Annals of Burns and Fire Disasters - vol. IX - n. 4 - December 1996

FACTORS AFFECTING RESULTS IN THERMAL HAND BURNS

(1)Pamukkale University Faculty of Medicine, Department of Plastic and Reconstructive Surgery, Denizli, Turkey
(2)Hacettepe University Faculty of Medicine, Department of Plastic and Reconstructive Surgery, Ankara

SUMMARY. One hundred and seven burned hand deformities reconstructed since 1978 in the clinic of Hacettepe University Department of Plastic and Reconstructive Surgery (Ankara, Turkey) were analysed retrospectively and the results evaluated statistically in relation to various factors (patient's age at time of burn, cause of burn, place of early therapy, degree of deformity, time of reconstruction, and methods of reconstruction). In the group of mild hand bum deforn-dties (95), 18 hands were reconstructed with Z-plasties, 65 with Z-plasties and skin grafts, and 12 with skin grafts. In the group of severe hand burn deformities (12), five hands were reconstructed with abdominal and groin flaps, four with forearm flaps, and three with distant flap transfers. The results obtained after ~he reconstruction of scald burns, domestic accidents, and bums during childhood showed a better range of motion. Early reconstruction, without any delay pending scar maturation, was also found to give better results, with greater improvement in range of motion. Hand deformities as a result of industrial accidents such as chemical burns could not be satisfactorily reconstructed as these were difficult cases with deep injuries in the hand's functional units.

The hand is used in manipulatory and exploratory functions, and the upper extremity is thus the most frequently injured part of the human anatomy. A study of product-related injuries estimated that 36% of these involved the hand and the upper extremity, and that 39% of burn wounds involved some portion of the hand and arm.' The proportion of hand involvement was reported as 72% and 85% in two series of burn patients, including electrical burns .2,3 Although some bums are minor, creating inconvenience rather than a therapeutic challenge, others have a considerable potential for causing chronic disability and expense variously for patients, employers and insurance carriers. In a group of 3167 survivors of bum injury, 31% of the patients required reconstruction for hand bums.' It is thus important that severe burns of the hands and upper extremities should be managed by physicians with specific knowledge of burn therapy, reconstruction and rehabilitation in order to maximize the final functional results .2,5,6 Otherwise, late reconstructions performed because of impaired function are usually difficult and not always satisfactory in outcome .7,8

This study was conducted in order to analyse the results of the reconstruction of burned hand deformities and to evaluate factors affecting the results.

Seventy-six patients with a total of 107 burned hand deformities reconstructed in the clinic of Hacettepe University Department of Plastic and Reconstructive Surgery since 1978 were analysed retrospectively. All the burns were thermal (electrical hand bums were excluded), and all were treated with a view to reconstruction. The patients received their early care in a number of different clinics. Following reconstruction they followed a physical rehabilitation programme for functional recovery. This study analyses retrospectively the history of the patients with regard to a number of factors, e.g. age at the time of burn, cause of burn, place of early therapy, degree of deformity, time of reconstruction, and method of reconstruction. The results were assessed by physical examinations performed in routine controls at yearly intervals and were grouped on the basis of functional improvement, such as gain in range of motion. The results were then evaluated statistically in relation to parameters taken from the patients' history.

Most of the patients had been burned during childhood before they were Wyears old (77.9% before that age and 22.1% after). 81.6% of the patients had been burned in domestic accidents and 18.4% in industrial accidents. 13.2% of the patients had been burned with flame, 22.3% had suffered contact burns due to falling over a stove, 59.2% had been scalded and burned by oil, and 5.3% had suffered chemical bums. During their early care, 57.8% of the patients had been treated in an out-patient clinic, 36.9% in a hospital surgery clinic, and 5.3 % in a bums unit.

Out of the 107 hand burn deformities analysed in this study, 88.8% were classified as mild deformities and 11.2% as severe, with deep structures affected by the burn injury and a poor active range of motion before reconstruction.

In 42. 1 % of the cases, the deformed hand reconstruction was performed within one year of the burn, without waiting for scar maturation. In the remaining 57.9% of cases, reconstruction was performed later, i.e. after more than a year.

In the group of mild hand deformities, 95 hands were reconstructed. Eighteen were reconstructed with Z-plasties only (Fig. 1), 65 with Z-plasties plus skin grafts (Fig. 2), and 12 with skin grafts only (Figs. 3,4). In the group of severe deformities, 12 hands were reconstructed with skin flaps (Fig. 5), including five groin and abdominal flaps, four reverse flow forearm flaps, and three distant free transfers (Table 1).

The results were evaluated in two groups: 46.7% of the reconstructions presented no improvement or limited gain in range of motion, and 53.3% presented satisfactory reconstruction results, with full range of motion (Table II). results than those in patients burned at a later age (x 5.59, p <0.02) (Table III). Hand burn deformities in patients burned before the age of ten years gave more satisfactory reconstruction

Fig. la - Hand burn deformity due to contact burn with flexion contraclure on palmar surface of 3rd, 4th and 5th metocarpophalangeal joints (14-year-old boy). Fig. 1b - After release of contracture by multiple Z-plasties. Fig. 2a - Hand bum defon-nity due to scalding with flexion contracture on palmar surface of 2nd, 3rd, 4th and 5th fingers (12-year-old girl). Fig. 2b - After reconstruction by contracture release with Z-plasties and full-thickness skin grafts. Fig. 3a - Hand burn deformity due to contact burn with flexion contracture on palmar surface of 2nd, 3rd, 4th distal metacarpal area (13-yearold boy). Fig. 3b - After reconstruction by resurfacing with full-thickness skin grafts. Fig. 4a - Hand bum deformity due to scalding with palmar contracture altering thumb motion (21 -year-old woman). Fig. 4b - After reconstruction by contracture release and surfacing with full-thickness skin graft. Fig. 5a - Severely deformed hand following flame burn with flexion contracture and ulnar deviation of fingers and stiff joints (54-year-old woman). Fig. 5b - Contracture released without excision, and palmar tissue defect covered by reverse flow radial forearm flap. still present.

Burned hand deformities reconstructed within one year gave better results than those reconstructed after more than one year (x = 11.20, p <0.001) (Table VII).

Thermal injuries are characterized by varying degrees of damage to the skin and underlying structures, depending on the temperature and type of the heat source, the duration of exposure, and the area affected by the heat. The aetiological factors can be classified as flash burns, flame burns, contact burns, and scalds .2~9 In this study most of the hand deformities occurred as a result of domestic accidents, caused by flame, falling over a stove (especially during childhood), and scalds.
The large number of domestic burns involving children emphasizes the importance of education regarding the concept of prevention, with especial attention to young people, and the need to improve burn safety products.
Improper care during the acute phase may lead to secondary deformities that could otherwise have been prevented. During hand burn treatment, if attention is paid to basic principles, if care is taken to eliminate oedema by mobilization, if infection is prevented by topical antibacterials, and if the burn wound is covered early by tissue replacement (when necessary), then the hand will most likely regain good functionality. 2,5,6,9 Unfortunately, not all patients present to a plastic surgeon immediately after they have suffered a hand burn.' Many are seen in the acute phase by health operators who do not give high priority to hand function, while some patients have such severe total body surface area burns that appropriate care for the hands comes too late to prevent deformity.' During the early acute phase the patients in this study were treated in a number of different clinics where the health personnel were not specialized in hand burn care and therefore had no specific knowledge of hand wound healing or the prevention of post~bum hand deformities. A clear understanding of wound healing and scar contracture and a good knowledge of the management of hand burns are essential if any sense is to be made of the myriad of deformities that may be encountered. In our group of reconstructions there was no relation between the final results and the health services where the patients had originally been treated as these did not differ as regards the quality of the health personnel and their care and management of the hand burns. Even burns unit personnel who are accustomed to dealing with major burns may pay little attention to hands as they are more concerned with the patients' systemic problems.
In the vast majority of patients the initial thermal injury is limited to the skin alone; the underlying tendons and joints are usually spared. Prolonged wound healing, with its attendant oedema, infection, fibrosis and immobilization, can lead to secondary joint contractures, rupture of extensor tendon mechanisms, and adhesion of gliding tissues. In general, however, it is remarkable how often the deep structures are spared, particularly in children. This may explain why better reconstruction results have been obtained in post-burn deformities in children, despite certain difficulties presented by children's generally low attendance at physical therapy programmes and by some resistant deformities, such as the inhibition of bone growth following epiphyseal plate destruction. The better results of childhood hand burn deformities may also be related to the fact that such lesions are usually superficial contact burns and scalds, while in older patients the lesions are often due to deep flame bums or chemical burns sustained in industrial accidents.
Post-burn hand deformities can be difficult to analyse as acute injuries vary widely, early treatment is often less than optimal, and there are frequently multiple problems in each hand. For the sake of discussion and treatment, it is helpful to divide these deformities into categories of different degree, all of which may be present in a single hand. Soft tissue deformities, including deformities of the dorsal and volar skin surface, joint deformities with or without tendon injury, and amputations can be regarded as mild deformities. Bad injuries leading to complex deformities including all the above, plus tendon and even bone defects, can be classified as severe: it is difficult to reconstruct these deformities, which usually give rise to poor functional improvement. Fortunately, however, these are rare.  In our study only 11.2% of the deformities concerned severely burned hands; they were very poor in their active range of motion before reconstruction, and even after reconstruction functional improvement was unsatisfactory. For these reasons we can affirm that better results were achieved after mild post-burn hand deformities.
Once the complex injury has been dissected into its components, the physician, patient, vocational rehabilitation worker and employer can meet as a team and decide what procedures have priority in returning the injured patient to work. The hand surgeon must be aware of the other parts of the body with burn deformities that may necessitate surgery. A time-related plan with specific recovery goals is imperative because it has been shown that if patients do not return to work within a certain length of time following injury, their chances of employment are reduced." The logical approach is thus to make a careful record of all the anatomical abnormalities secondary to the burn injury. If patients are to return rapidly to their work and normal daily life, the hand has to be reconstructed as soon as possible. In this study, reconstruction times were not planned on the basis of sear maturation, and we found that the results of reconstruction performed after a year, when scars were mature, were not better than reconstructions performed earlier. The reacquisition of functional capacity as soon as possible is an important factor in the prevention of joint stiffness and tendon adhesion, and thus in the achievement of better results.
In the reconstruction of the burned hand, each case must be carefully evaluated in the context of total patient care: only then can the best individual procedure or treatment plan be chosen. As the fundamental problem is the loss of surface covering, it is usually necessary to add skin by skin grafts or flaps when dealing with the reconstruction of post-burn deformities. Z-plasties and other local flap procedures often do not provide enough tissue and they present a higher complication rate when performed in the context of scars and increased tension. Further stable tissue coverage must therefore be added. The entire scar should be removed, and any residual contracture released. Usually replacement or resurfacing with skin grafts is satisfactory. Flap coverage may occasionally be necessary if further reconstruction for deep structures such as tendons or joints is planned. Deep structures injured at the time of burning, or ignored during the phase of acute management, may give rise to chronic problems which are a challenge in reconstruction, such as joint subluxations or deviations resulting from imbalance in ligaments and muscular forces. In severe deep burns, tissue transfer, even with free tissue, is not sufficient to improve hand function as long as tendon and joint problems still exist. This limiting effect on functional recovery explains why the reconstruction of severely burned hands may be unsuccessful.

Hand burn deformities are usually difficult cases for reconstruction. The results depend above all on the type of burn and the level of the injury. If deep structures such as tendons, ligaments and joints have been affected directly by the bum, or if secondary infection and joint stiffness develop as a result of improper initial therapy, the reacquisition of a full range.of motion after reconstruction is not always possible. It can therefore be concluded that the correct initial treatment of hand bums is a matter of great importance for the avoidance of secondary deformities, as it guarantees hand function more surely than reconstruction.

RESUME. Les Auteurs, après avoir réalisé une analyse rétrospective des 107 difformités de la main brûlée reconstruites depuis 1978 dans la clinique du Service Universitaire de Chirurgie Plastique et Reconstructive Hacettepe (Ankara, Turquie), ont effectué une analyse statistique des résultats par rapport à divers facteurs (l'âge du patient au moment de la brûlure, cause de la brûlure, lieu de première thérapie, degré de difformitè, temps de reconstruction, et méthodes de reconstruction). Dans le groupe de difformités légères de la main brûlée (95 cas), 18 mains ont été reconstruites avec des plasties en Z, 65 avec des plasties en Z et des greffes cutanées, et 12 avec des greffes cutanées seules. Dans le groupe de difformités sévères de la main brûlée (12 cas), cinq mains ont été reconstruites avec des lambeaux abdominaux et inguinaux, quatre avec des lambeaux d'avant-bras, et trois avec des lambeaux à distance. Les résultats obtenus après la reconstruction des brûlures par ébouillantement, les accidents domestiques et les brûlures des enfants ont indiqué une capacité meilleure des mouvements. Aussi la reconstruction précoce, sans attendre la maturation des cicatrices, a montré des résultats meilleurs, avec une amélioration supérieure des mouvements. Les difformités de la main dues aux accidents industriels, comme les brûlures chimiques, présentaient de gros problèmes pour la reconstruction parce qu'il s'agissait de cas difficiles, avec des lésions profondes des éléments fonctionnels de la main.

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