Management of Burns to the Hand: Daily Care

Dressings
A number of dressings are available for the treatment of clean partial-thickness burns. Porcine heterograft (pigskin) is inexpensive, but becomes inelastic once applied, hindering hand and finger motion. Allograft (human cadaver skin) provides an excellent temporary dressing but is too expensive for routine use. Biobrane biosynthetic wound dressing (Bertek Pharmaceuticals, Morgantown, West Virginia) is a bilayer semisynthetic dressing consisting of an elastic nylon fabric bonded to a semipermeable silastic membrane and coated with collagen polypeptides. Gloves manufactured from this material are available in a variety of sizes and are ideal dressings for clean partial-thickness burns of the hands (Figure 1). The gloves can be applied in the emergency department and then monitored daily on an outpatient basis. Nonadherence of the dressing indicates the possibility of infection or that the burn is full thickness. In the case of infection, the dressing should be removed, and topical antimicrobials placed. The gloves are flexible, facilitating hand therapy, and are less painful than daily washing and application of topical creams. The dressing material lifts off the burn wound, as epithelialization proceeds, and is trimmed with scissors.

Positioning
A burned hand that is not properly positioned, splinted, or ranged will develop contractures. These represent major disabilities that are not easily corrected by later reconstructive surgery (Figures 2A and B). The typical contracture is an "intrinsic minus" position where the metacarpophalangeal (MP) joints are fixed in hyperextension and the proximal intraphalangeal (PIP) joints are fixed in a position of flexion.[3] The collateral ligaments of the MP joint are the most important structures of the burned hand. For this reason, positioning of the burned hand should place the MP joints at maximum flexion (90 degrees of flexion) to maximally stretch the collateral ligaments. The anatomic position for splinting is not the "Fosters Beer Can" grip but rather involves 30 degrees of wrist extension, MP joints at 90 degrees of flexion, and IP joints fully extended. The thumb should be fully abducted. During the resuscitation of a patient with a massive burn injury the authors prefer to use a volar cockup splint extending from forearm to palm, elevating the wrist approximately 70 to 80 degrees for the first 24 to 48 hours. Elevation of the wrist to this degree will pull the MP and IP joints into a safe position. This splint may be secured to the forearm over the burn dressings with Velcro straps and is easily loosened to compensate for progressive edema.

Splints
Hand therapy is moving away from static splinting in favor of active ranging. Static splints are now more often used for cases where the patient is unable to cooperate or participate in hand care or are used to maintain daytime gains in motion while the patient sleeps. After the edema of resuscitation resolves, a static splint should cover the volar forearm to the fingertips and should maintain the wrist in 30 to 40 degrees of elevation, the MP joints in 90 degrees of flexion, the IP joints in extension, and the thumb in abduction. Continuous passive motion machines (CPM) are a useful adjunct to hand therapy but are expensive. Finger burns may limit the ability to attach the CPM machine to fingertips. In refractory cases, the authors maintain burned hands in a functional position by temporary (two week) K-wire arthrodesis of the MP and IP joints.

 Encourage the patient to move his or her hands and fingers often, especially at dressing changes. The nurse or family can move the fingers and hand for the patient if the patient is unable to do so. Active and passive range-of-motion exercises should be done.

PALMAR HAND BURNS I. Etilogy: A. Age range 6month 3 years B. 70% contact burns II. Initial concerns A. Palmar creases 1. distal palmar 2. thenar crease 3. palmar digital 4. proximal palmar crease B. ROM while healing (pt may bleed, OK) 1. Edema..no splinting and may limit ROM 2. Blisters (intact) 3. Tendon exposure/possible tendon involvement C. Splinting 1. Palmar extension with digits in Hyperextension and wrist in extension 2. NO splinting if hand is very swollen or if blisters remain intact D. Education 1. patient 2. parents/caregivers E. Childs ROM > Adult ROM F. Home Exercise Program G. Skin Grafting III. Burn is healed A. Splinting B. Massage C. Skin care D. Caregiver Education 1. areas of concern 2. what to look for E. Signs of potential Scar formation IV. A scar is forming A. Coban wrap hand 1. cowrap is more gentle 2. massage B. Interim Glove C. Jobst Glove 1. size of hand 2. silicone gel sewn into glove 3. otoform

D. Silicone Gel 1. softens scar 2. break down 3. rash 4. water based gel E. Follow-up 1. reconstruction