priate choice for local coverage when the donor site remains uninjured. An Allen’s test, as well as Doppler examination of the superficial palmar arch, should be performed prior to raising the flap to ensure adequate perfusion of the hand. Skin grafting of the donor site in the case of a fasciocutaneous flap or recipient site in the case of a fascial flap will be necessary. The distally based posterior interosseous flap is a fasciocutaneous flap harvested from the dorsal aspect of the forearm and does not disrupt either of the major blood vessels perfusing the hand [1]. Although the flap’s perfusing vessel is sometimes hypoplastic or absent, this flap is especially useful when there has been an injury to either the radial or ulnar artery.

Distant flaps. When local flaps are unavailable due to injury, distant flaps may be considered. The primary distant flaps used for hand coverage are the abdominal (random) or groin (pedicled) flaps [27]. In either case, a flap of Scarpa’s fascia, subcutaneous tissue, and skin is templated, raised, and sutured onto the hand. The hand is left in-situ for 2–3 weeks after which the flap is divided (Fig. 3). Vascularization of the flap can be determined, when in doubt, using indocynanine-green fluorescence video angiography [21]. A variant of groin or abdominal flaps may be performed in which only Scarpa’s fascia is transferred and skin grafted, leaving behind the groin or abdominal skin and subcutaneous tissue – the Crane procedure.

Free tissue transfer. Free tissue transfer may be necessitated when extensive burns prevent local or distant pedicled flaps. Numerous options exist including a contralateral radial forearm fascial flap, dorsalis pedis fascial flap, temporoparietal fascial flap, perforator flap (ex. thin anterolateral thigh perforator flap), and muscle flaps (ex. serratus anterior, rectus abdominus, or gracilis) [4, 13]. All have been used with success to provide durable, pliable coverage. Prior to considering a free tissue transfer, the viability of the recipient vessels must be evaluated to ensure that they have not also been damaged.

Skin substitutes

Skin substitutes may be useful in cases of extensive burn injury where there is limited donor site to allow

Fig. 3. A pedicled abdominal flap was used in this case to provide soft tissue coverage over exposed joints and tendons of the hand. In this case two separate flaps were used – one for the thumb and one for the digits

for the harvest of quality autografts for hand coverage. Skin substitutes are applied to the freshly excised wound bed and, as in the case of autograft, it is essential that the wound bed be viable and hemostatic prior to skin substitute placement. Depending on the skin substitute used, the autograft may be placed over the substitute in one operation or in a second procedure after the substitute has had adequate time to vascularize. Two popular skin substitutes are Integra (Integra Life Sciences, Plainsboro, NJ) which requires two procedures and Matriderm (Dr. Otto Suwelack Skin & Health Care AG, Billerbeck, Germany) which is a one-stage product. Each approach has relative benefits and drawbacks. A full discussion of skin graft substitutes is beyond the scope of this chapter; however, their use has been described in several small case series studies involving the hand [6, 11, 12, 16, 31].

Amputation

Severe burns of the hand may result in injuries for which salvage is either impossible or impractical. The ultimate goal of treatment of hand burns is optimization of function. The loss of a digit may provide the patient with a more favorable outcome when compared to an insensate, painful, and stiff finger.

Delayed amputation is also sometimes required when all other treatments options have been exhausted or have failed. Length should be protected at all times. As is the case with all severe hand burns, realistic discussions about the goals of reconstruction should take place prior to embarking on a plan of treatment. In addition, an area of viable soft tissue on a digit which is to be amputated may be useful for coverage of other areas of the hand. For example, if the dorsal aspect of a digit is burned down through the tendon and joint, a filet flap from the volar aspect of the digit can be used to cover any exposed metacarpophalangeal joints or tendons.

Hand therapy

Hand therapy is an integral component in the treatment of any hand injury. Surgical management of hand burns without proper post-operative hand therapy – including splinting, edema management, and range-of-motion exercises – preferably led by an experienced burn therapist, is likely to result in suboptimal results. Hand therapy should begin within 24-hours of injury. Edema management is initiated with elevation and proceeds to compressive wraps. Custom compressive gloves and sleeves should be fitted to the patient when there is no longer concern for a shear injury [17]. Any hand which begins to assume a clawed posture should be splinted in the intrinsic plus position with the wrist in 30 degrees of extension, the metacarpophalangeal joints in 70–90 degrees of flexion, and the interphalangeal joint in full extension to 15 degrees of flexion. The first webspace should also be held in an abducted position. This posture will maintain the collateral ligaments in tension and help to avoid fixed contractures. Palm burns, which are at significant risk of flexion contracture, should be splinted with all joints in full extension. Range of motion exercises should be withheld in the acute phase of graft or flap healing, but should be initiated as soon as possible thereafter, usually after five days in the case of splitor full-thickness skin grafting. If prolonged splinting is required, range of motion exercises out of the splint should occur several times a day. Night time only splinting should be considered and independent therapy should be encouraged. Passive range of motion should be performed on intubated

patients daily. Patients should not be discharged from the hospital until they have demonstrated that they are self-sufficient with both hand therapy and wound care [20].

Secondary reconstruction

Even optimal care of burned hands may result in excessive scarring and contracture. Hand contractures may be categorized as digital, palmar, dorsal, or syndactyly [14] (Fig. 4). Secondary reconstructions include scar release, rearranging or lengthening scar, and replacing deficient tissues with grafts or flaps. Treatment of contracted tissue should be initiated after the scar has fully matured, often a period of 12 months. The patient must also be mentally prepared to return to the operating room and participate in postoperative rehabilitation. In case of pediatric patients, parental compliance must also be assured. However, in some cases of severe contracture, early release and grafting should be considered.

The approach to secondary reconstruction begins with defining the problem or functional deficit. A discussion of realistic goals and expectations should follow. Physical therapy should be initiated to both improve contracture and demonstrate future compliance. Coverage options, both local and distant, should be inventoried. If two hands require sur-

Fig. 4. Digital contractures of the burned hand extending from the palm to the digits

gery, only one should be addressed at a time. Surgeries with competing post-operative needs, such as prolonged immobilization and early motion, should also be performed separately. Standard plastic surgery techniques such as Z-plasty and Z-to-Y flap release are commonly performed to release hand contractures The Z-plasty is particularly well suited for web spaces and the Z-to-Y flap release is appropriate for small, linear contractures. Full-thickness skin grafts may be required after the release or excision of scar to accommodate for increased excursion. In cases of long-standing contracture, consideration of Kirschner wire fixation in extension for 3 weeks may help to prevent recurrence of contracture.

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