Annals of the MBC - vol. 4 - n' I - March 1991

EARLY EXCISION AND GRAFTING FOR BURNS OF THE HAND

Kadry M.K.M., Bemelmans D., Cate A.

Plastic Surgery Department, Faculty of Medicine, Cairo University, Egypt and Lyons University Egypt, Hospital, France

SUMMARY. The technique of early excision and grafting for 2nd- and 3rd-degree bums of the hand was attempted on 15 patients with 26 burned hands. The functional results were very good in 9 cases, good in 10cases, average in 4 patients and bad in 3 cases. This represents a 91.5% functional recovery.

Introduction

The poor results of the classical conservative approach to bums of the hand, consisting of firm splintage for two weeks or even 'longer, were distressing (Robertson, 1958). Bums of the hand are particularly suitable for early excision and grafting because the early replacement of the burned skin allows early mobilization. The treatment of deep dermal bums of the hand by early excision and grafting is now widely accepted and practised by many surgeons (Janzekovie, 1970, Jackson el al., 1972, Lawrence el al., 1973, Stone et al., 1973). Indication in plastic surgery, as in any other surgery, is a primordial act. Although early excision and grafting often appear to be the best technique for bums of the hand, it does not however always solve all the problems. The aim of this work is to evaluate the technique and to lay stress on the proper indications.

Material and methods

In this work early excision and grafting were practised on 15 patients with 26 burned hands (Tab. 1).
Nine cases were males and 6 were females. Their age ranged between 18 and 60 years, with an average age of 32 years.
The percentage surface area burned was between 10 and 60% with a 25% average.
The excision was carried out after 12-72 h with an average time of intervention at 30 h.
Hospital stay ranged between 20 and 90 days, with an average of 47 days.
The bum depth was evaluated by the pin-prick test, and cases with 2nd- and 3rd-degree burns were selected. Charred hands were excluded, as well as cases involving children and elderly patients.

Technique of early excision and grafting

Excision is carried under general endotracheal anaesthesia. A central venous pressure (CVP) by a jugular on subclavian route is established, since adequate blood replacement is usually necessary. When both upper limbs are affected, it is advisable that 2 teams of surgeons should operate synchronously.
Excision is performed without a tourniquet, using a scalpel in a proximal to distal direction. Bleeding is in fact the main element allowing separation of viable from nonviable tissues, and this will make it easier to preserve the subcutaneous venous plexus.
Haemostasis is ensured with hot saline packs with 1/100,000 adrenaline and a bipolar coagulator. A completely dry field is essential for the placing of the grafts. The slightest doubt about haemostasis is a definite indication for a delayed grafting in a few days, when haemostasis is ensured and granulation has started (Tab. 1, 2).
Split grafts are taken from the thighs with a thickness of 0.5 min. The skin needed to cover a hand exceeds by far all expectations. Grafts are pierced and put transversely or obliquely across the joints to avoid linear contracted scars.
It is always advisable, whenever time allows, to reconstruct web spaces properly. Grafts in the webs are compressed by a thread stretched like a bow anteroposteriorly (Tab. 2).
Immobilization is done in the best functional position, the wrist being kept in a neutral position. The fingers are carefully separated and a pad of gauze will maintain the concavity of the palm. A stitch between the thumb and the index will preserve the first web space (Tab. 2).
Finally a light dressing is applied with slight compression by an elastic bandage to exert good pressure on the graft and to prevent serious soiling when mo~ility is allowed.

Dressing and Post-Operative care

The first dressing is usually done between the 6th and 8th post-operative day. A bath for 5 to 10 minutes will help separation of the superficial layers. If there is good take of the graft, tulle gras will separate spontaneously and evacuation of a few haematoma may be required.
Physiotherapy, both active and passive, is given gradually from the 10th day onward.

Number of cases 26 burned hands in 15 patients
Sex MaleYernale 9:6
Age 18-60 years, average 32 years
% Surface area burned 10-60%, average 25%
Time of excision 12-72 h, average 30 h
Hospital stay 20-90 days, average 47 days

Tab. 1

 

I. Functional,recovery: Very Good 9 cases
Good 10 cases
Average 4 cases
Bad 3 cases
II. Occupation: Restoration of Original Occupation 20 cases
Rehabilitation required 3 cases
III. Subsequent surgical intervention for better functional recovery

i. Re-excision and grafting
ii. Lateral Digital Flaps (Sterling Bunnel)
iii. Inverted Double Z

  4 cases
IV. Hydrometric, barometric, thermic sensitivity troubles always noticed, usually improved by crenotherapy    

Tab. 2 Results of functional recovery

Results

The take of the skin grafts was very satisfactory in most of the cases. The time of complete healing ranged between 2 and 7 weeks.

The immediate complication was failure of graft take, which may be due'to:

  1. Infection
  2. Haematoma
  3. Bad immobilization
  4. Failure to recognise the burn depth.

From the functional point of view, a 91.5% recovery was obtained. The results are shown in Tab. 2.

Discussion and conclusions

Indication in plastic surgery, as in any form of surgery, is a primordial act. Malfeyt (1976), comparing the results of early excision and grafting to cases allowed to granulate before grafting, concluded that it is the treatment of choice for deep dermal bums of the hand.
The aim of early excision an grafting should be:

  1. to interfere with the great oedematous phase, which carries important vascular risks;
  2. to control infection with subsequent arthritis leading to serious complications;
  3. to recover a proper functional state, by early covering of the noble elements of the hand. This will allow for an early re-education, both active and passive.

By early excision and grafting, full functional recovery may be achieved within 2 weeks, whereas in the conventional method, desloughing alone requires 3 weeks, and the shortest possible time for full healing is therefore about 5 weeks. It also virtually abolishes pain and morbidity.
Janzekovic (1970), Lawrence & Carney (1973), and Stone and Lawrence (1973) recommend tangential excision and grafting for deep partial- to full-thickness skin loss. Their indications completely confirm those applied in our series, since 2nd-degree intermediate bums are well known to proceed to frightful contractions necessitating surgical intervention.
Early excision and grafting are however not justifiable in the following conditions;

  1. charred hand; once the paratenon is affected this is an indication for a flap cover;
  2. children, since vascular risks are very important;
  3. old patients, particularly those who are algodystrophic.

The optimum time for early excision should be before the fourth day. It is well known that the first reaction phase of bums ends on the third day after injury. Oedema starts to subside, depth diagnosis at this point is reliable and infection is limited. The -optimal time for selective excision linked with the definitive limitation of the primary necrosis therefore coincides with the latency of infection.
In our series we preferred early excision, using a scalpel for tangential excision, since a subcutaneous orientation coming from the depth to the surface, in a proximal to distal direction, does not exist. Furthermore this is a more adjustable technique which allows preservation of the venous plexus. Excision is better carried without a tourniquet, since bleeding is the main element allowing separation of viable from nonviable tissues.

 

RESUME La technique de 1'excision et de la greffe pr6coce dans les cas de br6lure du 26me et 36me degr6 de la main a W utilis6c chez 15 patients avec 26 mains brfil6es. Les r6sultats fonctionnels 6taient tr&s bons (9 cas), bons (10 cas), moyens (4 cas) et mauvais Q cas). Cela repr6sente une r6cup6ration fonctionnelle de 91,5%.

BIBLIOGRAPHY

  1. Jackson D.M., Stone P.A.: Tangential excision and grafting of bums. British Journal of Plastic Surgery, 25: 416, 1972.
  2. Janzekovie Z.: Early excision and immediate grafting of bums. Journal of Trauma, 10: 1103, 1970.
  3. Lawrence J.C., Carney S.A.: Tangential excision of bums. Studies on the metabolic activity of the recipient areas for skin grafts. British Journal of Plastic Surgery, 26: 93, 1973.
  4. Malfeyt G.A.M.: Bums of the dorsur~ of the hand treated by tangential excision. British Journal of Plastic Surgery, 26: 10, 1976.
  5. Olivari N.: Early surgical treatment of burned hand. Transactions of the Sixth International Congress of Plastic and Reconstructive Surgery, p. 716, Ed. Daniel Marchac, Masson, Paris, New York, Barcelona, Milan, 1976.
  6. Robertson D.C.: The management of the burned hand. Journal of Bone & Joint Surgery, 40A: 625, 1958.
  7. Stone P.A., Lawrence J.C.: Healing of tangentially excised and grafted bums in man. British Journal of Plastic Surgery, 26: 20, 1973.

 

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