Annals of Plastic Surgery and Reconstructive Microsurgery no. 1/2005

GENERAL CONSIDERATIONS REGARDING INDICATIONS OF TREATMENT IN POSTBURN SEQUELLAS OF THE HAND ( I I rd part )

E. TURCU, I. P. FLORESCU, CAMELIA ONEL

Our paper presents few considerations regarding conservative management associated with surgical procedures in postburn sequellas of the hand.

Postburn sequellas of the hand involve (due to its great variety) multiple therapeutically procedures (surgical and conservative management) depending of the case. Nowadays, one should choose the surgical moment in relation with special requests (if the sequella affects hand function, than the procedure it's going to be done as soon as is possible).

Conservative management is not a prolongation of surgical treatment; it is an adjuvant therapy performed before and after the operation, having surgical indications and surgical steps adapted on the case.

The first measure of fighting against digital joined stiffness in pacients with deep hand's burns is the prevention of joint stiffness. The priority in treatment and prevention of posttrauma/postburn oedema is hand splintage.

Oedema impairs the hand in "intrinsec minus position "and such a type of joint ankilosis is difficult to be corrected.

Joint stiffness prevention requests metacarpophalangeal joint splintage in flexion and interphalangeal joint splintage in extension ("intrinsic plus position"). One could demand: why MF joints splinted in flexion doesn't develop secondary stiffness or joint ankilosis in such a position and if theese deformities appear than why they are emendable by conservative management ?

The answer stays in structure and function of volar plate of MF joint

In maximum flexion the length of volar plate is -2/3 of his completely extension normal length (in extension). The volar plate's pocket in MF joint is smaller and it presents susceptibility to develop fibrosis but lesser than the volar plate's pocket of IF joint.

The volar plate of interphalangeal joint slides proximal and distally during flexion-extension movements, protecting the joint Nolar plates contraction at the level is smaller and the volar plate's pocket is larger then the MF joint one.

So, the possibility of oedema and fibrosis development is higher. Conservative management of postburn joint stiffness consisted in:

• Passive elongations, first gently than with increasing force; During the movements the other joints are blocked, so they are not able to take over parts of the movement.
• Amovible splintage for progressive flexion -extension. The positions could be maintain using simple devices or other type of splintage .The recommendation is to change the position as frequent as is possible during the day and alternatively them and during the night.
• Active- passive mobilisation associated with overnight splintage.
• Oil massage in longitudinal and transversal directions freeing superficial and deep plans.

Obtaining a limited mobility could be a success (for example gaining 50-60 grd flexion in MF joint means the surgical procedure is no more indicated).

The falling of conservative management involves a more aggressive treatment (surgery).

One should mention that the management for deep dermal burns of the hand, (involving precocious treatment) consists in oedema releasing (using elevation of upper limb); escharothomy and circular incisions, immediately active mobilisation.

Due to the pain and oedema, the burn's hand adopted a characteristic attitude: radiocarpal joint in flexion, MF joint in extension ,IF joint in flexion and the thumb adducted.

Is mandatory to begin the active rehabilitation programme as soon as is possible before oedema installation. The majority of pacients cooping in active mobilisation programme could develop a vicious hand position during the night requesting overnight hand splintage.

The non-cooperating patients need passive mobilisation preventing tendons adhesions and joint capsular contraction. When oedema started to get over (after 48-72 hours) the overnight hand mobilisation is the rule to prevent secondary deformition.

The hand shouldn't be immobilized in functional position; it should be kept in the most advantages positions to cure secondary deformities. Thermoplastic splintage is performed in such a way to maintain radiocarpal joint in posterior flexion (15-20) ,MF joint in flexion (75-80) and IF joint in 10 flexion , with thumb abduction. The favourable evolution of the trauma at the level is generated by skin integrity. The layers of the skin are adapted to special functions: prehension and sensibility.

The first reaction in the tissues after hand burn consisted in liquid effraction in soft tissue and at the joint level. Oedema affected joint capsule and collateral ligaments leads in reduction of their length.

Intrasinovial liquid in large amount produces to joint capsule distension and the joint tends to adopt the position allowing the maximum liquid accumulation.

This is the key point of explanation of "negative hand "position. Any secondary reconstruction in post burn sequella (involving deep structures: tendons, joints) requests a good skin coverage using local or distant tissue having good quality.

Frequently, precocious conservative management prevents functional problems and keep the best possible joint mobility. In this situation the only reconstruction necessary involves just the skin for functional and aesthetic improvement. In post burn hand sequellas (without ancient joint deformity irreductible and with normal tendon or with the possibility of tendon reconstruction) the first surgical step consists in skin repair.

The second step is represented by in tenoplasty, especially for extensor tendon associated with joint arihrolysis. Alternating passive and active mobilization should be performed immediately to prevent tendons adhesion after tenoplasty or tenolysis. In first 10 days the fibroblasts increase their number and migrate from epithenon to the site of future internal tendinous scar ,generating active collagen synthesis. At 21 days after the tenoplasty the mobilized tendon demonstrated lesser proliferation of fibroblasts. In the third week the fibroblast present endoplasmic reticulum and Golgi apparatus well developed indicate an active proteins synthesis without any sign of collagen resorbtion.

At 42 days after tendon reconstruction, the fibroblasts continue to proliferate and the synthesis of active collagen in parallel pattern bands. In the same manner, in endothenon one could notice such a fibroblastic activity but lesser in cases with active rehabilitation programme than in cases without any mobilization.

The new vascularisation network invades completely the healing aria and the adhesions are not develope in cases with tendons mobilization. The digital joint damages are secondary during the time of eschar detersion or they begin later in cicatrisation phase.

Joint involvement is due to: fibrosis, capsular and ligament's contraction, tendon's contraction, deviation of extensor structure at this level and deformity of the joint surface leading to subluxation. All theese modifications are grown in cases of prolonged immobilization in vicious position. Ancient post burn sequellas with irreversible and total damage of the joint request arthrodesis in functional positions.

The mandatory aim of this type of surgery is to establish at least one digital pinch and prehension.

Despite this purpose, there are many situations requesting arthrodesis this one beeing the only possible surgical procedure with result. The achievement of "hook "prehension is of small functional value.

The conclusion is that: therapeutically management of burns hand and postburn sequellas should be done as soon as is possible to prevent irreversible damages of important structures involved in all biomechanical aspects.

It's the only way to avoid secondary unsuccessfully surgical procedures. We highly recommended conservative management before and after the operation as an adjuvant surgery but never ever as the only treatment in severe hand's burns.

All the problems due to postburn hand sequellas remain in actuality because of lots severe work accidents, affected young patients, who request tremendously efforts to obtain functional hand rehabilitation and social reinsertion.

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