THE TREATMENT OF EARLY AND LATE HAND CONTRACTURES FOLLOWING BURN INJURY (1978-1991)

Antonopulos D., Danikas D., Dotsikas R, Nikolakopoulu G., Maurogiorgos C, Christophorou M.

Clinic of Plastic Reconstructive Surgery and Burns, St. Andrew's General Hospital, Patras, Greece

SUMMARY. The results are presented of a retrospective study of various types of bums and scalds involving various levels of the hand and the digits. All cases from 1978 to 1991 were included. The patients were treated in a number of hospitals and private clinics in Greece. The causes of the contractures are evaluated, as also the type of primary treatment. Surgical correction of these complications was carried out with various techniques and splinting was necessary many times.

Introduction
The hands are the commonest site of bums. Hand burns can be caused by flame, contact with hot objects, or electric current (A.C. or D.C.). Chemical burns also occur when the cause is a chemical substance. All such burns can happen at home or at work. Some are industrial in origin.
Scalds are injuries due to direct contact with boiling liquids. Burns and scalds can be superficial split-thickness (superficial or deep) or full-thickness. Burns on the volar surface of the hand are normally not full-thickness injuries unless they are electrical, chemical or the cause is direct contact. On the dorsal surface of the hand they are often full-thickness, owing to the thin skin of the dorsum.

Material and methods
In this study we present our experience from 1978 to 199 1. The total number of burns and scalds treated was 720. 114 patients developed contractures at the burn site.
175 patients received primary treatment elsewhere. They subsequently developed contractures and were referred to us at an early or later stage.
The following immediate measures were taken for patients with burned hands: good local wound care, debridement of devitalized tissue, and longitudinal incisions for decompression of the volar surface of the hand. Relaxation incisions were also essential for circumferential burns.
We used homografts, and sometimes heterografts, which are good for temporary biological dressings. The placing of the hand in a functional position is of great importance. Early excision and'grafting were performed in selected cases in full-thickness lesions.

Discussion and conclusions
In superficial burns we used occlusive dressing. Healing can be expected in 10-15 days, no matter what regime of treatment has been decided. in superficial split-thickness burns healing may be delayed longer. Some hypertrophic scarring can be expected in all regimes.
In deep split-thickness burns, hypertrophic scarring and early contractures are frequent. Early excision and grafting were essential in certain cases. Late contractures developed in some cases.
In split-thickness (superficial and deep) burns we used splinting, local treatment, such as pomades, and the infusion of triemcinolone (dermojet), and physiotherapy.
We treated full-thickness burns with primary excision and reconstruction with grafts and flaps.
Contractures developed at the following sites: dorsal and volar palm, interdigital and on the fingers.
For the treatment of the dorsal-volar contractures we performed release with the use of grafts and flaps. Splinting was necesssary, followed by physiotherapy.
The treatment of the interdigital and finger contractures was the same, except that we performed a staged release when many digits were involved. Staged release is essential for maintaining an adequate blood supply.
Our conclusion is that early treatment is necessary for the prevention of contractures. We propose the following immediate measures to be taken for every burned or scalded hand: good local wound care, debridement of devitalized tissue, and longitudinal incisions for decompression of the volar surface of the hand. Although not an immediate measure, early physiotherapy is necessary for the functional recovery of the hand.

RESUME Les auteurs présentent les résultats d'une étude rétrospective de certains types de brélures et d'ébouillantements qui intéressent divers niveaux de la main et des doigts. Tous les cas depuis 1978 jusqu'A 1991 sont inclus. Les patients ont été traités dans plusicurs hépitaux et cliniques privées en Grèce. Les auteurs considerent les causes des contractures et les modalités du traitement initial. Dans la plupart des cas il était nécessaire d'exécuter la correction chirurgicale des complications, en employant diverses techniques, et d'appliquer des attelles.

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