The treatment of hand burns

Postburn contractures of the hand

Several functionally limiting sequelae can follow deep thermal injury to the hand. Despite appropriate initial management, contractures are common. Whereas acute burn care is often managed by multidisciplinary, specialized burn units, postburn contractures may be referred to hand surgeons, who should be familiar with the patterns of burn contracture and nonsurgical and operative options to improve function and expected outcomes. The most common and functionally limiting sequelae are contractures of the webspace, hand, and digits. Webspace contractures and postburn syndactyly are managed with scar excision and local soft tissue rearrangement or skin grafting. The burn claw hand presents as extension contracture of the metacarpophalangeal joints and flexion contractures of the proximal interphalangeal joints. The mainstays of management of these contractures include complete surgical excision of scar tissue and resurfacing of the resultant soft tissue defect, most commonly with full-thickness skin grafts. If scar contracture release results in major exposure of the tendons or joints, distant tissue transfer may be required. Early motion and rehabilitative modalities are essential to prevent initial contracture formation and recontracture after surgical release.

Light-stable bis(norharmane)silver(I) compounds: synthesis, characterization and antiproliferative effects in cancer cells

Four different-anion Ag(I) compounds with the ligand norharmane (9H-Pyrido[3,4-b]indole; Hnor) and having the general formula [Ag(Hnor)2](anion) (anion=ClO4(-), NO3(-) and BF4(-)) [Ag(Hnor)2(MeCN)](PF6) are reported, and studied in detail regarding their coordination mode and in vitro antiproliferative effects. X-ray structural analysis revealed that the complex with the PF6(-) anion has a MeCN solvent molecule weakly coordinated to Ag(I), making the metal coordination T-shaped, while the other compounds present the classical linear Ag(I) coordination. The compounds showed certain cell growth inhibitory effects in two different cancer cell lines, with the perchlorate containing complex being the most toxic and in fact comparable to cisplatin. Notably, the compounds are stable in visible light; and the luminescence in the solid state was found to be extremely weak, whereas in MeOH solution all compounds show a moderate to weak emission band at 375 nm, when excited at 290 nm.

Prevention and surgical management of postburn contractures of the hand

In addition to burn surgeons, skilled nurses, and therapists, hand surgeons are a key part of the multidisciplinary team caring for patients following thermal injury to the hand. Despite appropriate initial treatment and compressive therapy, contractures are common after deep burn. The most common and functionally limiting are web space and hand contractures. Web space contractures can be managed with excision followed by local soft tissue rearrangement or skin grafting. The classic burn claw hand deformity includes extension contracture of the metacarpophalangeal joints and flexion contractures of the proximal interphalangeal joints. The mainstay of management of these postburn contractures includes complete surgical release of scar tissue and replacement by full-thickness skin graft. In cases in which scar contracture release results in major exposure of the tendons or joints, distant tissue transfer is required. This review focuses on prevention and management of late sequelae of thermal injury to the hand focusing on contractures of the webspaces and hand.

Management of Burns and Anesthetic Implications

Burn injuries are highly complex and affect almost every major organ system in the body. The treatment of burn patients requires the presence of a well-organized team of caregivers who understand the multifaceted consequences of burn injuries and who are adept at coordinating care. An understanding of the multitude of abnormalities that must be addressed helps to guide therapy in these patients. Careful anesthetic and perioperative management of these patients carries special importance in this fragile patient population as a part of their often lengthy recovery and rehabilitation.

Assessment of burned hands reconstructed with Integra(®) by ultrasonography and elastometry

INTRODUCTION

Hand injuries have major psychological, social and professional repercussions. Treatment of burned hands is suggested to be early and optimal to avoid catastrophic consequences and allow social and professional rehabilitation. Our study analyses the long-term results obtained with Integra(®), a dermal substitute used for the treatment of deep burns of the hands.

PATIENTS AND METHODS

A total of 29 hands were treated with Integra(®). Long-term monitoring was performed on 12 hands with a clinical, ultrasonographic and elastometric study. The results were compared with those from a series of healthy hands. This study, with a low number of subjects, is a pilot report.

RESULTS

This study showed a low complication rate, with a high percentage of engraftment of thin skin, and good cosmetic and functional quality. The thickness and viscoelasticity of the skin treated with Integra(®) in our series appeared to be similar to those of healthy skin.

CONCLUSION

Integra(®) artificial skin is an attractive alternative in the treatment of deep burns of the hand and can achieve results with aesthetic and functional characteristics that are close to those of healthy skin.

The effect of hand burns on quality of life in children

There is limited data regarding the long-term outcomes for children with hand burns. The objective of this study was to prospectively document recovery after burn injury using a validated health outcomes burn questionnaire for infants, children, and adolescents. A single center prospective study was conducted on consecutive children aged 0 to 4 years and 5 to 18 years comparing outcomes between children with and without hand burns. Age specific American Burn Association/Shriners Hospitals for Children Burn Outcomes Questionnaires were administered at admission, first clinic after discharge, 3, 6, 12, 18, and 24 months after injury. One hundred eighty-one consecutive patients were enrolled in the study. Demographic, injury, and survey outcome data were available for 145 patients for at least 24 months after injury. Children with hand burns had significantly longer hospitalization, intensive care unit days, ventilator days, and TBSA burns. Initial Burn Outcomes Questionnaire scores for children with hand burns were significantly lower than controls and children with burns not involving the hand. For ages 0 to 4 years and 5 to 18 years, only the domain specific to upper extremity function was significantly decreased between the groups over the entire study period. Despite severe injury, children with hand burns have continued improvement in quality of life for at least 2 years after injury. The presence of a hand burn in the context of large TBSA burn is a marker of more severe acute illness and predicts increased resource utilization. Rehabilitative efforts after upper extremity injury should continue to target both physical function and the psychosocial impact of burn injury.

Scar and contracture: biological principles

Dysregulated wound healing and pathologic fibrosis cause abnormal scarring, leading to poor functional and aesthetic results in hand burns. Understanding the underlying biologic mechanisms involved allows the hand surgeon to better address these issues, and suggests new avenues of research to improve patient outcomes. In this article, the authors review the biology of scar and contracture by focusing on potential causes of abnormal wound healing, including depth of injury, cytokines, cells, the immune system, and extracellular matrix, and explore therapeutic measures designed to target the various biologic causes of poor scar.

Severe burn injuries: acute and long-term treatment

BACKGROUND

The physician that initially sees a patient with an extensive and deep dermal burn injury must be able to provide initial acute treatment and to make a well-founded decision whether to have the patient transported to a burn care center (BCC). Physicians from a variety of specialities will be involved in the management of long-term sequelae.

METHODS

This article provides an overview of the treatment of severe burns and their commonest complications. Special attention is paid to initial emergency treatment (first aid) and to late complications, because physicians from multiple specialties are often involved in these phases of treatment. The data and guidelines that are summarized here were obtained through a selective Medline search and supplemented by the authors' experience in their own burn care center.

RESULTS

Analgesia, careful fluid balance, and early intubation are important elements of the initial emergency treatment. Long-term complications of burns, such as disfiguring scars on exposed areas of skin and functionally significant contractures, often require surgical treatment. Early measures for scar care may improve the outcome.

CONCLUSIONS

The effective treatment of severe burns is interdisciplinary, involving general practitioners and emergency physicians as well as plastic surgeons and physicians of other specialties. Knowledge of the basic principles of treatment enables physicians to care for patients with burns appropriately both in the acute setting and in the long term.