Flap Reconstruction for Deep Hand Burns: A Case Series

Introduction Deep hand burns are severe injuries that frequently result in exposure of tendons and bone because of the thin subcutaneous tissue of the hand. In such cases, skin grafting alone is often insufficient, and flap reconstruction is required. Heat-press injuries are particularly challenging because combined thermal and crush mechanisms make tissue viability difficult to evaluate. The optimal timing of debridement and reconstruction also remains controversial. Methods We retrospectively reviewed the medical records of six patients (six hands) with acute deep hand burns distal to the wrist who required flap reconstruction between April 2004 and April 2025. Clinical variables including injury mechanism, injury location, burn depth, timing of surgery, reconstructive procedures, and outcomes were evaluated. Results The study included three (50.0%) male and three (50.0%) female patients ranging in age from 21 to 61 years. Four (66.7%) injuries were caused by heat-press mechanisms, one (16.7%) by contact with heated metal, and one (16.7%) by flame burn. Three (50.0%) patients had injuries limited to the digits, one (16.7%) patient had injuries extending from the digits to the dorsal aspect of the hand, and two (33.3%) patients had injuries extending from the digits to the palm and dorsum. Five (83.3%) patients had grade 3 injuries according to the Tajima classification. Debridement and flap reconstruction were performed simultaneously within one to 10 days of injury in four (66.7%) patients. In one (16.7%) patient with extensive burns, flap reconstruction was delayed until 64 days after injury because treatment of the life-threatening burns was prioritized. In another patient (16.7%), delayed necrosis became clinically apparent after the initial debridement performed 11 days after injury, requiring additional reconstruction with a free anterolateral thigh flap 42 days after injury. Ultimately, digital amputation was required in three (50.0%) patients. Patients with predominantly dorsal injuries achieved relatively favorable outcomes, whereas palmar or combined palmar-dorsal injuries were associated with poor prognosis. Conclusions Deep hand burns involving the palmar aspect or both the palmar and the dorsal aspects carry a high risk of progressive necrosis and amputation despite flap reconstruction. Our findings suggest that early coverage using well-vascularized flaps and carefully staged treatment strategies considering delayed necrosis may be important for tissue preservation and functional reconstruction.