treatment of hand burn
TRANSCRIPT
b u r n s 3 5 ( 2 0 0 9 ) 3 2 7 – 3 3 7
Review
The treatment of hand burns
Lars-Peter Kamolz *, Hugo B. Kitzinger, Birgit Karle, Manfred Frey
Vienna Burn Centre, Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna,
Waehringer Guertel 18-20, A 1090 Vienna, Austria
a r t i c l e i n f o
Article history:
Accepted 12 August 2008
Keywords:
Hand burns
Surgery
Grafting
Skin substitutes
Epidermal replacements
Splinting
Reconstruction
a b s t r a c t
In more than 80% of all burns, the hand is involved. Even if a burned hand does not play
a major role for the survival of a patient, its function and aesthetic appearance are of utmost
importance for the re-integration into society and professional life. Adequate treatment
demands a number of major decisions: necessity of an escharotomy in the early post-
traumatic phase, the timing of surgery and the type of wound coverage, as well as
immobilization and rehabilitation.
Rapid wound closure is of utmost importance, but infection control and the preservation
of active and passive motion are also essential for optimal recovery of the injured hand. The
treatment of hand burns requires the interdisciplinary teamwork of surgeons, physio- and
occupational therapists, psychologists, motivated health care personnel and consequent
treatment strategies.
# 2008 Elsevier Ltd and ISBI. All rights reserved.
avai lab le at www.sc iencedi rec t .com
journal homepage: www.e lsev ier .com/ locate /burns
Contents
1. Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 328
2. Mechanisms of the injury and anatomic characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 328
3. Aims and principles of treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 328
4. Determination of burn depth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
5. Escharotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
6. Treatment of edema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330
7. Splinting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330
8. Wound management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330
9. Surgical treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
10. Palm burns. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
11. Methods of coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
12. Skin substitutes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
13. Exposed joints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 332
14. Reconstruction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 332
14.1. Claw deformity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 332
14.2. Palmar contractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334
* Corresponding author.E-mail addresses: [email protected], [email protected] (L.-P. Kamolz).
0305-4179/$36.00 # 2008 Elsevier Ltd and ISBI. All rights reserved.doi:10.1016/j.burns.2008.08.004
b u r n s 3 5 ( 2 0 0 9 ) 3 2 7 – 3 3 7328
14.3. Web space deformities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334
14.4. Hypertrophic scars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334
14.5. Amputation deformity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334
14.6. Nail bed deformity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334
15. Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335
16. Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335
1. Introduction
Although hand burns affect less than 3% of the total body
surface area (per hand), they are classified as severe injuries,
which require treatment in a specialized burn centre. In
more than 80% of severely burned patients, the hand is
involved [1]. Even though hand burns do not often play a
major role in mortality, they are important factors in
successful re-integration into society and professional life
after discharge from hospital [2]. Adequate treatment of the
hands is often neglected in the acute phase in favor of the
treatment of other body parts or intensive care, but already
in this acute phase the course for a successful restoration of
hand function is set. At the end of the 1940s, surgeons
pointed out that failing to mobilize fingers will lead to early
stiffening and therefore to a loss of hand function [3]. Apart
from functional rehabilitation, aesthetic outcome must be
considered since hands cannot, similar to the face, be
hidden by clothes so easily.
Optimal hand burn management demands a number of
major decisions concerning necessity of a escharo- or fasciot-
omy in the early post-traumatic phase, time and type of surgical
debridement, type of wound coverage, and immobilization and
rehabilitation. These efforts primarily aim to restore hand
function or as Peacock [4] stated it, the preservation and not the
restoration of finger and hand function. Sheridan et al. [5]
succeeded in regaining normal hand function in 97% of the
patients with superficial dermal burns, whereas in patients
with deep dermal and full-thickness burns the success rate was
only 81%.
2. Mechanisms of the injury and anatomiccharacteristics
Most deep dermal and full-thickness hand burns affect the
dorsum of the hand. Full-thickness palmar burns occur
relatively rarely, and mostly in infants who have just started
grabbing things. The low incidence of palmar involvement in
adults is due to the fact that hands are used to protect the face
against a severe burn trauma and thereby only the dorsal parts
of the hands are exposed. Moreover the skin of the palm has a
higher tolerance for thermal energy due to its thickness and its
well-developed stratum corneum.
There are some special characteristics in the hand’s
anatomy. Its physical sturdiness, the sensory qualities and
the high capillary density in the stratum papillare make this
skin unique. The proportion between skin surface and tissue
volume is extraordinary: there is a disproportional shift in
favor of the hand. A volume of 1 cm3 correlates with a skin
surface of 2.5 cm2, whereas this value decreases in the forearm
to 0.5 cm2 [6].
There are distinctive differences between the dorsum of
the hand and the palm. The skin at the extensor side of the
hand is thin and mobile, thus facilitating extensive flexion
of the finger joints. The palmar skin is sturdy and resistant
to pressure, contains essential sensory end organs and
adheres strongly to the palmar aponeurosis. Significant
density of Merkel’s tactile disks, Meissner’s tactile corpus-
cles, Vater-Pacini’s lamellated corpuscles and free nerve
ends are found in the skin. That is the reason why hand
burns may cause severe sensory deficits [7]. In contrast to
other body parts, blood vessels, tendons and joints are
located very close to the skin surface. This circumstance
makes these structures extremely vulnerable when exposed
to high thermal energy.
3. Aims and principles of treatment
An optimal treatment of a hand burn can only be provided by a
close interdisciplinary co-operation among surgeons, phy-
siotherapists, occupational therapists, psychologists and moti-
vated health care personnel [8]. Rapid wound healing must be
the primary aim [9] in order to achieve a well-functioning hand,
which will facilitate a rapid re-integration of the burn patient
into society and normal life. According to Robson et al. [10],
treatment of handburns can be divided into aims and principles
(Table 1).
The key aims are:
� P
revention of additional or deeper injuries.� R
apid wound closure.� P
reservation of active and passive motion.� P
revention of infection or loss of functional structures.� E
arly functional rehabilitation.The following aims should be gained by applying basic
treatment principles:
� D
etermination of dimension and depth of the burn.� E
scharotomy (if indicated).� A
pplication of adequate wound dressings.� D
ecision upon conservative or surgical treatment.� S
urgical management (necrosectomy, skin grafts, skinsubstitutes, free flaps, etc.).
� E
arly hand therapy with splinting.� F
unctional rehabilitation by early active and passive motiondue to physiotherapy.
� S
econdary and tertiary corrections (if indicated).
Table 1 – Treatment aims and principles.
b u r n s 3 5 ( 2 0 0 9 ) 3 2 7 – 3 3 7 329
4. Determination of burn depth
After stabilizing the burn patient’s vital functions, a clinical
examination should provide exact information about the
severity of trauma (burn depth, secondary injuries,. . .).
Clinical assessment remains the most frequent technique
to measure the depth of a burn wound although this has been
shown to be accurate in only 60–75% of the cases, even when
carried out by an experienced burn surgeon. There are other
modalities available, which are useful to provide an objective
assessment of burn wound depth. These modalities range
from simple clinical evaluation to biopsy and histology and to
various perfusion measurement techniques such as thermo-
graphy, vital dyes, video angiography, video microscopy, and
laser Doppler techniques [11–19]. Concerning the recent
literature, Laser Doppler imaging seems to be the only
technique that has shown to be accurate in predicting wound
outcome with a large weight of evidence. Moreover this
technique has been approved for burn depth assessment by
regulatory bodies including the FDA.
5. Escharotomy
The maintenance of perfusion is the first and foremost aim in
the acute treatment of hand burns. During the acute phase,
deep dermal, circumferential or near circumferential burns
should be cared for most attentively because they can cause
circulatory impairment. Tissue underneath a deep dermal or
full-thickness burn will expand due to the increasing edema
and the pressure within the compartment will rise. Eschar-
otomy will lead to decompression, the compartment pressure
will decrease and the tissue perfusion will increase. The
presence of a near circumferential or circumferential deeper
burn and increasing edema should indicate immediate
escharotomy. Missing pulse of the radial or ulnar artery under
adequate resuscitation is a sign of a progressive ischemia and
requires immediate escharotomy. Delayed decompression
may cause circulatory disorders, nerve damage, extensive
muscle necrosis and thus function loss. Even for experienced
surgeons it is sometimes extremely difficult to determine
whether an escharotomy of the hand will be necessary or not.
In the case fingers are affected regardless of burn depth, the
dorsum of the hand appears pale white, the nail bed is
deregulated and a loss of sensibility can be observed, an
escharotomy will be inevitable [20].
When determining the need for escharotomy, it should be
noted that the edema can increase for up to 36 h after injury
due to the increased vascular permeability. Thus the risk for
the development of a compartment syndrome in massive
burns is much higher. In such cases a prophylactic eschar-
otomy might be indicated. The evaluation of a burned hand
must always be carried out in the context to the other burned
areas [5].
In urgent cases, an escharotomy can be carried out at
bedside under sterile conditions, but it is recommended to do
it in the operating room. An incision on the arm and hand is
best carried out by electrocautery in order to reduce bleeding.
During incision attention should be paid to the ulnar nerve at
the medial epicondyle, to the superficial branch of the radial
nerve and to the tendon of the flexor carpi radialis muscle at
the distal forearm due to their superficial location. At the wrist
it may be obligatory to decompress the carpal tunnel. On the
finger, a monopolar needle or a No. 15 blade can be used to split
the eschar completely without injuring the extensor tendons
or the palmar neurovascular bundle [21]. In order to achieve
as few motion-limiting scars as possible, the line of incision is
radial on thumb and little finger and ulnar on the other fingers
b u r n s 3 5 ( 2 0 0 9 ) 3 2 7 – 3 3 7330
[22]. This line can be defined well by putting the fingers in
maximum flexion, marking the lateral extensions of the finger
joint flexor wrinkles and completing them to a continuous
line. Salisbury and Levine [23] showed that the number of
finger amputations could be significantly reduced by carrying
out adequate digital escharotomy.
Ischemic necrosis of the intrinsic muscles is accompanied
by a significant functional impairment because the fingers
may develop an intrinsic-minus position [24]. In deep hand
burns and in the case of an intrinsic tightness, the intrinsic
compartment should be decompressed. Intrinsic tightness is
diagnosed by securing the metacarpophalangeal joint in the 08
position and flexing it passively in the proximal or distal
interphalangeal joints. Resistance is an indication for intrinsic
tightness, which requires an additional fasciotomy of the
intrinsic muscles. For that purpose the area between meta-
carpals II/III and IV/V is incised longitudinally whereby the
extensor tendons remain covered. From there a fasciotomy of
the intrinsic compartments can be carried out easily. To
prevent desiccation of the free structures, wounds are covered
temporarily by skin substitutes, e.g., Epigard1.
Formally, fasciotomy has to be distinguished from eschar-
otomy. In an escharotomy, eschar is incised to the subcuta-
neous fat tissue, whereas in case of a fasciotomy the muscle
fascia is also opened. This intervention is indicated in case an
escharotomy did not provide the desired increase in perfusion
or if the patient suffers from electrical burns [22].
6. Treatment of edema
Immediately after a burn, it is reasonable to cool the hand by
applying water in order to eliminate the high thermal energy
and to reduce pain. In most favorable cases cooling also
reduces edema formation and thereby burn wound progres-
sion [25]. Massive burns should not be cooled in order to avoid
a massive decrease of body temperature, which will lead
consecutively to burn wound progression. An effective and
simple way to prevent or to decrease the development of
edema is a continuous elevation of the hand above heart level.
7. Splinting
Joint contractures inhibit free movement of the finger joints.
This is extremely evident in claw hand deformity. The defor-
mation is caused by the injury, wound infection, inadequate
wound coverage, long time immobilization and inappropriate
splinting and positioning of the hand.
In patients with severe burns the incidence of edema is
significantly increased. The reason for the intrinsic-minus
position of the hand is an increased fluid accumulation in the
joints with distension of the joint capsule and imbibition of the
collateral ligaments and subsequent ligament contraction.
The intrinsic-minus position is wrist flexion with a simulta-
neous hyperextension of the metacarpophalangeal joints
(MCP), a flexion of the proximal and distal interphalangeal
joints (IP) and a thumb adduction. This defective position
emanates in the MCP joints. If the MCP joints are extended,
joint capsule and collateral ligaments flag [26]. The joint is
relatively unstable with a high degree of freedom for rotation,
abduction and adduction. The contact areas of the corre-
sponding joint surfaces are minimized. The combination of
these factors will provide the biggest volume capacity for
interstitial fluid accumulation. In flexion, the collateral
ligaments are tightened with maximum contact of joint
surfaces, which reduces fluid accumulation within the joint.
In the presence of edema, intra-articular fluid increase causes
extension of the MCP joint, similar to a hydraulic pump. In this
position, the tension of the flexors increases whereas the
tension of the extensors decreases. This causes flexion in the
proximal as well as in the distal IP joints. In contrast to the
MCP joints, the volumetric capacity of the IP joints in flexion
and extension is nearly identical, so that there is no hydraulic
effect. Thus flexion of the IP joints is the immediate
consequence of the extension of the MCP joints.
So, the therapeutic principle must be an optimal position-
ing of the hand in order to avoid permanent contractures and
deformities [27]. Ideally, a thermoplastic fixation device
should be fitted in intrinsic-plus position on the day of injury.
The hand should be slightly extended in the wrist with 208–308,
flexed in the MCP joint with approximately 808 and completely
extended in the IP joints. The thumb is placed in maximum
abduction to prevent adduction contractures.
In awake and co-operative patients, a night splint is often
sufficient. Active and passive exercises with the hand should
be carried out twice a day. Only in deep dermal or full-
thickness burns, in which there is suspicion of an injured
extensor tendon apparatus, a flexion of the IP joint should be
avoided to prevent a rupture of the central slip and thus a
Boutonniere or buttonhole deformity.
8. Wound management
The acute burn wound must be cleaned and debrided. Until
some years ago, blisters were not removed because it was
believed that they serve as a biological wound dressing. Recent
studies showed though that the blister’s secretion contains
prostaglandins and other pro-inflammatory cytokines, for
example, interleukin-6 and interleukin-8 [28,29]. Therefore it
is recommended to remove the blisters [22].
Superficial hand burns may be treated with special lipid
regulating ointments (e.g., Bepanthen1) for a few days. It is
important to familiarize the patient with the immediate active
mobilization of the hand.
Superficial partial-thickness burns require dressings, which
protect the wound against infection and reduce pain at the
same time.
Paraffin gauze dressings (e.g., Bactigras1, Grassolind1)
provide maximum mobilization of the hand and avoid painful
adherence to the wound. Alternatively, epidermal substitutes,
such as Biobrane1 or Suprathel1 can be applied. Advantages
are accelerated epithelialization and pain reduction.
In deep dermal and full-thickness burns, antiseptic agents,
which can penetrate into deeper layers, such as silver-
sulfadiazine (Flammazine1) should be applied [30]. The
released silver ions bind to the microbial genes (DNA) and
inhibit the reproduction of bacteria and fungi. Sulfadiazine
inhibits the production of folic acid which is necessary for the
b u r n s 3 5 ( 2 0 0 9 ) 3 2 7 – 3 3 7 331
reproduction of bacteria [31]. In case of later surgical
debridement an unfavorable effect of silver-sulfadiazine is
that it softens the necrosis thus complicating a tangential
excision. If applied broadly, the systemic resorption of silver
ions may cause an impaired acid–base balance, leukopenia as
well as liver and kidney damage [32]. In smaller burns,
povidone iodine (Betaisodona1-ointment) can be used alter-
natively [33]. Povidone iodine stains the burn wound thus
complicating the determination of burn depth. In large burns,
the application of povidone iodine is contraindicated due to a
potential induction of hyperthyreosis or the risk of an acute
iodine-intoxication. According to a study by Homann et al.
[34], a new formula for ointments with hydrogel and povidone
iodine (Repithel1) has lead to a faster healing in superficial
burns.
In general, burn wound dressings should be changed at
least once a day—in the presence of heavy wound secretion
even more often. It is particularly important to keep hand
dressings as thin as possible in order to allow mobilization.
This also includes the supply of thumbs and fingers with tube
dressings. Alternatively, a latex glove can be used, which has
been previously filled with the desired ointment.
9. Surgical treatment
As soon as the burn depth can be determined exactly—usually
on the second or third day after injury, the wounds should be
excised and covered [22]. During the first 5 days, the burn
wound is defined as ‘‘sterile’’ and thus optimal for surgery.
After these 5 days there is a higher risk for infection and graft
failure [35]. In case of the fact that a surgical intervention is not
possible in the initial phase, it is recommended to postpone
the coverage until the infection has been treated sufficiently.
Adequate splinting and physical therapy should be provided in
order to achieve results nearly as good as after early surgical
debridement and coverage [36].
Superficial burns that heal spontaneously within two
weeks do not require surgical treatment but daily wound care,
as described above. Goodwin et al. [37] showed that a
hypertrophic scar formation is very rare in these cases and
that the functional outcome is very good. In full-thickness
burns, especially in contact burns, e.g., caused by hot metals
or tar, there is no need to wait days to start excision and
grafting. But in most of the burn wounds it is difficult to
determine the burn depth and its potential progression
exactly immediately after trauma. In these cases the question
remains if there is enough dermal tissue left to ensure
conservative healing within two weeks or if the waiting
period justifies the risk for the development of hypertrophic
scars and scar contractures [38].
The strategies that have been applied over the last decades
have considerably changed. Until the 1960s, conservative
treatment with antimicrobial ointments was the standard
treatment. Functional outcomes were poor. Nowadays early
debridement and early grafting has lead to much better results
[39,40].
The treatment and grafting strategies for deep dermal
burns are still developing: e.g., covering the wound with
biosynthetic epidermal substitutes like Suprathel1 leads to
results as good as after traditional skin grafting [41]. In
predominantly deep dermal and full-thickness hand burns,
early debridement and skin grafting is still the method of
choice.
The surgical therapy that is most often applied on hand
burns is tangential excision: the necrotic skin is abraded in
layers until capillary hemorrhage occurs. In isolated hand
burns the blood loss can be reduced significantly by use of a
tourniquet [42]. In these cases, the surgeon cannot rely on the
capillary bleeding but has to pay attention to other character-
istics as the whitish color of vital dermis and the yellow color
of vital fat tissue.
10. Palm burns
Contact burns in toddlers are often palmar burns. Surgical
intervention is very rarely indicated because the skin of the
palm is thick and well-protected. A surgical debridement is
difficult to carry out due to the palm’s distinct anatomy and
the tight coherence to the palmar aponeurosis. A substitution
is only applicable to a limited degree. These factors justify a
conservative treatment for 3–4 weeks. In case of the fact that a
necrosectomy is required, a sparing debridement is important.
Since the palm is used excessively in daily life, thick split
thickness or full-thickness grafts should be used [43]. After
surgical treatment, scar contractures of the palm are often
long-term complications [44].
11. Methods of coverage
The methods of choice for the coverage of the hand are
autologous split skin grafts applied as unmeshed sheet grafts
[45]. Sometimes fluid retention underneath the graft with the
risk of graft loss can be avoided by scarifying with a No. 11
blade. Alternatively, split skin grafts can be processed into
mesh grafts with various expansion levels or used in Meek
technique [46]. These techniques should only be applied in
case that there are not enough autologous donor sites
available. In comparison with mesh grafts, sheet grafts show
a lower tendency to shrink and provide better aesthetic
outcome. In the post-operative stage the hands are put in
intrinsic-plus position by a palmar forearm splint; hand
therapy will be determined as early as possible dependent
on the wound condition.
12. Skin substitutes
In general there are two types of skin substitutes: temporary
and permanent substitutes. It must further be enumerated
whether an epidermal, a dermal or a combined dermal–
epidermal substitute material is indicated [47]. The following
section will only deal with those skin substitutes that are well
established in the treatment of hand burns.
The authors apply biological active epidermal skin sub-
stitutes, as, for example, allogeneic human keratinocytes, in
infant deep dermal hand burns [48] in order to achieve faster
healing and better cosmetic outcome. In teenagers and adults,
b u r n s 3 5 ( 2 0 0 9 ) 3 2 7 – 3 3 7332
synthetic epidermal skin substitute materials, e.g., Biobrane1
and Suprathel1 are used.
Biobrane1 is constructed of a semipermeable silicone film
with a nylon fabric partially embedded into the film. Porcine
collagen type I is also incorporated. Biobrane1 is suggested
for use in superficial partial-thickness burns [49]. Ready-
made Biobrane1 gloves facilitate the application. Benefits of
Biobrane1 are pain reduction, avoiding dressing changes,
possibility of immediate active and passive mobilization of the
hand and continuous observation of the wound due to the
transparent material. After complete epithelialization, the
film is easily removed. In comparison to Flammazine1
dressings, the healing time is reduced up to 7 days in wounds
treated with Biobrane1 [50]. Downsides of this material are the
relatively high costs and small fluid accumulations that collect
underneath the membrane have to be punctured in order to
avoid infection [51].
Suprathel1 is a copolymer consisting of polyactide,
trimethylene carbonate and caprolactone. It is supplied as a
membrane, whose properties are similar to those of Bio-
brane1. Benefits of Suprathel1 are painless dressing changes,
faster epithelialization and the potential for early hand
therapy [52]. Studies demonstrated that Suprathel1 provides
good healing of deep dermal burns within three weeks after
trauma [53]. After healing Suprathel1 will spontaneously
degrade.
Integra1 has been the most popular dermal equivalent in
the field of permanent dermal replacements. Integra1 is a
matrix consisting of bovine collagen and glycosaminoglycans.
Integra1 must be applied in a two-step procedure. The reasons
why Integra1 is used primarily in the field of reconstruction
these days are that the hand remains immobile for a longer
period of time. Moreover the risk of infection is elevated
[54,55].
Another new dermal substitute is Matriderm1, which
consists of bovine collagen and elastin. A distinctive advan-
tage of Matriderm1 is that it can be applied in a one-step
procedure. First studies in hand burns could confirm this one-
stage skin reconstruction [56]. Scar quality and viscoelasticity
are as good as the functional outcome (Fig. 1), but there is a
need for more studies to confirm these results.
Combined skin substitutes as, for example, allogeneic skin
or Epigard1 are applied in those cases where the period
between trauma and definite coverage has to be bridged. The
advantage of allogeneic skin is the fact that it is a biological
scaffold which supports wound bed preparation. Moreover it
reduces the risk of infection and protects the wound from
water loss [57].
13. Exposed joints
The areas above the extensor-sided PIP joints must be
particularly well observed. If primary skin transplantation is
not successful, infection of the joint accompanied by cartilage
erosion and finally ankylosis will follow. In this phase the
formation of granulation tissue is gained. In these cases the
best achievable acute result will be an instable scar, which can
be replaced later by adequate tissue, e.g., a dorsal metacarpal
artery flap (DMCA-flap) [58].
In case tendons, joints and bones are also affected by the
burn, these structures must be debrided, regardless of their
function. A reconstruction which adheres to the principle of
the reconstructive ladder is justified in these situations.
When choosing flaps, it must be borne in mind that more
reconstructive interventions will become necessary later on.
Larger defects on the dorsum of the hand with exposed
tendons and bones are treated in the acute phase with
groin flaps, even today [59]. The temporary immobilization
of the shoulder joint is well tolerated and the donor site
of the flap is cosmetically inconspicuous. In case that the
injury is an isolated severe hand burn or the patient’s
general condition is stable, free microvascular tissue
transfer is an excellent means of coverage [60–62]. Excellent
cosmetic outcome is achieved by using lateral upper
arm flaps or gracilis muscle flaps. If there is also a
peritendon necessary due to an injured paratenon, solutions
can be found Formby use of serratus or other fascial flaps
[63,64].
14. Reconstruction
Adequate treatment of the hand burn in the acute phase
determines the functional outcome. Due to the complex injury
accompanied by the destruction of highly specific soft tissue,
deformities sometimes cannot be avoided even under optimal
therapy. The deformities after hand burns were outlined by
Achauer [65]:
(A) C
law deformity.(B) P
almar contracture.(C) W
eb space deformity.(D) H
ypertrophic scars.(E) A
mputation deformity.(F) N
ail bed deformity.Numerous surgical techniques have been described for
treatment. Generally, the patient suffers from a combination
of various deformities. The most frequent problems following
hand burns are scar and soft tissue contractures, as they
might appear following spontaneously healed deep burns,
split skin grafting of inadequate size and thickness, with
missing and/or not correctly positioned splints or inadequate
physical therapy.
14.1. Claw deformity
Hypertrophic linear scars or scarred areas on the dorsum of
the hand can lead to a hyperextension in the MCP joints, in
rare cases even to a dislocation of the joint and to limited
flexion. Buttonhole deformities are often seen at the PIP joints
in deeper burns. The central extensor denatures due to the
direct heat damage or desiccates following a longer period of
exposure. That makes the side slips move in the palmar
direction, which are situated now at the flexor side of the
central joint. So, an attempted extension causes a flexion of
the central joint. Whereas there are numerous treatments for
buttonhole deformity in a non-burned hand, attempts to
reconstruct this deformity in a burned hand are often not
b u r n s 3 5 ( 2 0 0 9 ) 3 2 7 – 3 3 7 333
promising. A good alternative is the arthrodesis of the joint in
functional position. Functionally inhibiting defective positions
of the distal joints are rare but can be corrected by arthrodesis
if necessary.
Fig. 1 – a Deep hand burn (deep dermal and full-thickness) prior
(MatridermW and split thickness skin graft); (c) long-term result
compression therapy; (d) skin elasticity.
In large and thick scars which cause a hyperextension of
the MCP joints, excision of the scar with subsequent skin
grafting is required. In case of the fact that a resection of the
scarred and contracted subcutaneous tissue is required,
to surgery; (b) early result after a single step reconstruction
(1 year after surgery) after single step reconstruction and
b u r n s 3 5 ( 2 0 0 9 ) 3 2 7 – 3 3 7334
Matriderm1 as a dermal skin substitute has shown good
results in combination with split thickness skin grafts [56]. In
deep dermal burn wounds, contractures are not only due to
scars but also due to defective extensor aponeurosis, defective
tendons, defective joint capsules and muscles. Depending on
the extent of the scar excision, an adequate coverage of the
defect according to the reconstructive ladder should facilitate
high quality soft tissue coverage. For this purpose there are
numerous options available: the groin flap, the radial forearm
flap and the interosseous posterior artery flap and/or free
muscular and fasciocutaneous flaps. In case joint contractures
have already developed (due to a longer persisting defective
position of the MCP joints) an open capsulotomy should only
be carried out after creating sufficient soft tissue coverage.
14.2. Palmar contractures
Post-traumatic contractures of the palm can develop due to
secondary healing or due to inadequate positioning of the
hand. They might also occur after a successful primary
surgical treatment. Tendency to developing a tendon con-
tracture in the wrist and the fingers as well as developing an
adduction contracture in the thumb require splinting with
slight wrist extension and 808 flexion of the MCP joints with
stretched PIP and DIP joints (intrinsic-plus position) and
maximum abduction of the thumb. In case contractures
develop, a surgical incision or excision of the scar followed by
full-thickness grafting is the method of choice [66]. Isolated,
linear scars with sufficient tissue in the vicinity can be
dissolved by one or multiple z-flap plasties. In the presence of
a longer existing tendon contracture of the MCP or PIP joint, a
release of the periarticular structures, as, for example, the
articular capsule, the collateral tendons and the palmar plate
is often required to achieve a complete extension of the joint
[67]. In these cases a digital ischemia distal of the mobilized
joint might occur due to traction of the palmar vessels. For a
definitive arthrodesis of the joint, the phalanges have to be
shortened in this situation in favor of a functionally beneficial
arthrodesis angle with still good perfusion.
An early physiotherapy and particularly a consequent
nightly splinting over a period of at least 6 months are the
decisive factors in avoiding a contracture relapse.
14.3. Web space deformities
Syndactily or web space deformities are commonly observed
following conservative treatment of deep burns, but also after
surgery. In an intact hand, the web space goes in a 458 angle
from the extensor-side of the MCP joints in the palmar
direction to the center of the phalanx. This anatomy can
change considerably in burned web spaces. A palmar scar
contracture can be distinguished from a dorsal scar contrac-
ture, which stretches – like a roof – over the commissure
(syndactylia). A correction by using local flaps is generally
successful [68]. In very severe cases the combination of local
flaps and full-thickness grafts are the method of choice [69].
The span of the first web space is of particular importance
for the grip function of the hand. In addition to scar
contracture, a possible cause for a limited grip function might
be adduction contracture of the thumb. Such a contracture is
caused by a secondary fibrosis of the adductor pollicis and the
dorsal first interosseus muscle. In case of a slight scar
contracture, a z-plasty or butterfly plasty is sufficient. In
more distinct contractures, full-thickness grafts are used.
Depending on the intraoperative findings an additional release
of the adductor pollicis muscle may be required. Hereby, the
muscle is detached at its root at the third metacarpal or from
its inset at the base of the thumb [70]. In rare and intense cases,
a reconstruction of the first web space supported by a flap is
necessary.
14.4. Hypertrophic scars
In burns it takes the scars at least 1 year until they are healed
and mature. Thus, correction of scars should be carried out
ideally after that period. In case of scar-related, functional
constraints, e.g., in the finger joints, early correction may be
necessary. Isolated scars with extensive surrounding soft
tissue can be corrected by small, local flaps, e.g., a z-plasty.
Alternatively, numerous other flaps, as, for example, a cross-
finger or reversed cross-finger-flap [71] or full-thickness grafts,
can be used [72]. The application of a tailor-made compression
glove, possibly with silicone inlets, can reduce hypertrophic
scarring and scar contractures significantly [73,74].
14.5. Amputation deformity
In severe burns e.g., caused by high voltage, a loss of thumbs or
fingers might be possible. The numerous techniques for a
reconstruction of the trauma-related isolated amputation
injury can be adopted only to a limited extend for a burned
hand. The desired functional outcome is limited due to a
combined defect of essential structures. Generally, hand
function can be improved by a phalangization with deepening
of the web space [75], by a distraction osteogenesis of the
metacarpalia [76], by a pollicization [77] or by a toe transfer
[78]. The precondition for these interventions is a high quality
soft tissue coverage. For this purpose free tissue transfer is
often necessary to create good soft tissue surrounding.
14.6. Nail bed deformity
Defective nail growth following burn of the hand is frequently
observed. In very few cases the reason for that is direct
impairment of the nail bed or the germinative matrix. More
often the reason is a secondary contracture of the soft tissue
proximal to the nail bed. This leads to an eversion of the nail
bed with proximal dislocation and to a loss of contact between
dorsal nail matrix and nail and/or eponychium and nail. This
causes coarse nails with longitudinal furrows. Injuries of the
nail bed occur very often even after slight trauma. The extent
of the nail bed eversion and the defective growth are
proportional. A defect in the germinative matrix causes a
cleft nail and/or a completely missing nail.
Various techniques have been published for the treatment
of nail bed eversion, including dissolution of the underlying
contractures by wrapping local flaps or skin grafts with
subsequent reposition of the nail bed. Bilateral and proximal
pedicle skin flaps are often used to create sufficient tissue at
the extensor side [79]. That causes an unnatural diminution at
Fig. 2 – Custom made compression glove with an additional
compression topcoat for the web spaces (by courtesy of
ThuasneW).
b u r n s 3 5 ( 2 0 0 9 ) 3 2 7 – 3 3 7 335
the donor site. A newer technique is described by Donelan and
Garcia [80].
15. Rehabilitation
The best treatment of burn scars is their prevention, an
appropriate timing and burn depth specific surgery, and well-
fitting pressure garments worn as soon as the skin grafts are
stable. Silicone sheets [81,82] have been useful on the dorsum of
fingers and web spaces, placed under the pressure garment
glove. Pressure garments [83] (Fig. 2) are worn 24 h a day at least
for an initial period of approximately 6 months in burns with
prolonged healing time or burns that have required skin
grafting. Subsequent pressure garment use is individualized
depending on scar quality and response. The exact mechanism
by which pressure garments alter scar formation is not clear
[22]. They do, however, seem to improve the quality of scars in
both texture and color in the long-term [84]. Other scar
manipulation techniques, such as steroid injection [85,86],
can be used as indicated. Heat and ultrasound is used to assist
with joint mobilization and scar contracture treatment, but also
laser is used to improve scar quality [87]. Physical and occu-
pational therapies progress from the acute phase to rehabili-
tation. Hand therapy continues until function returns to
normal or treatment is no longer providing improvement. A
maintenance hand therapy program is then continued.
16. Summary
Burns very often affect the hands. Small burns can cause
severe deformities accompanied by loss of function. Rapid
wound closure is of utmost importance because the risk of
infection, of hypertrophic scar formations and contractures
increases with a prolonged healing time. Important parts of
the treatment include early excision and early coverage
within the first days after injury. The success of the treatment
also depends heavily on infection control and the preserva-
tion of the active and passive motion of the hand as well as on
an early splinting and functional rehabilitation. The inter-
disciplinary teamwork of surgeons, physio- and occupational
therapists, psychologists, motivated health care personnel
and consequent treatment strategies can contribute to regai-
ning normal hand function.
Conflict of interest
There is no conflict of interest.
r e f e r e n c e s
[1] Luce EA. The acute and subacute management of theburned hand. Clin Plast Surg 2000;27:49–63.
[2] Harvey KD, Barillo DJ, Hobbs CL, Mozingo DW, FitzpatrickJC, Cioffi WG, et al. Computer-assisted evaluation of handand arm function after thermal injury. J Burn Care Rehabil1996;17(2):176–80.
[3] Braithwaite F, Watson J. Some observations on thetreatment of the dorsal burn of the hand. Br J Plast Surg1949;2:21–31.
[4] Peacock EE. Management of conditions of the handrequiring immobilization. Surg Clin North Am 1953;1297–309.
[5] Sheridan RL, Hurley J, Smith MA, Ryan CM, Bondoc CC,Quinby Jr WC, et al. The acutely burned hand: managementand outcome based on a ten-year experience with 1047acute hand burns. J Trauma 1995;38(3):406–11.
[6] Morel Fatio D. Surgery of the skin. In: Tubiana R, editor.The hand. Philadelphia: WB Saunders; 1961. p. 224–5.
[7] Schmidt H-M, Lanz U. Chirurgische Anatomie der Hand. 2.,uberarb. und aktualisierte Aufl. ed. Stuttgart: G. Thieme;2003.
[8] Deb R, Giessler GA, Przybilski M, Erdmann D, Germann G.Die plastisch-chirurgische Sekundarrekonstruktion vonSchwerstbrandverletzten. Chirurg 2004;75:588–98.
[9] Hentz VR. Burns of the hand. Thermal, chemical, andelectrical. Emerg Med Clin North Am 1985;3:391–403.
[10] Robson MC, Smith Jr DJ, VanderZee AJ, Roberts L. Makingthe burned hand functional. Clin Plast Surg 1992;19:663–71.
[11] Godina M, Derganc M, Brcic A. The reliability of clinicalassessment of the depth of burns. Burns 1978;4:92–6.
[12] Heimbach D, Afromowitz M, Engrav L, Marvin J, Perry B.Burn depth estimation—man or machine. J Trauma1984;24:373–8.
[13] Droog E, Steenbergen W, Sjoberg F. Measurement of depthof burns by laser Doppler perfusion imaging. Burns2001;27:561–8.
[14] Pape S, Skouras C, Byrne P. An audit of the use of laserDoppler imaging (LDI) in the assessment of burns ofintermediate depth. Burns 2001;27:233–9.
[15] Watts A, Tyler M, Perry M, Robberts A, McGrouther D. Burndepth and its histological measurement. Burns2001;27:154–60.
[16] Kamolz L, Andel H, Haslik W, Donner A, Winter W, MeisslG, et al. Indocyanine green video angiographies help toidentify burns requiring operation. Burns 2003;29:785–91.
[17] Jeng JC, Bridgeman A, Shivnan L, Thornton PM, Alam H,Clarke TJ, et al. Laser Doppler imaging determines need forexcision and grafting in advance of clinical judgement: aprospective blinded trial. Burns 2003;29(7):665–70.
[18] La Hei E, Holland A, Martin H. Laser Doppler imaging ofpaediatric burns: burn wound outcome can be predicted
b u r n s 3 5 ( 2 0 0 9 ) 3 2 7 – 3 3 7336
independent of clinical examination. Burns 2006;33:550–3.
[19] Monstrey S, Hoesksema H, Verbelen J, Pirayesh A, BlondeelP. Assessment of burn depth and burn wound healingpotential. Burns 2008;34:761–9.
[20] Wong L, Spence RJ. Escharotomy and fasciotomy of theburned upper extremity. Hand Clin 2000;16:165–74. vii.
[21] Weinzweig J, Weinzweig N. Burns of the hand and upperextremity. In: Berger RA, Weiss A-P, editors. Hand surgery.Philadelphia: LWW; 2004. p. 1073–84.
[22] Smith MA, Munster AM, Spence RJ. Burns of the hand andupper limb—a review. Burns 1998;24:493–505.
[23] Salisbury RE, Levine NS. The early management of upperextremity thermal injury. In: Salisbury RE, Priutt BA,editors. Burns of the upper extremity. Philadelphia: WBSaunders; 1976. p. 36–46.
[24] Salisbury RE, McKeel DW, Mason Jr AD. Ischemic necrosisof the intrinsic muscles of the hand after thermal injuries. JBone Joint Surg Am 1974;56:1701–7.
[25] Raine TJ, Heggers JP, Robson MC, London MD, Johns L.Cooling the burn wound to maintain microcirculation. JTrauma 1981;21:394–7.
[26] Kitzinger HB, Lanz U. Die Anatomie der Fingergelenke.DAHTH 2004;6:3–11.
[27] Prasad JK, Bowden ML, Thomson PD. A review of thereconstructive surgery needs of 3167 survivors of burninjury. Burns 1991;17:302–5.
[28] Ono I, Gunji H, Zhang JZ, Maruyama K, Kaneko F. A study ofcytokines in burn blister fluid related to wound healing.Burns 1995;21:352–5.
[29] Heggers JP, Ko F, Robson MC, Heggers R, Craft KE.Evaluation of burn blister fluid. Plast Reconstr Surg1980;65:798–804.
[30] Dimick AR. Management of patients with thermal injuries.Am Surg 1971;37:637–41.
[31] Klasen HJ. A historical review of the use of silver in thetreatment of burns. II. Renewed interest for silver. Burns2000;26:131–8.
[32] Wang XW, Wang NZ, Zhang OZ, Zapata-Sirvent RL, DaviesJW. Tissue deposition of silver following topical use ofsilver sulphadiazine in extensive burns. Burns Incl ThermInj 1985;11:197–201.
[33] Zellner PR, Bugyi S. Povidone-iodine in the treatment ofburn patients. J Hosp Infect 1985;6(Suppl. A):139–46.
[34] Homann HH, Rosbach O, Moll W, Vogt PM, Germann G,Hopp M, et al. A liposome hydrogel with polyvinyl-pyrrolidone iodine in the local treatment of partial-thickness burn wounds. Ann Plast Surg 2007;59(4):423–7.
[35] Germann G, Steinau HU. Aktuelle Aspekte derVerbrennungsbehandlung. Zentralbl Chir 1993;118:290–302.
[36] Levine BA, Sirinek KR, Peterson HD, Pruitt Jr BA. Efficacy oftangential excision and immediate autografting of deepsecond-degree burns of the hand. J Trauma 1979;19:670–3.
[37] Goodwin CW, Maguire MS, McManus WF, Pruitt Jr BA.Prospective study of burn wound excision of the hands. JTrauma 1983;23:510–7.
[38] Edstrom LE, Robson MC, Macchiaverna JR, Scala AD.Prospective randomized treatments for burned hands:nonoperative vs. operative. Preliminary report. Scand JPlast Reconstr Surg 1979;13:131–5.
[39] Haynes Jr BW. Early excision and grafting in third degreeburns. Ann Surg 1969;169:736–47.
[40] Janzekovic Z. A new concept in the early excision andimmediate grafting of burns. J Trauma 1970;10:1103–8.
[41] Uhlig C, Rapp M, Hartmann B, Hierlemann H, Planck H,Dittel KK. Suprathel—an innovative, resorbable skinsubstitute for the treatment of burn victims. Burns2007;33(2):221–9.
[42] Cartotto R, Musgrave MA, Beveridge M, Fish J, Gomez M.Minimizing blood loss in burn surgery. J Trauma2000;49:1034–9.
[43] Jang YC, Kwon OK, Lee JW, Oh SJ. The optimal managementof pediatric steam burn from electric rice-cooker: STSG orFTSG? J Burn Care Rehabil 2001;22:15–20.
[44] Barret JP, Desai MH, Herndon DN. The isolated burned palmin children: epidemiology and long-term sequelae. PlastReconstr Surg 2000;105:949–52.
[45] Logsetty S, Heimbach DM. Modern techniques for woundcoverage of the thermally injured upper extremity. HandClin 2000;16:205–14.
[46] Raff T, Hartmann B, Wagner H, Germann G. Experiencewith the modified Meek technique. Acta Chir Plast1996;38:142–6.
[47] Vogt PM, Kolokythas P, Niederbichler A, Knobloch K,Reimers K, Choi CY. Innovative wound therapy and skinsubstitutes for burns. Chirurg 2007;78(4):335–42.
[48] Kamolz LP, Luegmair M, Wick N, Eisenbock B, Burjak S,Koller R, et al. The Viennese culture method: culturedhuman epithelium obtained on a dermal matrix based onfibroblast containing fibrin glue gels. Burns 2005;31(1):25–9.
[49] Whitaker IS, Prowse S, Potokar TS. A critical evaluation ofthe use of Biobrane as a biologic skin substitute: a versatiletool for the plastic and reconstructive surgeon. Ann PlastSurg 2008;60:333–7.
[50] Barret JP, Dziewulski P, Ramzy PI, Wolf SE, Desai MH,Herndon DN. Biobrane versus 1% silver sulfadiazine insecond-degree pediatric burns. Plast Reconstr Surg2000;105(1):62–5.
[51] Weinzweig J, Gottlieb LJ, Krizek TJ. Toxic shock syndromeassociated with use of Biobrane in a scald burn victim.Burns 1994;20:180–1.
[52] Schwarze H, Kuntscher M, Uhlig C, Hierlemann H, Prantl L,Noack N, et al. Suprathel, a new skin substitute, in themanagement of donor sites of split-thickness skin grafts:results of a clinical study. Burns 2007;33(7):850–4.
[53] Uhlig C, Rapp M, Dittel KK. Neue Strategien zur Behandlungthermisch geschadigter Haut unter Berucksichtigung desEpithelersatzes Suprathel1. Handchir Mikrochir Plast Chir2007;39:314–9.
[54] Dantzer E, Queruel P, Salinier L, Palmier B, Quinot JF.Integra, a new surgical alternative for the treatment ofmassive burns. Clinical evaluation of acute andreconstructive surgery: 39 cases. Ann Chir Plast Esthet2001;46:173–89.
[55] Heitland A, Piatkowski A, Noah EM, Pallua N. Update on theuse of collagen/glycosaminoglycate skin substitute-sixyears of experiences with artificial skin in 15 German burncenters. Burns 2004;30:471–5.
[56] Haslik W, Kamolz LP, Nathschlager G, Andel H, Meissl G,Frey M. First experiences with the collagen-elastin matrixMatriderm as a dermal substitute in severe burn injuries ofthe hand. Burns 2007;33(3):364–8.
[57] Philipp K, Giessler GA, Germann G, Sauerbier M. Dieakzidentelle thermische Verletzung der Hand.Unfallchirurg 2005;108:179–88.
[58] Germann G, Funk H, Bickert B. The fate of the dorsalmetacarpal arterial system following thermal injury to thedorsal hand: a Doppler sonographic study. J Hand Surg[Am] 2000;25:962–8.
[59] McGregor IA, Jackson IT. The groin flap. Br J Plast Surg1972;25:3–16.
[60] Chick LR, Lister GD, Sowder L. Early free-flap coverage ofelectrical and thermal burns. Plast Reconstr Surg1992;89:1013–9. discussion 1020–1011.
[61] Baumeister S, Germann G, Giessler G, Dragu A, Sauerbier M.Wiederherstellung der verbrannten Extremitat durch
b u r n s 3 5 ( 2 0 0 9 ) 3 2 7 – 3 3 7 337
Transplantation freier Lappenplastiken. Chirurg2004;75:568–78.
[62] Sauerbier M, Ofer N, Germann G, Baumeister S.Microvascular reconstruction in burn and electrical burninjuries of the severely traumatized upper extremity. PlastReconstr Surg 2007;119:605–15.
[63] Fotopoulos P, Holmer P, Leicht P, Elberg JJ. Dorsal handcoverage with free serratus fascia flap. J Reconstr Microsurg2003;19:555–9.
[64] Flugel A, Kehrer A, Heitmann C, Germann G, Sauerbier M.Coverage of soft-tissue defects of the hand with free fascialflaps. Microsurgery 2005;25:47–53.
[65] Achauer BM. Management of the burned patient. EastNorwalk: Appleton & Lange; 1987.
[66] Iwuagwu FC, Wilson D, Bailie F. The use of skin grafts inpostburn contracture release: a 10-year review. PlastReconstr Surg 1999;103:1198–204.
[67] Hintringer W. Arthrotenolyse der Mittelgelenke (PIP).Technik und Ergebnisse. Handchir Mikrochir Plast Chir2002;34:345–54.
[68] Hirshowitz B, Karev A, Rousso M. Combined double Z-plasty and Y-V advancement for thumb web contracture.Hand 1975;7:291–29360.
[69] Gulgonen A, Ozer K. The correction of postburncontractures of the second through fourth web spaces. JHand Surg [Am] 2007;32:556–64.
[70] Witthaut J, Leclercq C. Anatomy of the adductor pollicismuscle. A basis for release procedures for adductioncontractures of the thumb. J Hand Surg [Br] 1998;23:380–3.
[71] Groenevelt F, Schoorl R. Cross-finger flaps fromscarred skin in burned hands. Br J Plast Surg 1985;38:187–9.
[72] Ulkur E, Uygur F, Karagoz H, Celikoz B. Flap choices to treatcomplex severe postburn hand contracture. Ann Plast Surg2007;58:479–83.
[73] Kealey GP, Jensen KL, Laubenthal KN, Lewis RW.Prospective randomized comparison of two types ofpressure therapy garments. J Burn Care Rehabil 1990;11:334–6.
[74] Perkins K, Davey RB, Wallis KA. Silicone gel: a newtreatment for burn scars and contractures. Burns InclTherm Inj 1983;9:201–4.
[75] Tubiana R, Roux JP. Phalangization of the first and fifthmetacarpals. Indications, operative technique, and results.J Bone Joint Surg Am 1974;56:447–57.
[76] Matev IB. Thumb reconstruction through metacarpal bonelengthening. J Hand Surg [Am] 1980;5:482–7.
[77] Ward JW, Pensler JM, Parry SW. Pollicization for thumbreconstruction in severe pediatric hand burns. PlastReconstr Surg 1985;76:927–32.
[78] Achauer BM. The burned hand. In: Green DP, Hotchkiss RN,Pederson WC, editors. Operative hand surgery. 4th ed.,Philadelphia: Churchill Livingstone; 1999.
[79] Achauer BM, Welk RA. One-stage reconstruction of thepostburn nailfold contracture. Plast Reconstr Surg1990;85:937–40. discussion 941.
[80] Donelan MB, Garcia JA. Nailfold reconstruction forcorrection of burn fingernail deformity. Plast Reconstr Surg2006;117:2303–8. discussion 2309.
[81] Perkins K, Devey RB, Wallis KA. Silicone gel: anewtreatment for burn scars and contractures. Burns1982;9:201–4.
[82] Katz BE. Silicone gel sheeting in scar therapy. Cutis1995;56:65–7.
[83] Kealy GP, Jensen KL, Laubenthal K.N., Lewis RW.Prospective randomized comparison of types of pressuretherapy garments. J Burn Care Rehabil 1990;11:334–6.
[84] Giele HP, Liddiard K, Currie K, Wood FM. Directmeasurement of cutaneous pressures generated bypressure garments. Burns 1997;23(2):137–41.
[85] Oikarinen A, Autio P. New aspects of the mechanism ofcorticosteroid-induced dermal atrophy. Clin Exp Derm1991;16:416–9.
[86] Tang YW. Intraoperative and postoperative steroidinjection for keloids and hypertrophic scars. Br J Plast Surg1992;45:371–3.
[87] Gaida K, Koller R, Isler C, Aytekin O, Al-Awami M, Meissl G,et al. Low level laser therapy–a conservative approach tothe burn scar? Burns 2004;30(June (4)):362–7.