nc dhsr oems: comprehensive management of hand burns
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Comprehensive Management of Hand Burns
Comprehensive Management Comprehensive Management of Hand Burnsof Hand Burns
C. Scott Hultman, MD, MBA, FACSChief and Program Director, Division of Plastic Surgery
Associate Director, NC Jaycee Burn CenterUniversity of North Carolina, Chapel Hill
May 2010
University of North Carolina Jaycee Burn Center
University of North Carolina University of North Carolina Jaycee Burn CenterJaycee Burn Center
• Regional Burn Center (6 states)– North Carolina: 9.5 million people
• 22 ICU beds, 20 floor beds• 900 admissions per year• 30 nurses, therapists• Out-patient clinic• 4 surgeons
Overview of Hand BurnsOverview of Hand BurnsOverview of Hand Burns
• Resuscitation 0-3 days• Resurfacing 1-3 weeks• Reconstruction 3 months - ?• Rehabilitation months• Reintegration years
RehabilitationReconstruction
of function Restoration of body image
Burn Injury
Resuscitation
Resurfacing
Recovery
Hand Burns: Mechanism
Hand Burns:Hand Burns: MechanismMechanism
• Scald hot water, soup, microwave
• Flame house fire
• Abrasions motor vehicle collisions
• Electrical low voltage
• Chemical IV contrast, chemotherapy
• Infections meningococcemia, TENS/SJS
• Cold frostbite (rare)
Hand Burns: Resuscitation Hand Burns:Hand Burns:
ResuscitationResuscitation
• History: Mechanism
• Physical Examination: Wound Characteristics
• Restoration of Perfusion• Damage Control• Wound Care• Occupational Therapy• Systemic Issues
Hand Burns: Resurfacing Hand Burns:Hand Burns: ResurfacingResurfacing
• Excision• Temporary Coverage• Grafting• Flaps• Amputation
DermabrasionWeck scalpel bladeVersajet (water pick)Tangential Fascial
DermabrasionWeck scalpel bladeVersajet (water pick)Tangential Fascial
Hand Burns: Resurfacing Hand Burns:Hand Burns: ResurfacingResurfacing
• Excision• Temporary Coverage• Grafting• Flaps• Amputation
Biobrane (nylon netting)
Integra (synthetic collagen)
Xenograft (pigskin)Allograft (cadaver skin)VAC (negative pressure
sponge dressing)
Biobrane (nylon netting)
Integra (synthetic collagen)
Xenograft (pigskin)Allograft (cadaver skin)VAC (negative pressure
sponge dressing)
Hand Burns: Resurfacing Hand Burns:Hand Burns: ResurfacingResurfacing
• Excision• Temporary Coverage• Grafting• Flaps• Amputation
Split-thickness sheet graft
Split-thickness meshed graft (1/4:1)
Full-thickness skin graftCultured skin -- never
Split-thickness sheet graft
Split-thickness meshed graft (1/4:1)
Full-thickness skin graftCultured skin -- never
Hand Burns: Resurfacing Hand Burns:Hand Burns: ResurfacingResurfacing
• Excision• Temporary Coverage• Grafting• Flaps• Amputation
Random dorsal handLocal “Kite” from digitRegional reverse forearmDistant pedicled groinFree transfer latissimus muscle
Random dorsal handLocal “Kite” from digitRegional reverse forearmDistant pedicled groinFree transfer latissimus muscle
Hand Burns: Reconstruction
Hand Burns:Hand Burns: ReconstructionReconstruction
• Stiffness• Swan Neck Deformity• Tendon Adhesions• Boutonniere Deformity• Mallet Finger• Claw Hand• Nail Plate Abnormalities• Hypertrophic Scar
• Palmar/digital Contractures• Web Space Deformities• Axillary Contractures• Elbow Dysfunction• Amputation Deformity• Thumb Loss• Chronic Pain• Nerve Compression
Syndromes
dorsaldorsal
volarvolar
Web Space ReconstructionWeb Space ReconstructionTechniquesTechniques
ZZ--plastyplasty
hourhour--glass flapglass flap
YVYV--plastyplasty transposition flaptransposition flap
VMVM--plastyplastyjumping man Zjumping man Z--plastyplasty
dorsaldorsal
volarvolar
aa bb
aa bb cc
cc’’
dorsaldorsal
volarvolar
bb’’aa’’ cc’’
aa’’ bb’’
cc
STARplastySTARplastyTechniqueTechnique
HultmanHultman CS, CS, Ann Ann PlastPlast SurgSurg, 2005, 2005
Hand Burns: Recovery
Hand Burns:Hand Burns: RecoveryRecovery
• Rehabilitation – Occupational Therapy– Physical Therapy– Skin Care: Garments, Sunscreen, Moisturizers– Scar Management: Message, Silicone, Lasers (PDL, CO2 )
• Reintegration– Neuro-psychiatric Support– Functional Capacity Evaluation– Vocational Rehabilitation– Return to Work
Hot Press Hand Injuries:A Paradigm for Multidisciplinary Management
C. Scott Hultman, MD, MBA, FACS
SESPRSPuerto RicoJune 2009
UNCUNC
||
PlasticPlastic
||
SurgerySurgeryLeading through Innovation, Serving with CompassionLeading through Innovation, Serving with Compassion
•• crush and thermal crush and thermal component component
•• wide range of wide range of morbidity morbidity
•• limited number of limited number of published reportspublished reports
•• longlong--term outcome term outcome unknownunknown
IntroductionIntroductionHotHot--Press Hand InjuriesPress Hand Injuries
HotHot--Press Hand Burn Treatment, Press Hand Burn Treatment, AchauerAchauer et al,et al, J Burn Care J Burn Care RehabilRehabil 1998, 19;1281998, 19;128--130130
•• n=17, 1994n=17, 1994--19961996
•• nonnon--op (41%), STSG (47%), flap (12%)op (41%), STSG (47%), flap (12%)
•• ““normal hand function,normal hand function,”” ““goodgood”” cosmesiscosmesis
•• one complication (minor graft loss)one complication (minor graft loss)
•• no secondary reconstruction performedno secondary reconstruction performed
IntroductionIntroductionHotHot--Press Hand InjuriesPress Hand Injuries
•• to provide a comprehensive, longitudinal, to provide a comprehensive, longitudinal, institutional review of hotinstitutional review of hot--press hand injuriespress hand injuries
•• to assess functional morbidity, need for to assess functional morbidity, need for secondary reconstruction, and vocational secondary reconstruction, and vocational rehabilitationrehabilitation
•• to propose recommendations for managementto propose recommendations for management
PurposePurposeHotHot--Press Hand InjuriesPress Hand Injuries
•• Prospectively assembled database Prospectively assembled database
•• N=56 patients N=56 patients
•• December 1994 to December 2008 December 1994 to December 2008
•• North Carolina Jaycee Burn CenterNorth Carolina Jaycee Burn Center
•• MultiMulti--disciplinary team of surgeons, hand disciplinary team of surgeons, hand therapists, rehabilitation counselors, social therapists, rehabilitation counselors, social workers, psychologists, and chaplainsworkers, psychologists, and chaplains
MethodsMethodsHotHot--Press Hand InjuriesPress Hand Injuries
HotHot--Press Hand InjuriesPress Hand InjuriesDistribution of Cases by Year, n=56Distribution of Cases by Year, n=56
•• ageage: : 37.0 years (range 1837.0 years (range 18--62)62)
•• gendergender: 41 female patients: 41 female patients
15 male patients15 male patients
•• languagelanguage: Spanish: Spanish--speaking 26/56 (47%)speaking 26/56 (47%)
ResultsResultsHotHot--Press Hand InjuriesPress Hand Injuries
Mechanism of Injury
drydry--cleaning press cleaning press (39)(39)steam presssteam press (3)(3)industrial press industrial press (11)(11)home appliance home appliance (3)(3)
ResultsResultsHotHot--Press Hand InjuriesPress Hand Injuries
•• time to presentationtime to presentation: : mode: 0 days median: 3 days mean: 8.8 days range: 0-120 days
•• admissionsadmissions: 39/56 patients (70%): 39/56 patients (70%)
•• length of staylength of stay: 10.4 days (range 2: 10.4 days (range 2--40) 40)
•• length of followlength of follow--upup: 17.5 months (range 1: 17.5 months (range 1--45)45)
ResultsResultsHotHot--Press Hand InjuriesPress Hand Injuries
Burn Wound Characteristicstotal surface area: 118 cm2 (range 4-400 cm2)location: dorsal >> volar
hand and forearmleft (32), right (21), bilateral (3)
depth: superficial partial thickness (5)deep partial thickness (8)full thickness (43)
ResultsResultsHotHot--Press Hand InjuriesPress Hand Injuries
Surgical Managementoperative intervention: 48/56 pts (85.7%)
damage control: fasciotomy/CTR (4), amputation (4), fracture reduction/fixation (3)
staged excision: 17/48 pts (35%)acute coverage: STSG (35), FTSG (5), groin flap (7),
completion amputation (1)secondary coverage: posterior interosseous flap,
DMCA flap, radial forearm adipofascial turnover flap, free lateral arm flap, free serratus flap
ResultsResultsHotHot--Press Hand InjuriesPress Hand Injuries
Functional Morbidity 38/56 pts (67.9%)chronic painchronic pain 1414compressive neuropathycompressive neuropathy 1111contracture (dorsal, contracture (dorsal, volarvolar, web), web) 1111nail plate abnormalities nail plate abnormalities 55boutonniere deformity boutonniere deformity 55stenosingstenosing tenosynovitistenosynovitis 4 4 mallet fingermallet finger 22intrinsic tightnessintrinsic tightness 22late flexor tendon rupturelate flexor tendon rupture 11unstable thumb IP jointunstable thumb IP joint 11
ResultsResultsHotHot--Press Hand InjuriesPress Hand Injuries
Secondary Reconstruction 28/56 (50%)nerve decompression 11
CTR (8), digital (4), Guyon’s canal (2), cubital tunnel (2), ulnar dorsal sensory (1), digital nerve graft (1)
contracture release 11tendon reconstruction 11
tenolysis (5), tendon repair (4), transfer (2), tenotomy (2), central slip recon (2)
joint reconstruction 5 capsulotomy (3), arthrodesis (3)
ResultsResultsHotHot--Press Hand InjuriesPress Hand Injuries
Neuro-Psychiatric Sequelaenerve compression syndrome 11chronic pain syndrome 10reflex sympathetic dystrophy 4seizure disorder 2substance abuse 2post-traumatic stress disorder 9mood disorder 20
Critical support from Anesthesia, Physical Medicine, Neurology, Psychiatry, Alternative Medicine
ResultsResultsHotHot--Press Hand InjuriesPress Hand Injuries
•• all patients compliant with OT/PT all patients compliant with OT/PT
•• final impairment rating: 22.2% (8final impairment rating: 22.2% (8--84%), n=3184%), n=31
•• return to employmentreturn to employment full-time 14 (25%) restricted/modified 22 (39%) retired 1 (2%) disabled 4 (7%) lost to
follow-up 10 (18%) pending (need FCE, VR) 5 (9%)
ResultsResultsHotHot--Press Hand InjuriesPress Hand Injuries
•• potentially devastating injurypotentially devastating injury
•• significant longsignificant long--term morbidityterm morbidity
•• early and late complicationsearly and late complications
•• limitations in functional recoverylimitations in functional recovery
•• return to work can occur with return to work can occur with considerable rehabilitationconsiderable rehabilitation
SummarySummaryHotHot--Press Hand InjuriesPress Hand Injuries
Successful rehabilitation dependent uponSuccessful rehabilitation dependent upon::•• Timely referral to an accredited Burn CenterTimely referral to an accredited Burn Center
•• Aggressive Aggressive periperi--operative hand therapyoperative hand therapy
•• Early excision and staged coverage Early excision and staged coverage (groin flap)(groin flap)
•• Secondary reconstruction Secondary reconstruction (nerve decompression)(nerve decompression)
•• Psychosocial support Psychosocial support
•• Multidisciplinary approachMultidisciplinary approach
ConclusionsConclusionsHotHot--Press Hand InjuriesPress Hand Injuries
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