Contractures in burn injury part II: investigating joints of the hand. J Burn Care Res. 2008;29:606-613. [PMID: 18535473 DOI: 10.1097/bcr.0b013e31817db8e1]

The modified Patient and Observer Scar Assessment Scale: a novel approach to defining pathologic and nonpathologic scarring

BACKGROUND

Scarring is a highly prevalent and multifactorial process, yet no studies to date have attempted to distinguish pathologic from nonpathologic scarring.

METHODS

This article defines and proposes methods of classifying pathologic scarring as it pertains to clinical presentation.

RESULTS

The authors propose a new scar scale that incorporates pain and functional impairment.

CONCLUSIONS

The modified Patient and Observer Scar Assessment Scale is the first of its kind to factor in the functional deficits pain and pruritus of scarring into measurements of associated morbidity. This scale has great potential in evaluating patient response to treatment and analyzing clinical outcomes.

First web space post-burn contracture types: contracture elimination methods

First web space adduction contractures are a common consequence of hand burns. Many reconstructive techniques are used and investigation for more effective methods continues. Effective hand reconstruction usually considers anatomy as its foundation. Based on the experience of over 500 web space contracture elimination cases, three anatomical types of thumb adduction contractures were identified: edge, medial and total. Edge contractures (80% of all thumb adduction contractures) are caused by a fold in which only one sheet is scarred, either the palmar or dorsal surface. The contraction is caused by a trapeze-shaped length deficiency of the scar sheet, which has a surface surplus in width. Reconstruction consists of surface deficiency compensation with trapezoid flap prepared from the non-scarred side and skin-fat tissues of the web space. In most cases, the small scar-fat trapezoid flaps should be prepared from the non-scarred side to cover the donor wounds on both sides of the main flap. Medial contractures (10% of thumb adduction contractures) are caused by the fold, both sheets of which are scarred and have trapeze-shaped surface deficiency in length and surplus in width. Both fold sheets are converted into one or several pairs of trapezoid scar-fat flaps by radial incisions. The oppositely located flaps are transposed towards each other. As a result of the counter flaps transposition, the contracture is eliminated; the web space's shape and depth are restored by the use of flaps alone or in combination with skin grafting. The trapeze-flap plasty is very simple and effective with the length gain of up to 100-200%. Neither flap loss nor re-contracture occurs. Total contractures (about 10% of all) have no fold. Reconstruction consists of the creation of the central zone of the first web space depth with the rectangular subdermal pedicle flap; the wounds on both sides of the flap are skin grafted. The flap sustains normal web depth and prevents the contracture recurrence and skin graft shrinkage.

Postburn hand border contractures and eliminating them with trapeze-flap plasty

The hand burns can be complicated with the scar contracture of the ulnar or radial hand border. The contracture restricts the mobility of adjacent joints (fifth interphalangeal, wrist joints), causing deviation of the small finger and the whole hand. The contracture and deviation are caused by semilunar fold sheets of which are scars (medial contracture). The fold sheets have the trapeze-shaped surface deficiency in length and surface surplus in width. Thus, the local tissue flaps should have the corresponding form (trapeze-shaped flaps) for surface deficiency compensation. The sheets are transformed into trapezoid flaps along the total length of the semilunar fold with radial incisions until the full tension release is achieved. The incision's ends are split to complete the scar tension release. The distance between radial incisions at the fold's top is approximately 2 to 3 cm, which matches the width of the flap's end. The flaps are mobilized with the full fatty layer and transposed toward each other until the end of one flap reaches the base of the opposite flap. As a result, the skin surface lengthens by two to three times, which allows complete contracture elimination. The contractures were liquidated in all 16 patients without complications. The trapeze-flap plasty is recommended for a wide use in treatment of hand boarder contractures.

The use of AlloDerm on major burn patients: AlloDerm prevents post-burn joint contracture

In efforts to prevent and reduce joint contracture and scar formation after burn, we used the acellular human dermis (AlloDerm) as a dermal replacement in the acute stage. A total of 64 patients received AlloDerm graft selectively on joint areas during the study period from March, 2005 to July, 2007. From January to March, 2008, a total of 31 patients returned to our burn center to examine the functional results by measuring range of motion of joints. Additionally, the quality of grafted skin condition criteria of skin elasticity, scar thickness, trans-epidermal water loss, melanin and erythema level was measured in a total of 11 patients among them. By analyzing the limitation level of 55 joints excluding hand areas, we found that 24 joints (43.6%) showed no limitations, 12 joints (21.8%) showed limitations below 10%, 16 joints (29.1%) showed limitations between 10 and 19% and 3 joints (5.5%) showed limitations over 20%. The scar thickness of non-AlloDerm applied areas was 2.5+/-0.9 mm and AlloDerm applied areas was 1.8+/-0.7 mm (p = 0.396). Trans-epidermal water loss for non-AlloDerm applied areas was 20.9+/-7.7 g/h/m(2) and AlloDerm applied areas was 10.8+/-3.4 g/h/m(2) (p<0.001). Erythema value for non-AlloDerm applied areas was 436.1+/-65.8, whereas AlloDerm applied area was 394.4+/-61.2 (p<0.001). Acellular dermal matrix is a good option for treating major burns to prevent scar formation after burn and loss of joint function.

Acute management of hand burns

Hand burns occur commonly either as part of more extensive burn injuries or in isolation. Optimal management requires careful examination, appropriate wound care, timely surgical excision if warranted, and aggressive range-of-motion therapy.

Rehabilitation of the burned hand

Successful outcomes following hand burn injury require an understanding of the rehabilitation needs of the patient. Rehabilitation of hand burns begins on admission, and each patient requires a specific plan for range of motion and/or immobilization, functional activities, and modalities. The rehabilitation care plan typically evolves during the acute care period and during the months following injury.

Outcome assessment after hand burns

Overall outcome following hand burns is closely related to the depth of injury. Although even full-thickness burns tend to result in favorable outcomes, injuries to the deeper structures may result in some degree of impairment. Reviewing the existing literature on hand burns clearly demonstrates the need for validated measurement tools for the evaluation of hand burn outcomes.

Burn rehabilitation and research: proceedings of a consensus summit

Burn rehabilitation is an essential component of successful patient care. In May 2008, a group of burn rehabilitation clinicians met to discuss the status and future needs of burn rehabilitation. Fifteen topic areas pertinent to clinical burn rehabilitation were addressed. Consensus positions and suggested future research directions regarding the physical aspects of burn rehabilitation are shared.