Prospective study of burn wound excision of the hands

To examine the role of early excision and grafting in the preservation of maximal function of hands with deep dermal burns, we prospectively evaluated 164 burned hands in consecutively admitted patients (mean age, 29 years; mean burn size, 37% of body surface). All hands with burn depths of second degree, deep second degree, or third degree above the level of the tendons and joint capsules were assessed preoperatively, intraoperatively, and at discharge from the hospital. Patients were treated by excision and grafting in the first or second postburn week, by delayed grafting alone, or by allowing primary healing. Total active range of motion measurements were made on the day of discharge (mean, 64th postoperative day). Mean operative blood loss per hand was 1,270 ml. When all (alive and dead) patients undergoing early excision and grafting were examined by a binomial probability model, early surgery was shown to produce no adverse affect on survival. Excision and grafting of hands with deep dermal burns, whether early or late, offered no advantage over physical therapy and primary healing in maintaining hand function. Likewise, hands with more superficial burns responded equally to operative and nonoperative treatment. While early excision and grafting of hands with third-degree burns tended to produce poorer results than did initial nonoperative care and late grafting, the differences are just outside the range of significance. Early excision and grafting of selected third-degree injuries of the hands may be indicated in patients with small total body surface burns in order to shorten hospital stay. However, early surgical intervention in patients with massive burns should be directed toward area coverage, not toward hand excision.