The hand is crucial to functioning in many daily living tasks, which are required for self-care and needs of work. It is core to one’s aesthetics and communication. With psychosocial and functional impacts, people have an intimate relationship with their hands for interfacing with various aspects of their lives. In burn cases, although the hands only constitute 6% of the total body surface area, more than 80% of severe burn cases involve the hand. The commonality and need for hand burn surgery make understanding the current techniques and principles of management vital to any practicing burn surgeon. Expedited, well-planned, multidisciplinary intervention by a burn center is needed for optimal functional and aesthetic recovery.

Management planning necessitates a thorough assessment of the patient’s history and extent of burn injury. Successful treatment of the burned hand requires the surgeon, occupational and physical therapists, nursing staff, and other care team members to reduce injury and actively support rehabilitation. The initial history can guide management by elucidating the agent of injury (e.g., chemical, fire, high voltage), occupation, hand dominance, and other uses (e.g., instruments, sports). It is equally important to understand a patient’s expectations for their quality of life if possible.

From here, a complete skin exam is vital to identify the distribution of injury. With hand burns, one needs to gauge the involvement of the upper extremity and, thus, other body areas to assess perfusion and plan potential donor sites. Evaluating burn coverage on the dorsal or volar regions of the hand can help identify risks to vital structures.

Immediate first aid is aimed at halting and treating the burn process. Corrosive chemicals may need to be washed or burned. Clothing, wristwear, rings, and other jewelry or wearables should be removed to prevent further injury and expose burn sites. Burn wounds secondary to thermal injury should be cooled with cool water. Blisters, indicative of second-degree burns, have fluid with cytokines and prostaglandins that promote an inflammatory cascade in the burn wound environment. Thus it is recommended that blisters be removed to promote wound healing.

Burns should then be staged for depth of injury through a more in-depth physical exam. Assessing perfusion, pulses, capillary refill, blanching, skin color and texture, extremity movement, and sensation are tools to characterize the severity of the injury. Particularly, monitoring for signs of neurovascular compromise and eschar tissue formation can clue into the development of compartment syndrome. Dorsal surface burns with thinner skin can lead to more severe burns with exposure to tendons, nerves, vasculature, muscles, and bones. Palmar surface burns have a thicker skin pad that can predicate more conservative management with even deep second-degree burns. Patients should be continually followed up and reassessed for progression or clarity of wounds.

Repeated assessments with attention to neurovascular and motor function integrity can facilitate prompt identification of compartment syndrome. Progression can lead to limb loss, necessitating the need to decompress when appropriate immediately. Burn resuscitation, along with edema secondary to fluid extravasation from burn injury, can lead to delayed development of compartment syndrome. Active movement and hand elevation can help reduce hand edema. High-voltage galvanic electrical stimulation with physiotherapy has been shown to help minimize this edema acutely. Lymph pressures range between 1 and 2 cm H ₂ O; thus suspending the hand 50 to 100 cm above the hemostatic axis can create a sufficient gradient for lymphatic drainage.

Overall, the initial assessment of a patient with burned hand injuries can be outlined as follows:

• 1.

  Halt the burn process and remove blisters.

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  Monitor for diminished neurovascular motor function.

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  Assess the extent of the burn injury.

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  Obtain a thorough patient history of the inciting event and recovery goals.

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  Perform serial evaluations of wounds and signs of compartment syndrome.

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  Provide decompression if needed.

The goals of burn care after the immediate setting center around providing direct treatment for burn wounds, preventing further injury, and monitoring for developing complications. Early excision and grafting have been the centerpieces in short-term management. Burn wounds are debrided for eschar and necrotic tissue. Autografts can promote revascularization and early wound protection. Skin substitutes can augment this approach by facilitating reepithelization and assisting with the attachment of autografts. Occupational therapy (OT) and physical therapy (PT) can work to maintain active range of motion (ROM) with adjusted splints to prevent contractures while maintaining elevation for the burned hand.

Burn wounds should be assessed for depth of injury by looking for ability to blanch, color and texture, blistering, and pain sensation. First-degree burns strictly encompass the epidermal layer and can present with pain and erythema. Second-degree (or partial-thickness) burns also involve injury to the dermal layer, although the varying depth of injury to this layer can direct different management needs. Blistering, considerable pain, and a mottled color are commonly seen in these burns. Superficial versus deep dermal burns can be distinguished by more excellent recovery time (greater than 2 weeks in dermal), progressive lack of pain sensation, and color (pale indicates deep burn). Third-degree burns involve the full epidermal and dermal layers and are called full-thickness burns . Exam findings reflect pallor because of extensive vascular damage and thrombosis and eschar tissue, which is leathery in feel. The lack of pain sensation reflects complete damage to the nerve endings. Fourth-degree burns encompass injury to deeper structures such as bones, tendons, muscles, and fat.

Characterization by depth guides immediate nonoperative or operative management. Local wound care with dry appendages and antimicrobial topicals can manage superficial dermal burns. Deeper dermal and full-thickness burns rely on expedient excision and grafting. Localization of these burns on the hand also guides the approach to management. The thinner dorsum of the hand risks damage to tendons, bones, joints, and other vital structures. The glabrous palmar tissue has more protection, and even deep dermal burns can heal with local wound management. Circumferential or full-thickness burns should be emergently managed by escharotomy because of the high risk of compartment syndrome.

Escharotomies and fasciotomies are indicated in circumferential full-thickness burns with resistance or pain to passive motion, absent capillary refill, or reduced pulses. Pulses and perfusion can be monitored via Doppler signals and pulse oximetry. Damaging, restrictive eschar tissue should be managed with escharotomy to prevent hand necrosis. Full-thickness eschar incisions with a scalpel or electrocautery through eschar tissue are made to avoid vital structures and not penetrate past the fascia. An incision on the midlateral line extending from the acromion down to the midlateral aspect of the antecubital fossa to the radial wrist crease should be made. Additionally, another incision on the medial aspect, from the axilla, parallel to the other incision, up to the ulnar wrist crease should be cut. Superficial vital structures should be considered, such as the posterior aspect of the medial epicondyle, where the ulnar nerve is located. At the wrist, branches of the superficial radial nerve are at risk.

In these severe burn cases, nerve entrapment should be promptly released. Median nerve entrapment requires decompression of the carpal tunnel. This can be done with a curve incision parallel to the thenar crease that extends down the midline, distal to the wrist crease. This incision is brought down to longitudinally divide the palmar fascia, where the flexor retinaculum should be divided after identification of the median nerve. The radial nerve can be released by excising the radial tunnel between the brachioradialis and extensor carpi radialis longus tendons in the lateral epicondyle area. The ulnar nerve, most commonly compressed after burn injury, is decompressed by lengthening the muscle and tendon that border the cubital space around the medial epicondyle. ^,

The digits of the hand should be assessed for perfusion via capillary refill, color, and pain sensation. There should be a high index of suspicion for compromised perfusion as their lack of sharp volume changes can predispose them to compartment syndrome. For digit ischemia from elevated pressures, the longitudinal radial and ulnar incisions can be extended up to the midaxial aspects of the first and fifth digits. The second, third, and fourth digits should have ulnar-sided midaxial incisions made as well. These incision locations can help preserve the pinch function of the hand, avoiding the neurovascular bundles and extensor tendons. If perfusion does not improve, incisions should be cut on the contralateral aspect of each digit. ^,

In severe hand burn injuries, the intrinsic muscles of the hand are at particular risk of necrosis. These can be monitored by keeping the metacarpophalangeal (MCP) joint in extension and testing for resistance to passive flexion of the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints. Resistance is indicative of the need for escharotomy. Dorsal intermetacarpal incisions between the second, third, fourth, and fifth MCPs into the intrinsic compartment can help relieve hand pressures while avoiding vital joints, extensor tendons, and vasculature. These incisions can be converted into a fasciotomy if perfusion or movement is not restored by continuing past the fascia (the point when resistance is felt). The risk of not managing necrosis to the intrinsic muscles is developing an intrinsic minus deformity—extension of the MCP and flexion of the interphalangeal (IP) joints.

Enzymatic debridement of eschar wounds is becoming increasingly popular as an alternative to reducing the development of compartment syndrome and, thus, the need for a potentially damaging escharotomy. Considering the risks of this procedure, especially on the hand where longitudinal digit incisions are close to neurovascular bundles, can prompt one to elect for enzymatic debridement when a patient first presents. This can preserve vitalized tissue, reduce surgical debridement, and improve scar outcomes. Substrates like bromelain can degrade eschar tissue selectively over vitalized, nonnecrotic tissue to relieve inelastic, pressure-retaining wounds.

The severity of the burn wound dictates skin injury management. Second-degree burns require early excision and grafting. Excision is done layer by layer of the burn wound until capillary hemorrhaging is visualized, indicating vitalized tissue has been reached. Management encompasses different combinations of autologous split-thickness skin grafts (STSGs), substitutes, and wound dressings for these partial-thickness wounds. With deep dermal burns, grafts can be placed on the vitalized tissue postdebridement and then covered and protected with dressings. Sheet grafts are more commonly used as opposed to meshed, as they provide better aesthetic outcomes and reduced contracture formation. Silver-containing dressings can help with deep wound antimicrobial activity. Large wounds can be covered with a semi-transparent Gore-Tex bag or Aquacel Ag burn glove, allowing better wound monitoring, ROM, and fewer dressing changes. Antimicrobial topicals are particularly important in reducing infection risk in these wounds. Saline irrigation is recommended as it helps remove debris, microorganisms, and dressing materials.

There is a variety of skin substitutes and grafts that can be used for the treatment of deep burns. Synthetic skin substitutes like Biobrane are excellent ways to reduce morbidity and maximize aesthetic outcomes with superficial burns. There may be no immediate availability of autografts in severe, extensively burned patients. To preserve the burned hand, allografts can be used to cover the wound temporarily and later excised or used as a dermal bed for an autograft. AlloDerm, Integra, or Martiderm have been used with STSGs to repair full-thickness tissue injuries, reducing scar and contracture formation. Skin grafts for deep dermal burns are usually sourced from the forearm, buttocks, or thigh. The donor location of the graft is based on the thickness (full or split) needed and donor tissue viability. The instep and medial arch of the foot have been used for grafting to reduce scarring, hair growth, and hyperpigmentation associated with the previous grafts. When grafts are attached, the hand should be kept in a position that maximizes tendon stretch and prevents contracture formation. A few sutures along the corners of the grafts, with fibrin glue, is an effective method to secure the tissue and reduce scarring.

Full-thickness burns require flap coverage, which depends on which area (palmar, dorsal, web space, digit, nail) is involved. If underlying vital structures such as tendons, joints, or bones are burned, these should be debrided before coverage. Flaps provide a vascular bed that can replace perfusion for the thrombosed vascular bed of the wound. These flaps are free (vascular bed separated from donor site) or pedicled (bed remains attached). Various tissue layers can be integrated, with fascial, fasciocutaneous, and muscular flaps finding uses.

After treatment with graft/flap, seroma, hematoma formation, and accumulating hand edema should be monitored. Along with hand elevation, nonadherent compressive dressings help with reducing fluid buildup. Silver-based dressings are recommended for deeper burns because of their antimicrobial activity. At the same time, more superficial negative pressure wound therapy (NPWT) has been shown to secure graft/flap attachment and promote microcirculation to the wound. Bag-based NPWTs can help with the mobilization of the hand. ^, A core therapy with deep hand burns is immediate splinting with a thermostatic splint, keeping the hand in an intrinsic plus position: wrist neutral at 0 to 10 degrees flexed, MCPs flexed to 70 to 80 degrees, IPs fully extended, and thumb abducted. PT can facilitate early ROM exercises.

The dorsal hand has a thin skin layer, so burns are more commonly deeper. When attaching grafts or flaps to the dorsal hand, the wrist, MCP, and IP joints should be flexed to maximize skin coverage and prevent contracture formation. Deep dorsal burn wounds, not full thickness, can be managed with sheet STSGs. Typically, these are harvested from the anterior thigh or buttocks area. With deeper, full-thickness burns, wound repair is dictated by tendons, bones, and joint exposure. Without exposure to these vital structures, a skin substitute can be used with a STSG. Flaps are used for initial repair when any vital structures are exposed, with delayed grafting. This can be a radial forearm fascial or fasciocutaneous flap, which requires assessment of intact palmar arch vasculature via Doppler ultrasound. With burns this extensive on the hand, the ipsilateral forearm area is typically also damaged, restricting the use of this flap. Thus distant flaps, such as a tubed abdominal or groin flap, are required, where the hand is subfascially attached for up to 2 to 3 weeks for revascularization. Free tissue flaps are helpful if the body has extensive burns, aiming for thin, pliable tissue. The contralateral radial forearm fascia, dorsalis pedis fascia, temporoparietal fascia, or thin anterolateral thigh perforator flap can be used.

When the tendons of the digits are exposed, there is a risk of extensor contracture deficits forming. In such cases, K-wires are implanted along the affected digits to maintain them in a fully extended position. Local homodigital, heterodigital, and intermetacarpal flaps can be used for immediate flap coverage. ^, For more extensive burn injuries to the fingers, the posterior interosseus and anterior radial flaps have been used for coverage.

Palmar burn injuries are managed more conservatively because of the thicker, glabrous tissue with Pacinian corpuscles vital for pressure and tactile sensation. Deeper injuries are less common as burn injuries occur more frequently to the dorsal hand when one protects themselves from a burning source, and the thicker skin provides better protection. Deep, superficial dermal burns are managed nonoperatively with irrigation, topical antimicrobials, and dressings. FTSGs from the inguinal creases or flanks are used for minor full-thickness palm burns. The thenar base of the contralateral hand can serve as a donor site for a full-thickness glabrous skin graft, with quick donor site scar healing. The flaps above can be used for skin coverage for more extensive burn injuries.

A multidisciplinary team of occupational and physical therapists, psychologists, and surgeons manages intermediate and long-term rehabilitation. Active involvement of this diverse team is needed to reduce secondary burn wound complications such as contractures, graft/flap failure, muscle weakening, and psychological harm. OT should be actively involved in establishing proper splinting that is mindful of exposed vital structures, protects and secures grafts/flaps, and maintains the intrinsic plus position. Active work between OT and PT must be kept as splinting must be removed and reapplied to allow PT to conduct hand mobilization exercises. Ideally, nightly splinting with daily hand exercise can reduce contracture formation. Therapy is also a crucial aspect of recovery, with hand injuries resulting in self-perception, social, and employment-related concerns, and issues for an individual.

Several months of regular OT/PT sessions for extensive hand burns are required to optimize hand strength and ROM functionally. In the acute sense, the involvement of these teams centers on splint fitting while patients are started on exercise training programs. Therapies such as rehabilitation with dynamic MCP orthosis, intensive exercise programs, and augmenting therapy with virtual reality exercises have been reported to improve patient’s hand function. They assist with dressing changes that allow postoperative evaluation of grafts and flaps for desiccation and seroma/hematoma formation. Compression dressings or gloves can significantly reduce hand edema while promoting increased ROM. Some modified compression bandages, as well as silicone gel, have been shown to reduce scar thickness as well. In the long term, there is an essential educational role in expectation setting in burn rehabilitation. As the hand regains its strength and flexibility, PT/OT should be working to reengage patients with their activities of daily living.

Psychological intervention can help patients with depressive moods, suicidal tendencies, and suffering from current situations. Implementation of rational-emotive therapy helps patients develop tolerance toward emotional solid reactions associated with the injury. These are structured to build confidence and reduce self-image disorders in patients’ rehabilitation process. Combined with physical rehabilitation, these can help improve comprehensive health and psychological function. Patient aesthetic perceptions can be gauged via the Michigan Hand Outcomes Questionnaire.

Burned hand deformities stem from impaired wound healing, leading to contractures, hypertrophic scarring, and even potential limb loss. The active involvement of OT/PT, comprehensive patient education, and patient follow-up are integral to preventing the development of these deformities. Contractures are the most common postacute deformity, stemming from misplaced splints, poor wound coverage by graft/flap, or spontaneously from previously healed deep burn wounds. Prevention of contractures stems from acute-phase management, where focusing on tissue sparing through judicious debridement and proper splinting is essential. Burn contractures can be graded on four levels, shown in Table 2.

Methods of deformity reconstruction must be tuned to its severity and location. These can encompass more noninvasive methods like steroid injections or laser therapy. A superficially invasive method for scar lengthening is Z-plasty, and it can help in areas where tightened skin results in restriction of ROM. Grafts and flaps can be used for more severe wounds to the hand and replace extensive scarring or provide coverage for exposed tendons. For the loss of digits, web space deepening and pollicization have been helpful for the reconstruction of digit function and appearance. These methods, in increasing order of invasiveness, are briefly summarized here :

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  Laser therapy and steroid injections: These offer minimally invasive management for hypertrophic scars that lead to superficial mild contractures.

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  Primary closure: This involves removal of scar tissue with subsequent closure with surrounding nonexcised tissue. Useful for more minor deformities otherwise limited by increased tension induced to surrounding areas.

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  Z-plasty, rhomboid flap, trapezoid flap, and starplasty help release contractures and lengthen skin. Depending on the location of the contracture, different flaps can be used in a series or combination.

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  STSG: This is used in contracture release to fill skin deficits. The donor site remains minimally scarred and preserves its vascular bed, whereas the recipient site (if vascularized) can gain tissue.

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  Skin substitutes (Integra, AlloDerm): These can be applied to tendons or bones and complemented with a STSG. They are good substitutes for flaps if not possible.

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  FTSG: This is used for tissue deficits, preferably around the volar surface, digits, and web space where the recipient site has a thicker skin layer. Lower risk of contracture formation compared with STSG.

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  Local skin flaps can provide vascularized tissue coverage for tissue deficits, reducing the recurrence of contracture formation compared with grafts. Homodigital, heterodigital, and intermetacarpal flaps have been used for this purpose.

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  Regional flap: Larger regional flaps can be used when local flaps do not provide enough coverage. Examples include the reverse radial forearm fasciocutaneous flap and posterior interosseous artery flap.

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  Remote flap: When extensive burns to the forearm occur, distant flaps can help vascularized tissue. The groin and abdominal flaps are commonly used.

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  Free tissue flaps: These are indicated with complete body injury and need for ample wound coverage.

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  Pollicization: If the thumb is partially or fully missing, the index finger or (if not available) toe can be transferred to the fifth-digit space. This significantly improves the hand’s grasp function.

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  Hand transplantation: Vascularized composite allotransplantation can assist with severe deformity or total loss of the hand.