Burn Hand Deformities
One of the major determinants of the quality of life in burns survivors is the functionality of the hands. The burn hand deformities are largely preventable by good initial care, which include burn care, elevation of the hand, splinting, early grafting of deep burns and supervised physiotherapy.
Because of the high frequency of occurrence of hand burns, the frequency of burn hand deformities are also high.
Dorsal Hand Deformities
In the classical dorsal hand deformity, there is clawing of the fingers – hyperextension of the metacarpophalangeal joints due to oedema and flexion of the interphalangeal joints. With time, the joints become stiff and the extensor tendons undergo shortening. The poor skin quality due to burn at the PIP joint may expose the tendon and the extensor may rupture secondary to stretch and ischaemia.
The goal of burn hand deformities treatment is to make finger straight by bring the MCP joints in flexion position and release of the IP joints flexion deformity, that can be managed with skin grafts and flaps on dorsum of hand.
Volar Hand Deformities
Deep volar hand burns result in
- finger flexion contractures and
- Palmar contracture resulting in narrowing of the palm.
Full release of palmar contracture is usually possible by scar excision and is covered with full-thickness or thick split thickness grafts.
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Deformities of the thumb
The most common site of deformity in the thumb is at the MCP joint.
- When there is hyperextension contracture at the MCP joint it is known as swan neck-type deformity and,
- With flexion contracture deformity at the MCP joint of thumb, a boutonniere deformity occurs.
Both may be associated with first-web contracture.
If the burn hand deformities are of short duration and are due to skin contracture, release of the contractures will correct the deformity. However in long duration severe deformities, an overall plan has to be made according to the severity of deformity.
Adduction contractures of the first web space might require release of skin and Fibrous tissue with the aim that the pulp of the thumb will face the pulp of the other fingers at the end of release. The raw surface area created is covered with graft or flap
Other thumb deformities require proper planning in terms of contracture release, tendon balance, tendon transfer or joint orthodesis.
Burn Hand Syndactyly
Circumferential burns Or Burn Hand Deformities of the fingers when healed without grafting may cause syndactyly. Usually, the IP joints are stiff and there is paucity of skin to make flaps, as is performed in congenital finger syndactyly.
Most of the times, longitudinal division is done and the raw areas are grafted. To avoid web creep when separating burn syndactyly, the best available skin is used to make the web flap or Full-thickness skin is used at the web to prevent creep.
Post Burn Digital Amputation
Post burn digital amputations are managed with proper wound care and stump coverage.
Later the digital reconstruction can be done by toe transfer or digital prosthesis
Physiotherapy and aftercare of post burn hand deformities
- The gains achieved by surgery has to be maintained by proper splintage of the released joints.
- The K-wires are retained for 3 weeks to enable the grafts or flaps to settle.
- The massage of graft is must and Use of custom-made compression garments worn for 6 months.
- Physiotherapy has to be performed multiple times a day and the joints have to be splinted in between. Good physiotherapy will make all the efforts worthwhile.