessing the colour of moist and non-macerating surfaces, by the touch and pain test, by the capillary refilling test, and - in doubtful cases - by a small diagnostic excision. Results are much better in localized hand burns.

Primary burn wound excision, in the first 24 h, is especially indicated in following cases: deep subdermal hand burns in stable patients, electrical hand burns affecting deep structures, and circumferential extremity burns.

The age of the burn patient is an important factor in the choice of treatment programme. In the older age range, whether early tangential excision has been performed or not, the occurrence of subsequent partial necrosis and amputation is more frequent. They are also more exposed to even severer illness. In children it is necessary to postpone early tangential excision (ETE) and skin grafting (SG) of the burn wound until clear demarcation of burn necrosis is visible. In particular, in children, palm burns need a longer immobilization period. Also, co-operation during the course of physical therapy is more difficult, and this leads to a longer immobilization period. However, it is rare for stiffness to occur in small hand burns.

The purposes of this work are:

1. to estimate the advantage of early tangential excision and skin grafting with mesh non-expanded split-thickness skin graft (STSG) compared with ETE and skin grafting with sheet STSG;
2. to analyse these two skin graft types during harvesting and preparation for transplantation and in the post-burn period during healing of STSG with regard to the superior quality of mesh non-expanded STSG compared with sheet STSG.

Early tangential excision and skin grafting are used in all deep hand burn surfaces in order to achieve the main aim of wound healing, i.e. early closing. An analysis of the relationship of STSG to the appearance of haematoma, seroma, burn wound infection, STSG lysis, stiffness, scarring, and contractures clearly indicates the superior quality of mesh non-expanded STSG compared with sheet STSG.

Criteria for the estimation of the success of deep hand burn treatment are neither systematized nor standardized, but we believe that the results of our analysis of ETE and SG with non-expanded mesh STSG compared with sheet STSG are acceptable as regards the estimation of the success of deep hand burn treatment. Nevertheless, there is a certain degree of consensus that hand burns require a special manner of treatment. According to the American Burn Association, hand burns should be classified in the category of large functional burns. Their treatment must ensure the best possible hand function, and all procedures must be subordinated to this goal. It is better to prevent post-operative complications in good time than to solve them with difficulty during later treatment.

We use 1:1.5 or 1:2 mesh STSG, not fully expanded (max. 25-30%). In this way a larger transplantation surface is obtained, plus good seroma and haematoma drainage, a smaller rate of burn wound infection, and better overall STSG healing. In cases where there is a possibility of a crisis caused by harvesting, the lasting quantity of STSG is assured. The correct use of early physical, occupational, and pressure therapy (i.e. gloves and elastic bandages) reduces the formation of scars and the occurrence of contractures

Patients and methods

This work is a retrospective study based on the analysis of patient records from the Burn Unit of the Division of Plastic Surgery and Burns, Surgery Department, Split University Hospital, Split School of Medicine, Croatia.

Between 1989 and the end of 1997, a total number of 40 deep hand burns of various aetiology were surgically treated. The samples were well stratified, accidental, and independent. The patients were divided into two groups, each consisting of 20 cases. Altogether, 40 autotransplantations were performed - 20 mesh non-expanded and 20 sheet STSG.

Twenty-four patients (60%) were male, ten (25%) were female, and six (15%) were children. The average age of the males was 37.2 ± 18.1 yr and that of the females 44.8 ± 20.3 yr.

In 32 patients (80%) combined hand and body burns were present, while in 8 cases (20%) there were only hand burns.

The patients’ vital functions and general conditions were determined on admission to the burns unit. The initial procedure in all cases was reanimation. Debridement was performed in order to evaluate the extent, location, and primary contamination of the burn wound. The burn surface was dressed with adsorptive dressing and antiseptic solution or topical antibiotic cream, i.e. silver sulphadiazine (SSD).

Hand and forearm escharotomy and fasciotomy were performed in cases where signs were present of compressive ischaemia, with a decrease or loss of peripheral pulse, together with paresis and impaired capillary refilling. Additional release of the intrinsic compartment reduced the risk of ischaemic necrosis and subsequent intrinsic minus deformity of the burned hand.

The hand was positioned in an anti-deformation splint and elevated above the right atrium. A daily programme of exercise and hand occupational therapy was performed.

The pathogenesis of tissue damage in electrical injuries was complex. However, two main mechanisms predominated: 1. heating generated by electric current, resulting in thermal burns, and 2. denaturation of cell membrane proteins and lipids by direct electric force. Electrical injuries were divided into high-tension and low-tension injuries, based on voltage and the contact point.

Chemical injuries were categorized in four groups: acid burns, alkali burns, phosphorus burns, and chemical injection injuries. The mechanisms of injury and methods of treatment differed between the four groups, although there were some common factors.

Surgical treatment was always performed under general endotracheal anaesthesia with the use of a tourniquet.

The burn wound was excised using the early tangential excision technique, preserving the maximum amount of viable tissue, whenever possible. The best time to perform such excisions was between 3 and 5 days post-burn. This time interval best suited the line of reversible changes in blood vessels in the burn wound and the saprophyte flora latency time. Owing to the existing oedema, the excision was simple and bleeding soon stopped. Conversely, the excision became more complicated if performed more than 5 days post-burn. The reason for this was that the burn necrosis became deeper because of the activation of infection and other reactive inflammatory changes.

All sterile and clinically vital excised surfaces were primarily covered with the appropriate skin grafts.

Generally, sheet STSG is preferred to mesh STSG, although the mesh holes permit better haematoma and seroma drainage and additional wound infection control. The risk of fluid accumulation under sheet STSG can be reduced by fenestration of sheet STSG with a scalpel blade. Skin grafts are held in place at the edge using sutures or staples. We know that sheet and non-expanded mesh STSG have the same functional outcome. But the aesthetic outcome is different: sheet graft is superior to mesh graft.^5,26,51 In our opinion there is always the risk of a crisis due to STSG harvesting, and we therefore use mesh STSG, expanded to 25-30% of its surface. We have used this technique in patients with massive burns in whom the harvesting areas were extremely limited and who presented poor general conditions and burn wound infection prior to surgery. We covered the grafts with tulle grass, moist dressings with physiological solution, and bandaging. After surgery the hand was splinted in a protected position until the graft stabilized. Active motion usually started on post-operative day 7 (Figs. 1, 2).

Scars and contractures are best controlled by simultaneously combining early physical and occupational therapy with the use of pressure garments and contact media (i.e. silicon sheets). A higher level of functional recovery and quality of life are achieved in this way, as well as better aesthetic results.

The follow-up lasted from 3 months to 5 years and included 86% of the patients. All patients in the post-operative period were treated with pressure garments (i.e. gloves or elastic bandages). They were given individual physical and occupational therapy programmes and they exercised the hand. The following parameters were reviewed at check-ups: scars, stiffness, contractures, range of movement, use of pressure garments, and the functional and aesthetic outcome.

The following tests were used in the statistical analysis:

1. quantitative variable: chi-square test (¯2, p), Mann-Whitney test (z, p);
2. qualitative variable in-group: Kruskal-Willis analysis of variables, Fisher exact test (N = 20 and < 20), Student’s t-test.

Results

In the period from 1989 to the end of 1997, 40 autotransplantations were performed in deep hand burns, of which 20 were mesh and 20 sheet STSG. Of the 40 patients, 24 were male adults (60%), 10 were female adults (25%), and 6 were children (15%). In the group of patients in whom sheet STSG was performed there were 16 males (80%) and 4 females (20%), while in the group of patients in whom mesh non-expanded STSG was used there were 13 males (65%) and 7 females (35%). Male and female patients were statistically equally present in the two groups (¯2 = 0.5; p = 0.48).

The mean age of patients with mesh STSG was 41.05 ± 20.2 yr, while that of patients with sheet STSG was 37.6 ± 17.8 yr. In both STSG groups there were no significant statistical differences as regards male and female age (z = 0.65, p = 0.52).

Hot water and flames caused the majority of injuries, followed by electric current and chemical agents (Table I).

There were 32 combined burns (80%) and 8 localized hand burns (20%). In the first group, consisting of 32 patients (80%), we performed 14 sheet STSG (44%) and 18 mesh STSG (56%). In the second group, consisting of 8 patients (20%) there were 6 sheet STSG (75%) and 2 mesh STSG (25%). The statistical difference between the type of STSG and the anatomical distribution of the hand burns was not significant (¯2= 2.7, p = 0.44) (Table II).

The percentage of TBSA in the group of patients in whom sheet STSG was performed was 11.7 ± 7.1, while in the mesh STSG group the percentage of TBSA was 21.65 ± 11.5. There was a statistically significant difference between the TBSA percentage in the mesh STSG group and that in the sheet STSG group (z = 2.8, p = 0.05) (Graph 1).

There were no significant statistical differences as regards the depth of the hand burns hand and the type of STSG (¯2 = 1.13, p = 0.29) (Graph 2).

Early tangential excision was performed by day 6.7 ± 1.5 in IIB and III degree burns and by day 5.9 ± 1.7 in III and IV degree burns (Graph 3).

The relationship of STSG to the appearance of haematoma, seroma, and burn wound infection and lyses of STSG was analysed in the early post-operative period. There was found to be a statistically significant difference in the STSG type as regards the appearance of haematomas, seroma, lyses, and burn wound infection (¯2 = 8.8, p = 0.013) (Graph 4).

The total percentage of healing in mesh non-expanded STSG was greater (80.0 ± 7.3) than healing with sheet STSG (67.5 ± 11.2) (t = 4.2, p = 0.000) (Graph 5). An additional one to three regrafting operations were required for total healing of the sheet STSG.

The main criteria for operative success were the total number of operations, the percentage of STSG healing, range of movement, the occurrence of hypertrophic scars and post-burn contractures, web contractures, syndactyly and aesthetic appearance, and the use of pressure garments.

Later follow-up

In the follow-up study all the patients were treated with pressure garments. They received individual physical and occupational therapy programmes according to the previously prepared protocols. We did not find any statistically significant difference regarding scars, contractures, and aesthetic outcome between mesh and sheet STSG, when used with early pressure therapy (Tables III-V) (Figs 3, 4).

Discussion

Hand and wrist burns have absolute treatment priority. Nevertheless, when they are part of a larger burn involving other body parts, they are classified in a lower priority group for necrectomy and skin grafting. The main principle in deep hand burn treatment is to remove all necrotic tissue and to perform an immediate skin graft.

Any spontaneous demarcation and re-epithelialization in deep hand burns leads to delayed burn wound healing. More granulation tissue is produced, together with greater fibrosis and scar formation, contractures and joint stiffness, and other hand disabilities and malfunctions.

Basic treatment in every hand burn must assure the recovery of optimal functioning with stable soft tissue cover. Hand burns must not necrectomize before there is enough STSG to cover the burn wound. It is necessary to reduce to the lowest possible level the need for reconstruction procedures and rehabilitation. This is why early diagnosis and early surgical treatment of deep hand burns have much greater significance than subsequent reconstruction of the invalid hand.

Initial evaluation and early treatment

Early treatment is based on the pathomorphological changes that come with deep hand burns. It is of great importance to establish the aetiology and the circumstances of the injury. The hand and fingers immediately assume the intrinsic minus position.

The progressive pathological process, with vascular compromise and the appearance of a compressive syndrome in a limb, demands adequate escharotomy and fasciotomy and the release of the compartment (p = 0.0036).

Because of the development of post-operative oedema, the level of active and passive range of motion in small hand joints is significantly reduced. Any prolonged and inadequate immobilization results in poor long-term function.

Further acute hand burn treatment

Robson et al. suggest six principles to be observed in deep hand burn treatment, based on pathomorphological changes in the burn wound.

1. Primum non nocere - do no harm

In the stasis zone, potential live tissue is present and this zone must be preserved as much as possible. After primary burn wound debridement it is possible to use closed treatment, with gauze and bandages (wet adsorptive bandages), to dress the burn with topical antibiotic cream such as silver sulphadiazine, or to place the hand in a latex glove or PVC bag after applying the SSD. In most cases we used the closed treatment method - the open method with topical antibiotics was used in only 12 patients (30%).

1. The preservation of circulation

In all cases of compressive ischaemia we used escharotomy and fasciotomy (p = 0.036). This occurred especially in electrical and chemical burns.

3. Prevention of infection

Burns destroy the skin’s defences against bacteria. The burn wound is primarily contaminated with saprophyte microbes. Infection usually manifests secondarily. It may consist of focal or multifocal bacteraemia or burn sepsis; it deepens the burn and destroys epidermal cells and vascular vessels in the dermal layer. All our patients received an anti-tetanus protection and topical antibiotics, either as SSD cream or povidone iodine solution. We prescribed systemic antibiotic therapy based on the results of the microbiological analysis.

4.Closure of the burn wound

The protracted duration of burn wound healing produces a great deal of fibroblast and collagen, which are directly responsible for the formation of hypertrophic scars and contractures. In deep hand burns, where more dermal levels are damaged, there are more hypertrophic scars. Early use of STSG significantly stops the formation of myofibroblasts, thus significantly reducing wound contraction and the formation of scars and contractures, especially in zones of joints and articulations.

Special attention is needed in electrical and chemical burns because of the depth of such burns. Necrectomy and grafting must be adequate. In electrical burns, muscular and blood vessel damage must be established in good time - at first they may seem normal but later they are bound to progressively lyse. The chemical agents must be completely neutralized prior to wound closing.

Our work is based on early burn wound excision and immediate skin grafting with mesh non-expanded STSG. The advantages of this approach are manifold:

• the operation can be performed early (best between 3 and 5 days), when the depth is already fixed;
• the operation is performed under a tourniquet - dead tissue is completely removed by tangential excision, and the maximum amount of viable tissue is preserved whenever possible;
• the grafts can be adapted and fixed, so that they do not move;
• sufficient drainage of seroma and haematoma is ensured through the holes in the mesh non-expanded STSG;
• if burn wound infection occurs, it can be effectively controlled;
• the time required for the epithelialization of temporary holes in the skin grafts prevents the appearance of granulation tissue.

The main STSG selection criterion for covering burn wound defects after necrectomy is the percentage of TBSA. In our experience, whatever the TBSA percentage, there is always a crisis when STSG is harvested. In our cases, burn surfaces where mesh non-expanded STSG was used (21.05 ± 11.7% TBSA) were statistically significantly larger than burn surfaces where sheet STSG was used (11.7 ± 7.1% TBSA) (p = 0.05).

The advantages of mesh non-expanded STSG are the larger total square surface, good drainage through the holes, the significantly lower formation of haematoma and seroma, the rarity of wound infection, the greater percentage of STSG healing, and the acceptable aesthetic results.

Sheet STSG, on the other hand, requires a perfectly prepared wound without any signs of bleeding signs to obtain good healing results. The skin graft has to be larger because of the greater primary contraction after the harvesting graft.

Primary lysing of STSG is the consequence of insufficient excision, bad contact with the wound base caused by seroma and haematoma, and manifest wound infection. Secondary lysing is the consequence of later blood vessel thrombosis and the development of infection.26,27 In our work the main reasons for lyses and the rejection of mesh non-expanded STSG were the patient’s poor general conditions, a high TBSA percentage, and manifest burn wound infection.

After surgical treatment of deep hand burns we tracked the following parameters as the main indications of success:

• percentage of healing with STSG;
• * range of motion;
• scar type;
• contracture type;
• number of operations until total healing of STSG;
• aesthetic results.

The percentage of healing with STSG was higher in mesh non-expanded STSG because there were less haematoma and wound infection.

The statistical analysis of range of movement established that the maximum recovery of hand range of movement was given equally by non-expanded mesh and sheet STSG and by correct hand position with early physical and occupational therapy and compressive therapy.

Scars produce itching, blisters, and contractures, and they look bad. They can be just an aesthetic deformity, but they can also significantly affect hand function. Mild desmogenic and hypertrophic scars are best stabilized with the early use of pressure therapy, with or without contact media. Contractures are the worst consequence of deep hand burns, which greatly restrict hand function.

6.Preservation and recovery of motion

The correct positioning and immobilization of the burned hand, early physical and occupational therapy, early surgery and skin grafting, graft fixation, and active and passive range of movement, together with the maintenance of muscle tonus of the hand and upper arm, are the best guarantee for preserving and regaining hand motion.

Functional rehabilitation

The use of pressure garments and contact media (i.e. silicon sheets) greatly decreases oedema and significantly affects the process of maturation and distribution of collagen in the wound, while at the same time it reduces the risk of secondary wound infection.

Follow-up

Follow-up checks with an analysis of functional state of the hand were performed over a period of 3 months to 5 years. The patients performed regular daily graft care in various ways: applying an adsorptive cream one or more times a day, wearing elastic garments with contact media, and performing daily physical and occupational therapy and work activities according to individual programmes.

Today, there are no unique criteria for estimating the success of deep hand burn treatment methods, nor are they standardized. The formation of scars and contractures is reduced by using early tangential excision and skin grafting, in combination with early use of pressure garments and early physical and occupational therapy, in both types of graft, thus assuring the highest possible functional recovery and the best aesthetic results. The main results of our analysis of mesh non-expanded and sheet STSG concern the total number of operations, epithelialization of temporary holes in mesh grafts, range of movement in small joints, scar formation of scars, contractures, pressure therapy, and aesthetic effect. We believe that these results can be useful for estimating improvement in deep hand burns treatment with mesh non-expanded STSG, which was perforated but not completely expanded (maximum 25-30% of total surface of expansion).

Conclusions

The most significant advantages of the methods described can be summarized as follows:

1. Tangential excision performed on a good viable burn surface that is moist and non-macerating can remove all clinically dead tissue.
2. The biological potential of the excising surface is reduced to 20% and if it is still exposed to the desiccation that is destroying it, this obliges us to cover the excising surface with STSG either immediately or in any case within 24 h.
3. Intermediate skin grafts must be co-ordinated in size and shape with the functional hand zones. We position them perpendicularly.
4. We are of the opinion that the possibility of a crisis after harvesting grafts always exists, and for this reason we use mesh STSG. The mesh is not totally expanded, but only to around 25%. Harvesting and the preparation of mesh STSG with a good medical team take a little longer than using sheet STSG. After placing the grafts on the wound bed we fix them at the edges.
5. We cover the grafts with tulle gras and moist dressings, and use physiological solution and bandages.
6. The hand is positioned in an anti-deformation splint and elevated above the right atrium. A daily programme of exercise and hand occupational therapy is performed.
7. The holes in mesh STSG permit good drainage of seroma and haematoma. Any haematoma can be easily removed through the holes in the mesh.
8. The percentage of healing with mesh STSG is better than with sheet STSG because of the severe lyses in sheet STSG (i.e. more haematoma, seroma, and burn wound infection), the greater percentage of TBSA, and the patient’s poor general conditions.
9. The overall look of mesh STSG, although it remains visible, satisfies aesthetic requirements.
10. The use of early physical and pressure therapy significantly improves scar stabilization and the functional and aesthetic outcome.

RESUME. But: Evaluer les préférences et la qualité des greffes cutanées en filet non entièrement expansées par rapport aux greffes cutanées pleines dans le traitement chirurgical des brûlures profondes de la main. Méthode: Quarante patients hospitalisés dans la Division de Chirurgie Plastique et des Brûlures à Split en Croatie atteints de brûlures profondes de la main cliniquement manifestes de diverse étiologie ont été traités pendant la période 1989-1997. Les patients ont été divisés en deux sous-groupes. Le premier sous-groupe (20 patients) a été traité moyennant l’excision précoce tangentielle et des greffes cutanées en filet non expansées. Le deuxième groupe (composé aussi de 20 patients) a été traité moyennant l’excision précoce tangentielle et l’emploi de greffes cutanées pleines. Tous les patients ont été traités selon le protocole normal pendant la période pré-, péri- et post-opératoire. Les résultats du traitement ont été évalués et les avantages et la qualité des greffes cutanées en filet non entièrement expansées ont été confrontés à la greffe cutanée pleine pour le même but. Résultats: L’évaluation des résultats a été basée sur les résultats fonctionnels, la morbidité, l’aspect et la manifestation des infections de la brûlure, le type de greffe cutanée, les lyses de la greffe, la gamme de mouvement post-opératoire dans les petites articulations, la cicatrisation et les contractures, les résultats esthétiques et la qualité de vie. Les Auteurs présentent les résultats détaillés. Les critères principaux pour le succès du traitement étaient le numéro total des opérations avant la guérison complète des greffes cutanées, le pourcentage de la cicatrisation des greffes cutanées pleines et en filet non expansées, la gamme de mouvement des petites articulations, la manifestation des cicatrices hypertrophiques et des contractures à la suite des brûlures, les contractures à toile, la syndactylie artificielle et l’aspect esthétique. Dans la période du suivi (5 ans) tous les patients ont été traités moyennant les vêtements compressifs et la thérapie physique et occupationnelle individuelle. Conclusion: La méthode de l’excision tangentielle précoce et la greffe cutanée moyennant la greffe en filet non expansée dans les brûlures profondes de la main offrent de bons résultats fonctionnels et esthétiques. La greffe cutanée en filet non expansée a été employée dans les patients qui présentaient des conditions générales de santé médiocres, des signes évidents de la maladie des brûlés et un pourcentage élevé de la surface corporelle totale brûlée. Le taux plus élevé de la guérison, la formation réduite de l’hématome et le sérome, la réduction de l’infection des brûlures et les bons résultats fonctionnels et esthétiques démontrent que les greffes cutanées en filet non expansées présentent beaucoup d’avantages par rapport aux greffes cutanées pleines. La thérapie physique et occupationnelle précoce et l’emploi des vêtements compressifs réduisent la formation des cicatrices et des contractures, la rigidité chronique des articulations et d’autres limitations fonctionnelles.

BIBLIOGRAPHY

1. Salisbury R.E.: Burns of the upper extremity. In: Artz C.P., Moncrief J.A., Pruitt B.A. (eds), “Burns: A Team Approach”, W.B. Saunders, Philadelphia, 320-9, 1979.
2. Whittaker A.H.: Treatment of burns by excision and immediate skin grafting. Am. J. Surg., 3: 411-7, 1953.
3. Salisbury R.E.: Acute care of the burned hand. In: McCarthy J.G. (ed.), “Plastic Surgery”, W.B. Saunders, Philadelphia, London, Toronto, vol. 8, 5399-402, 1990.
4. Hunt J.I., Purdue G.F.: Acute burns, burn surgery, and post-burn reconstruction. SRPS, 8: 1-40, 1997.
5. Heimbach D.M., Engrav L.H.: “Surgical management of the burn wound”. Raven Press, New York, 1984.
6. Delming R.H.: “Burn trauma”. Thieme, New York, Stuttgart, 10-15, 1989.
7. Goodwin C.W., Maguire M.S., Pruitt B.A.: Prospective study of burn wound excision of the hand. J. Trauma, 23: 510-7,1983.
8. Huang T.T., Larson D.L., Lewis S.R.: Burned hand. PRS, 56: 21-28, 1975.
9. Levine B.A., Sirinek K.R., Peterson H.D., Pruitt B.A.: Efficacy of tangential excision and immediate autografting of deep second-degree burns of the hand. J. Trauma, 19: 670-3,1979.
10. Jelenko C. III: Chemicals that “burn”. J. Trauma, 14: 65-7, 1974.
11. Aschauer B.M.: Reconstruction of the burned hand. Euro J. Plast. Surg., 18: 166-70, 1995.
12. Robinson J.B., Friedman R.M.: Wound healing and closure. Selected Read. Plast. Surg., 8: 821-33, 1995.
13. Salisbury R.E., Dingeldein G.P.: The burned hand and upper extremity. In: Green D.P. (ed.): “Operative Hand Surgery”, Churchill Livingstone, New York, 1523-52, 1982.
14. Peterson R.A.: Electrical burns of the hand. J. Bone and Joint Surg., 48A: 407-24, 1966.
15. Neville R.M., Boswick J.A.: The management of electrical injuries of the extremities. Surg. Clin. North Am., 53: 1459-68, 1973.
16. Hunt J.L., Mason A.D., Pruitt B.A.: The pathophysiology of acute electrical injuries. J. Trauma, 16: 335-43, 1987.
17. Di Vicenti F.C., Pruitt B.A.: Electrical injuries review of 65 cases. J. Trauma, 9: 497-502, 1969.
18. Luce E.A., Gottlieb S.E.: “True” high-tension electrical injuries. Ann. Plast. Surg., 12: 321-8, 1984.
19. Holliman J.C., Saffle J.R.: Early surgical decompression in the management of electrical injury. Am. J. Surg., 144: 733-9, 1982.
20. Saydari R. et al.: Chemical burns. J. Burn Care Rehabil., 7: 404-9, 1986.
21. Frist W.: Long-term functional result of selective treatment of hand burn. Am. J. Surg., 149: 516-25, 1985.
22. Curreri P.W., Pruitt B.A.: The treatment of chemical burns: Specialized diagnostic, therapeutic, and prognostic considerations. J. Trauma, 10: 634-51, 1970.
23. Gant T.D.: The early enzymatic debridement and grafting of deep dermal burns of the hand. PRS, 66: 185-190, 1980.
24. Delming R.H.: “Burn trauma”. Thieme, New York, Stuttgart, 43-65, 1989.
25. Boswick J.A.: “Complication in hand surgery”. W.B. Saunders, Philadelphia, 75-84, 1986,
26. Janzekovic Z.: A new concept in the early excision and immediate grafting of burn. J. Trauma, 10: 1103-25, 1970.
27. Janzekovic Z.: The dermal burn. In: Derganc M. (ed.): Present clinical aspects of burns. A Symposium. Mariborski Tisak, Maribor., 215-22, 1968.
28. Herndon D.N. et al.: A comparison of conservative versus early excision. Ann. Surg., 209: 547-56, 1989.
29. Achauer B.M.: Reconstruction of the burned hand. Clin. Plast. Surg., 19: 623-9, 1992.
30. Jackson D.M., Stone P.A.: Tangential excision and grafting of burns: The method and repair of 50 consecutive cases. Br. J. Plast. Surg., 25: 416-26, 1972.
31. Habal M.B.: The burned hand: A planned treatment program. J. Trauma, 18: 587-95, 1978.
32. Peacock E.E., Madden J.W., Trier W.C.: Some studies on the treatment of burn hands. Ann. Surg., 171: 903-14, 1970.
33. Pegg S.P., Cavaye D., Fowler D.: Results of early excision and grafting in hand burns. Burns, 11: 99-103, 1984.
34. Sherif M.M., Sato R.M.: Severe thermal hand burns - factors effecting prognosis. Burns, 15: 42-6, 1989.
35. Falcone P.A., Edstron L.E.: Decision-making in the acute thermal hand burn: An algorithm for treatment. Hand Clin., 6: 233-42, 1990.
36. Helm P.A.: Burn rehabilitation: Dimension of the problem. Clin. Plast. Surg., 19: 551-73, 1992.
37. Boswick J.A.: The management of fresh burn of the hand and deformities resulting from burn injuries. Clin. Plast. Surg., 1: 621-31, 1974.
38. Skoog J.: Electrical injuries. J. Trauma, 17: 487-90, 1970.
39. Edstrom L.E., Robson M.C.: Evaluation of exercise techniques in the burn patient. Burns, 4: 113-9, 1977.
40. Pruitt B.A., Dolwing J.A.: Escharotomy in early burn care. Arch. Surg., 96: 502-7, 1968.
41. Skoog M.J., Scott F.A., Boswick J.A.: High-pressure injection injuries of the hand. J. Trauma, 20: 229-38, 1980.
42. Tompkins R.C.: Prompt eschar excision: A treatment system contributing to reduce burn mortality. Ann. Surg., 204: 272-83, 1986.
43. Helm P.A., Head M.D.: Burn rehabilitation - A team approach. Surg. Clin. North Am., 58: 1263-78, 1978.
44. Helm P.A., Walker S.C., Peyton S.A.: Return to work following hand burns. Arch. Phys. Med. Rehabil., 67: 297-8, 1986.
45. Hunt J.L.: Electrical injuries of the upper extremity. Major Prob. Clin. Surg., 19: 72-85, 1976.
46. Hunt J.L., Manson A.D.: The pathophysiology of acute electrical injuries. J. Trauma, 16: 335-47, 1976.
47. Curreri P.W., Asch M.J., Pruitt B.A.: The treatment of chemical burns: Specialized diagnostic therapeutic and prognostic considerations. J. Trauma, 10: 634-41, 1970.
48. Lewis G.K.: Chemical burns. Am. J. Surg., 98: 928-36, 1959.
49. Burke J.F., Bondoc C.C., Quinby W.C.: Primary burn excision and immediate management of the burned hand: A method shortening illness. J. Trauma, 14: 385-95, 1974.
50. Salisbury R.E., Levine N.S.: The early management of upper extremity thermal injury. In: Salisbury R.E., Pruitt B.A. (eds): “Burns of the upper extremity”, W.B. Saunders, Philadelphia, 36-46, 1976.
51. Robson M.C. et al.: Making the burned hand functional. Clin. Plast. Surg., 19: 663-71, 1992.
52. Salisbury R.E.: Burns of the upper extremity. In: Artz C.P., Moncrief J.A., Pruitt B.A. (eds): “Burns: A Team Approach”, W.B. Saunders, Philadelphia, 320-9, 1979.
53. Mahler D., Hirshowitz B.: Tangential excision and grafting for burns of the hand. Br. J. Plast. Surg., 28: 189-92, 1975.
54. Spinner et al.: Impending ischaemic contracture of the hand. Early diagnosis and management. PRS, 50: 341-9, 1972.
55. Davies J.W., Wang Y.W., Yung H.S.: Tangential excision of eschar for deep burns of the hand: Analysis of 156 patients collected over 10 years. Burns, 11: 93-8, 1984.
56. Bondoc C.C., Quinby W.C., Burke J.F.: Primary surgical management of the deeply burned hand in children. J. Pediat. Surg., 11: 355-62, 1976.
57. Fox C.L.: Silver sulphadiazine: A new topical therapy for Pseudomonas in burns. Arch. Surg., 96: 184-96, 1968.
58. Salisbury R.E., Wright P.: Evaluation of early excision of dorsal burn of the hand. PRS, 69: 670-83, 1982.
59. Montandon D. et al.: The contractile fibroblast. Its relevance in plastic surgery. PRS, 52: 286-95, 1973.
60. Parks D.H., Evans E.B., Larson D.L.: Prevention and correction of deformity after severe burn. Surg. Clin. North Am., 58: 1279-92, 1978.
61. Levine N.S., Buchanan R.T.: The care of burned upper extremities. Clin. Plast. Surg., 13: 107-18, 1986.
62. Deitch E.: Policy of early excision and grafting in hospital stay and improves survival. Burns, 12: 109-21, 1985.
63. Artz C.P.: Changing concepts of electrical injury. Am. J. Surg., 128: 600-75, 1974.
64. Saydari R. et al.: Chemical burns. J. Burn Care Rehabil., 7: 404-9, 1986.
65. Hunt J.L, Purdue G.F.: The elderly burn patient. Am. J. Surg., 164: 472-83, 1992.
66. Delming R.H.: Fluid and electrolyte management. Crit. Care Clin., 1: 27-44, 1985.
67. Parry S.W.: Reconstruction of the burned hand. Clin. Plast. Surg., 16: 577-89, 1989.
68. Tanner J.C., Vandeput J.J., Olley J.F.: The mesh skin graft. PRS, 34: 287-92, 1964.
69. Krizek T.J., Flagg S.V.: Delayed primary excision and skin grafting of the burned hand. PRS, 51: 524-9, 1973.
70. Smith D.J., McHung T.P.: Biosynthetic compound dressing - management of hand burns. Burns, 14: 405-11, 1988.
71. Burke J.F., Bondoc C.C.: Primary surgical management of the deeply burned hand. J. Trauma, 16: 593-9, 1976.
72. Wexler M.R., Yeschua R., Neuman Z.: Early treatment of burns of the dorsum of the hand by tangential excision and skin grafting. PRS, 54: 268-73, 1976.
73. Labandter H., Kaplan I., Savitt C.: Burn of the dorsum of the hand. Conservative treatment with intensive physiotherapy versus tangential excision and skin grafting. Br. J. Plast. Surg., 29: 352-4, 1976.
74. Hunt J.L., Sato R., Baxter C.R.: Early tangential excision and immediate mesh autografting of deep dermal hand burns. Ann. Surg., 189: 147-53, 1979.
75. Salisbury R.E., Wright P.: Evaluation of early excision of dorsal burns of the hand. PRS, 69: 670-5, 1982.
76. Magliacani G., Bormioli, Cerutti V.: Late results following treatment of deep burns of the hands. Scand. J. Plast. Surg., 13: 137-44, 1979.
77. Frandsen P.A., Nielsen O., Sommer J.: Treatment of second-degree burns of the hand: A comparison of occlusive dressing and gloves. Burns, 4: 20-4, 1977.
78. Leung P.C.: Treatment of burned hands. Burns, 6: 244-51, 1980.
79. Brcic A., Zdravic F.: Lessons learnt from 2409 burn patients operated by early excision. Scand. Plast. Reconstr. Surg., 13: 107-16, 1979.
80. Hentz V.R.: Burn of the hand. Thermal, chemical, and electrical. Emerg. Med. Clin. North Am., 3: 391-9, 1985.
81. Parshley P.F., Kilgore J., Miller S.H.: Aggressive approach to the extremity damaged by electric current. Ann. Surg., 150: 78-82, 1985.
82. Arturson G.: Pathophysiology of the burn wound. Ann. Chir. Gynaecol., 69: 178-99, 1980.
83. Salisbury R.E., McKeel D.W.: Management of electrical injuries of the upper extremity. PRS, 51: 648-52, 1973.
84. Skoog T.: Electrical injuries. J. Trauma, 17: 487-98, 1970.
85. Thompson P. et al.: Aggressive early excision of patients with major thermal burn. J. Trauma, 26: 7-18, 1986.
86. Moncrief J.A.: Third-degree burns of the dorsum of the hand. Am. J. Surg., 96: 535-44, 1958.
87. Moncrief J.A., Swicer W.E., Rose L.: Primary excision and grafting in the treatment of third-degree burns of the dorsum of the hand. PRS, 33: 305-16, 1964.
88. Green H.: Cultured cells for the treatment of disease. Sci. Am., 265: 96-102, 1991.
89. Gallico G.G. III.: Biologic skin substitutes. Clin. in Plast. Surg., 17: 519-26, 1990.
90. Groenevelt F., Kreis R.W.: Burns of the hand. Neth. J. Surg. 37: 167-72, 1985.
91. Carvajal H.F.: Acute management of burns in children. South Med. J., 68: 129-31, 1975.
92. Vodopija J., Francetic´ I., Tonkovic´ I., Kalenic´ S., Luetic´ V.: ZasŠtita od infekcije nakon ranjavanja. LijecŠ Vjesn., 113: 288-9, 1991.
93. Robins R.H.: Hand assessment charts. J. Hand Surg., 11B: 287-98, 1986.
94. Robson M.C.: Burn sepsis. Crit. Care Clin. North Am., 4: 281-98, 1988.
95. Nielsen B.A., Sommer J.: Surgical treatment of the deeply burned hand. Burns, 9: 214-7, 1983.
96. Pensler J.M. et al.: Reconstruction of the burned palm: Full-thickness versus split-thickness skin graft. Long-term follow-up. PRS, 81: 46-61, 1988.
97. Rudolf R.: Inhibition of myofibroblasts by skin grafts. PRS, 63: 473-85, 1979.
98. Deitch E.A. et al.: Hypertrophic scars. Analysis of variables. J. Trauma, 23: 895-903, 1983.
99. Lee R.C., Parson R.W.: Discussion of “early free flap coverage of electrical and thermal burns” by L.R. Chick, G.D. Lister, and L. Sowder. PRS, 89: 1020-8, 1992.
100. Chick L., Lister G.D., Sowder L.: Early free flap coverage of electrical and thermal burns. PRS, 89: 1013-9, 1992.
101. Aschauer B.M.: Reconstruction of the burned hand. Euro. J. Plast. Surg., 18: 166-70, 1995.
102. Barillo D.J., Harvey K.D., Hobbs C.L. et al.: Prospective outcome analysis of a protocol for the surgical and rehabilitative management of burns to the hand. PRS, 100: 1442-8, 1997.
103. Hanumadass M. et al.: Acute electrical burns: 10 years’ clinical experience. Burns, 12: 427-33, 1986.
104. Monafo W.W., Bessey P.Q.: Benefits and limitations of burn wound excision. World J. Surg., 16: 37-42, 1992.