Reconstruction of the burned hand

Several basic principles of burned hand care must be kept in mind at all times. Intervention should be early and aggressive, small splints should be placed within 24 hours, and early tangential excision of the burn should be done within 72 hours. Hemostasis should be absolutely meticulous prior to grafting. Depending upon the availability of donor site skin, full-thickness skin grafts, split-thickness grafts, or meshed split-thickness grafts (expanded or not expanded) are preferred. I have found the functional and cosmetic results to decrease with use in exactly the order stated. The skin graft should be placed with stent or bolster dressings and observed for "take" early. Light active range of motion is usually begun on the tenth postoperative day. Escharotomy or fasciotomy should be performed for any signs of ischemia. In order to control edema, one should be meticulous in the positioning of burned hands, emphasizing elevation, and early range of motion exercises. Pressure garments may be employed when the wound is stable and should continue for 6 to 12 months to control hypertrophic scar formation. Linear scars should not cross any hand joints; Z-plasties are employed over the web spaces. Whenever possible, flaps should be employed to preserve all web spaces and skin grafts used to cover the remainder of the hand. I am aggressive in releasing and reconstructing late deformities such as extension contractures of the wrist, the metacarpal hand, absence of the thumb, finger contractures, and burn syndactyly. These are listed in order of treatment priority. Only in this manner can the patient be returned to "normal life." Patient self-esteem will thus be increased markedly, as will quality of life. It is strongly urged that the surgeon be "captain of the team." The key person in this treatment regimen is the hand therapist, who uses appropriate splints, range of motion exercises, and desensitization programs. I encourage the use of multiple personnel on the "burn team." This may include psychotherapists and, in children, teachers with extraordinary qualities.