Early coverage of deep hand burns with groin flaps

A Prospective Study of Contracture of the Finger and its Management in a Tertiary Care Center

BACKGROUND

When the range of motion between two finger segments, both active and passive, is restricted, finger contracture occurs. The aim of this study is to investigate the best procedure to eliminate finger contracture and the functional and esthetic results of the different surgical procedures.

MATERIALS AND METHODS

A total of 31 patients with soft-tissue abnormalities of the hand were included in this prospective study. They underwent either contracture removal with K-wire and skin grafts or various flap procedures in the department of plastic surgery. Complaints of stiffness and discomfort were classified into five categories: none, mild, moderate, marked, and severe. The difficulty a person had in picking up objects, grasping, writing, etc., was used to determine the degree of disability. Absenteeism from work and surgical site infections were also recorded.

RESULTS

The mean age was 20.25 years, with a mean age of 23.05 for men and 15.83 for women. Overall, most cases occurred in the age range of 3-10 years. For K-wire surgery with skin grafting, the typical time off work was 24 days. The average recovery time ranged from 15.2 days for skin grafts to 16.9 days for tenolysis, 28.33 days for groyne flaps, and 41 days for abdominal flaps. Of all cases, 12 (38.00%) had a fair result, 10 (31.04%) had a moderate result, and 9 (30.96%) had an excellent result.

CONCLUSION

The most feasible method for treating these situations, which offers the greatest potential for a functional and cosmetic result, is contracture reduction with skin grafting.

Concepts in Early Reconstruction of the Burned Hand

BACKGROUND

Early reconstruction of burn sequelae of the hand can be challenging owing to high goals for functional and aesthetic outcome. A variety of reconstructive procedures with ascending levels of complexity exists and warrants careful indication.

METHODS

In this case series, the main reconstructive techniques for reconstruction of burn defects of the hand are described, illustrated, and discussed: split thickness skin grafting (STSG) with fibrin glue, dermal matrices with STSG, distant random pattern (abdominal bridge) flap, distant pedicled flap (superficial circumflex iliac artery flap), and free microvascular tissue transfer (anterolateral thigh flap). An algorithm for decision making in the reconstructive process is proposed.

RESULTS

Split thickness skin grafting provides sufficient coverage for partial thickness defects without exposure of functional structures; fixation with fibrin glue avoids unnecessary stapling. Dermal matrices under STSG provide vascularized granulation tissue on full thickness defects and can be used as salvage procedure on functional structures. Distant random pattern or pedicled flaps provide sufficient coverage of large full thickness defects with exposed functional structures but pose some challenges regarding patient compliance and immobilization. Free tissue transfer allows tailored reconstruction of large full thickness defects with exposed functional structures and can be safely and feasibly performed. Secondary and tertiary procedures are needed with more complex techniques; if applied correctly and consequently, all methods can yield favorable functional and aesthetic outcomes.

CONCLUSIONS

Reconstruction of the burned hand may require a broad armamentarium of surgical techniques with different levels of complexity, versatility, and applicability. Excellent results can be achieved with the right procedure for the right patient.

Plastic Surgery Challenges in War Wounded I: Flap-Based Extremity Reconstruction

Scope and Significance: Reconstruction of traumatic injuries requiring tissue transfer begins with aggressive resuscitation and stabilization. Systematic advances in acute casualty care at the point of injury have improved survival and allowed for increasingly complex treatment before definitive reconstruction at tertiary medical facilities outside the combat zone. As a result, the complexity of the limb salvage algorithm has increased over 14 years of combat activities in Iraq and Afghanistan. Problem: Severe poly-extremity trauma in combat casualties has led to a large number of extremity salvage cases. Advanced reconstructive techniques coupled with regenerative medicine applications have played a critical role in the restoration, recovery, and rehabilitation of functional limb salvage. Translational Relevance: The past 14 years of war trauma have increased our understanding of tissue transfer for extremity reconstruction in the treatment of combat casualties. Injury patterns, flap choice, and reconstruction timing are critical variables to consider for optimal outcomes. Clinical Relevance: Subacute reconstruction with specifically chosen flap tissue and donor site location based on individual injuries result in successful tissue transfer, even in critically injured patients. These considerations can be combined with regenerative therapies to optimize massive wound coverage and limb salvage form and function in previously active patients. Summary: Traditional soft tissue reconstruction is integral in the treatment of war extremity trauma. Pedicle and free flaps are a critically important part of the reconstructive ladder for salvaging extreme extremity injuries that are seen as a result of the current practice of war.

Simultaneous pedicled flaps for coverage of complex blast injuries to the forearm and hand (with supplemental external fixation to the iliac crest for immobilization)

The technique of two simultaneous pedicled flaps to a single extremity has recently proven useful in the care of war-injured military personnel. We present two cases of combat-injured Marines who underwent upper extremity reconstruction using simultaneous pedicled flaps. These cases illustrate a simple and successful alternative to free tissue transfer in providing coverage to complex soft tissue defects of the hand and forearm. Good outcomes were obtained in circumstances where free tissue transfer was not indicated.

Distant pedicle flaps for soft tissue coverage of severely burned hands: an old idea revisited

Burns to the hand that are complicated by exposure of bone, joint or tendon cannot be closed with conventional skin grafts and require flap procedures to prevent further damage. Local or regional flaps may be unavailable if electrical or blast trauma produces a large zone of injury, or when forearm burn injury extends beyond fascia. Free tissue transfer may not be tolerated by critically ill burn patients. In these circumstances, distant pedicle flaps are one option for safe and effective soft tissue coverage. Over a 5-year period, we have performed six distal pedicle flaps for coverage of exposed hand structures when local or free flaps were contraindicated or unavailable. The patients required an average of 4.5 surgical procedures to complete hand reconstruction and soft tissue coverage. Soft tissue coverage was completely successful in five patients and partially successful in one patient. Single stage local or free flaps remain the treatment of choice when burned hands cannot be covered with skin grafts. When these flap options are not available, distant pedicle flaps provide a safe alternative.

Acute hand burns in children: management and long-term outcome based on a 10-year experience with 698 injured hands

OBJECTIVE

To document long-term results associated with an coordinated plan of care for acutely burned hands in children.

SUMMARY AND BACKGROUND DATA

Optimal hand function is a crucial component of a high-quality survival after burn injury. This can be achieved only with a coordinated approach to the injuries. Long-term outcomes associated with such a plan of care have not been previously reported.

METHODS

Over a 10-year period, 495 children with 698 acutely burned hands were managed at a regional pediatric burn facility; 219 children with 395 injured hands were followed in the authors' outpatient clinic for at least 1 year and an average of >5 years. The authors' approach to the acutely burned hand emphasizes ranging and splinting throughout the hospital stay, prompt sheet autograft wound closure as soon as practical, and the selective use of axial pin fixation and flaps. Long-term follow-up, hand therapy, and reconstructive surgery are emphasized.

RESULTS

Normal functional results were seen in 97% of second-degree and 85% of third-degree injuries; in children with burns involving underlying tendon and bone, 70% could perform activities of daily living and 20% had normal function. Reconstructive hand surgery was required in 4.4% of second-degree burns, 32% of third-degree burns, and 65% of those with injuries involving underlying bone and tendon.

CONCLUSIONS

When managed in a coordinated long-term program, the large majority of children with serious hand burns can be expected to have excellent functional results.

The use of calcium alginate dressings in deep hand burns

Deep burns of the hand are a common serious surgical problem with major occupational and economic implications. Control of haemorrhage during excision and grafting is difficult and postoperative haematoma may reduce graft take. Following excision, important deep structures such as extensor tendons or joints may be exposed. Such tissues do not take free skin grafts satisfactorily. We have found calcium alginate dressings can be of immense help in minimizing these technical problems. We describe our experience in one patient; three other patients have been treated with equal success.

The acutely burned hand: management and outcome based on a ten-year experience with 1047 acute hand burns

Optimal hand function has a very positive impact on the quality of survival after burn injury. Over a 10-year period, 659 patients with 1047 acutely burned hands were managed at the Sumner Redstone Burn Center of the Massachusetts General Hospital. Our approach to acutely burned hands emphasizes ranging and splinting throughout hospitalization, prompt sheet autograft wound closure as soon as practical, and the selective use of axial pin fixation and flaps. This approach is associated with normal function in 97% of those with superficial injuries and 81% of those with deep dermal and full-thickness injuries requiring surgery. Although only 9% of those with injuries involving the extensor mechanism, joint capsule, or bone had normal functional outcomes, 90% were able to independently perform activities of daily living.

Management of burn wounds with prompt excision and immediate closure

The past 30 years have been witness to significant improvements in the overall care and prognosis of those suffering burn trauma. At the heart of this success is an aggressive approach to burn wounds. This approach, which is detailed in this review, involves early operative removal of devitalized tissue and biological coverage of resultant wounds, with particular attention to wounds in specialized areas.

Burn wound healing: James Ellsworth Laing memorial essay for 1991

This essay has concentrated on the basic processes, clinical techniques involved in burn wound healing and how the two relate to each other. The achievement of early, sound, durable burn wound healing is one of the fundamental aims of burn care in order to minimize subsequent morbidity and mortality. It must be remembered that all patients with burns are individuals. There is no standard way to treat a burn and treatment must be tailored to suit the needs and requirements of both the patient and the burn wound. Burn wound healing is not the specific domain of any one specialist. It requires input from all disciplines and can be best achieved by the burn team approach.