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BURNS

Introduction

Our hands reflexively assume a defensive posture to protect the rest our body when confronted with trauma. Consequently, hands bear the brunt of injuries in cases of burns.  Severe burns involve the hand in at least 90% of the cases. The collaborative efforts of hand surgeons, burn specialists and hand therapists are imperative for the most effective treatment of burns to the hands. Assessing burn severity is not always straightforward, and several methods can be used to determine wound depth. Treatments are specifically tailored to each patient based on not only wound depth, but also the cause and anatomical structures involved. When treating burn patients, the primary objectives are to salvage as much of the hand as possible, avert the potential of contractures, and maintain functionality by implementing the best techniques with passive and active range of motion therapy.3

Pathophysiology

  • Wound depth determines the degree of pathology a burn will have on the skin. Superficial burns trigger a resilient response to blister and re-epithelialize with or without local wound care. With deeper burns, encompassing the epidermis and partial- and full-thickness dermal layers, the skin loses its capacity to regenerate and is severely compromised owing to the loss of underlying vital structures. Hypertrophic scarring and contracture are the body’s debilitated response to heal and seal off the wound bed.
  • Hypertrophic scarring results from the overexpression of transforming growth factor B1 (TGF-B1) and connective tissue growth factor released by fibrocytes that infiltrate deep burns.2
  • Fluid contained within blisters contains proinflammatory cytokines, an excellent medium for bacterial growth, and is therefore considered counterproductive to the healing process. However, blistered skin provides an autonomous protective barrier by covering the wound until healed.  Thus, removing burn blisters remains controversial.3
  • The threat of contracture is limited to deep, partial- and full-thickness burns.  Desiccation of underlying tendons and/or muscles or rupture of the lateral bands will result in outward contraction of the hand, functional morbidity and disability, in addition to embarrassment relating to the disfigurement.4
  • Because the subcutaneous layer of tissue overlying the dorsal aspect of the hand is relatively thin compared with that of the palmar aspect, extensor tendons are more susceptible to contractures than are the flexor tendons.4

Related Anatomy

  • Anatomical structures involved will vary depending on the severity of burn. The greater the wound depth, the greater risk of neurovascular, muscular, tendinous and bony structures being involved.

Incidence and Related Conditions

  • Flame and scald burns account for 75% of those burn patients requiring hospitalization.4
  • Flame burns occur most frequently at home (61%); 6% occur during recreational events, and 6% occur in the industrial/occupational setting.4
  • 19% of burns reported involve children younger than age 5 years. Post-burn flexion contractures are most often seen in children after touching or immersing their hand in something hot, including a rotating object or machine.4
  • 30% of burns involve the upper extremity.3

Differential Diagnosis

  • Eczema
  • Rheumatic skin disease
  • Birth deformity
  • Self-inflicted mutilation

Burn Severity

Symptoms vary based on burn severity, which is graded by degrees (Fufa et al., 2014).

  • First-degree burns are confined to the epidermis
    • Superficial
    • Erythema
    • Pain
    • Devoid of blistering
  • Second-degree burns
    • Partial-thickness burns, superficial
      • Blister formation followed by sloughing
      • Painful, owing to survival and exposure of nerve endings
      • Intact capillary wound bed with intact capillary refill (blanching).
      • Injury will usually re-epithelialize completely within 10-14 days with local wound care; hair, sebaceous glands, and sweat glands will be restored.3,5
    • Partial-thickness burns, deep
      • Pain is absent because the wound depth extends beneath nerve endings
      • Few epithelial cells remain and take longer than 2–3 weeks to heal
      • Increased chance of hypertrophic scarring owing to collagen deposition.3,5,6
      • Topical antimicrobial dressing affords the ability to determine wound depth and time needed to heal.5
      • May require skin grafting.5
  • Third-degree burns
    • Full-thickness burns involve epidermis and dermis
    • Pallor is due to secondary thrombosis
    • Leathery, firm, desiccated or carbonized skin on exam3,5
    • Insensate owing to destruction of cutaneous nerve endings
    • Full-thickness burns will not re-epithelize
  • Fourth-degree burns
    • Full-thickness burn
    • Most severe, encompassing destruction of fat, tendon, muscle, vasculature, nerves, bone, and joints 3,4
    • Heals by scar tissue formation4,6
    • Compartment syndrome may occur concomitantly with fluid resuscitation in cases of deep-partial or full-thickness burns 3
    • Levels of contractures also are graded (Types I–III) based on degrees of extension and flexion, with the most severe form of contracture being the claw-hand deformity 4
    • Web contractures are not uncommon in severe cases involving dorsal-, palmar- , or inter-digital web spaces 4
ICD-10 Codes

  • BURNS

    Diagnostic Guide Name

    BURNS

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    BURNS    
    - FINGER (NOT THUMB)    
    - FIRST DEGREE    
       - SINGLE FINGER T23.122_T23.121_ 
       - MULTIPLE FINGERS (NOT THUMB) T23.132_T23.131_ 
       - MULTIPLE FINGERS AND THUMB T23.142_T23.141_ 
    - SECOND DEGREE    
       - SINGLE FINGER T23.222_T23.221_ 
       - MULTIPLE FINGERS (NOT THUMB) T23.232_T23.231_ 
       - MULTIPLE FINGERS AND THUMB T23.242_T23.241_ 
    - THIRD DEGREE    
       - SINGLE FINGER T23.322_T23.321_ 
       - MULTIPLE FINGERS (NOT THUMB) T23.332_T23.331_ 
       - MULTIPLE FINGERS AND THUMB T23.342_T23.341_ 
    - THUMB    
      - FIRST DEGREE T23.112_T23.111_ 
      - SECOND DEGREE T23.212_T23.211_ 
      - THIRD DEGREE T23.312_T23.311_ 
    - HAND, DORSUM    
      - FIRST DEGREE T23.162_T23.161_ 
      - SECOND DEGREE T23.262_T23.261_ 
      - THIRD DEGREE T23.362_T23.361_ 
    - HAND, PALM    
      - FIRST DEGREE T23.152_T23.151_ 
      - SECOND DEGREE T23.252_T23.251_ 
      - THIRD DEGREE T23.352_T23.351_ 
    - WRIST    
      - FIRST DEGREE T23.172_T23.171_ 
      - SECOND DEGREE T23.272_T23.271_ 
      - THIRD DEGREE T23.372_T23.371_ 
    - MULTIPLE SITES, WRIST AND HAND    
      - FIRST DEGREE T23.192_T23.191_ 
      - SECOND DEGREE T23.292_T23.291_ 
      - THIRD DEGREE T23.392_T23.391_ 
    - FOREARM    
      - FIRST DEGREE T22.112_T22.111_ 
      - SECOND DEGREE T22.212_T22.211_ 
      - THIRD DEGREE T22.312_T22.311_ 

    Instructions (ICD 10 CM 2020, U.S. Version)

    THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY T22 AND T23
    A - Initial Encounter
    D - Subsequent Routine Healing
    S - Sequela
    USE ADDITIONAL EXTERNAL CAUSE CODE TO IDENTIFY THE SOURCE, PLACE, AND INTENT OF THE BURN (X00-X19, X75-X77, X96-X98, Y92)

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
Hand Burns
  • Right hand second degree burn after child fell into a fire pit
    Right hand second degree burn after child fell into a fire pit
  • Left hand second degree burn after child fell into a fire pit
    Left hand second degree burn after child fell into a fire pit
  • Right hand deep 3rd degree degree burn
    Right hand deep 3rd degree degree burn
  • Right hand amputations, contractures, and scarring after severe burn
    Right hand amputations, contractures, and scarring after severe burn
Pathoanatomy Photos and Related Diagrams
Burn Diagrams
  • First degree burn of the dorsum of the hand. Note burn area (B) and depth (arrow). Note this superficial burn is devoid of blisters, has associated erythema and significant pain because of intact nerve endings.
    First degree burn of the dorsum of the hand. Note burn area (B) and depth (arrow). Note this superficial burn is devoid of blisters, has associated erythema and significant pain because of intact nerve endings.
  • Second degree burn of the dorsum of the hand. Note burn area (B) and depth (arrow). Note this partial thickness burn will have blisters, has associated blanching and significant pain if there are intact nerve endings. Findings will vary according to burn depth.
    Second degree burn of the dorsum of the hand. Note burn area (B) and depth (arrow). Note this partial thickness burn will have blisters, has associated blanching and significant pain if there are intact nerve endings. Findings will vary according to burn depth.
  • Third degree burn of the dorsum of the hand. Note burn area (B) and depth (arrow). Note this is a full thickness. There will be no associated blanching and no pain because nerve endings have been destroyed.
    Third degree burn of the dorsum of the hand. Note burn area (B) and depth (arrow). Note this is a full thickness. There will be no associated blanching and no pain because nerve endings have been destroyed.
Symptoms
Severe pain in the burned areas
History of a burn
Typical History

A young child touches a stove, iron or runs across the deck, trips and falls into an uncovered fire pit.

Positive Tests, Exams or Signs
Work-up Options
Treatment Options
Treatment Goals

Minimize tissue and fuctional loss

Conservative
  • For superficial and partial-thickness wounds (first- and second- degree superficial burns)
    • Evacuation of fluid from blisters, rather than debriding, is recommended 3
    • Cleanse with gentle soap
    • Apply topical cream and change dressing daily
    • Elevate arm to prevent edema
Operative
  • Pertaining to deep, partial- and full-thickness burns (deep second-degree to fourth-degree burns)
  • Second (deep, partial-thickness) and third-degree burns are managed similarly, whereas fourth-degree burns require staged reconstruction and possibly amputations 6
    • Early debridement of devitalized tissue is indicated for deep, partial- and full-thickness burns to avert potential contractures and need for reconstructive surgery 3,6
    • Weck knife for excision provides precision between web spaces and tendons
    • Versajet (Smith & Nephew Wound Management, Hull, UK) helps to remove thin layers of devitalized tissue one layer at a time and works to smooth out the wound surface 5
    • Brennen mesher (Brennen Medical, LLC, St Paul, MN) is used to mesh graft in closely when donor sites limited.
    • Wound VAC : a negative pressure  dressing  which serves to enhance opposition of tissue grafts, manage egress of fluid, remove infectious debris, bring wound margins closer together, and  promote granulation
    • Escharotomies are performed emergently to establish ample circulation distally in deep partial or full thickness burns to prevent dermal compartment syndrome.3
    • Fasciotomy to relieve build-up of pressure and save muscles within fascial compartments.
    • Necrotic tissue is excised or amputated in severe cases and may require specialized wound coverage in effort to preserve digital length7
    • Cleanse with a gentle soap
    • Proper and early wound coverage has proved to facilitate early motion recovery4
    • In cases where all digits and thumb are circumferentially burned, the use of a paraumbilical flap together with an abdominal wall marsupial flap provide ample wound coverage and allows for mobility 7
  • Split-thickness skin graft is standard; however, the type and placement of the graft will depend on the extent and location of the burn, patient age, and surgeon’s preference.6  Alternative coverage options include:
    • Allograft (cadaver skin)
    • Xenograft (most often pig skin)Autograft (the patient’s own skin)
    • Radial forearm flap 6
    • Skin substitutes and wound dressings 3,5
    • Dorsal metacarpal arterial (DMCA) flaps may facilitate the salvage metacarpal phalangeal joints (MCPs) and proximal interphalangeal joints 8
      • Before implementing, imperative to check feasibility using Doppler sonography.
    • After debridement, adherence of an allograft is indication that debridement was sufficient. If not, repeat debridement and graft 5
  • Full-thickness grafts
    • Uncommon and used for palm area
    • Sources of full-thickness grafts include:
      • Hypothenar eminence
      • Upper inner arm
      • Proximal wrist crease
      • Groin (hairless regions)
    • Tangential excision and grafting or excision and primary closure are means by which a third-degree burn is treated 5
      • Proper orthosis fabrication is vital to prevent contractures and “burn claw deformity;” it is implemented perioperatively
      • Anti-deformity position in an orthosis which keeps the wrist extended 25°, MP joints flexed 80-90°, PIP and DIP joints extended and thumb abducted is key to prevent severe post burn contracture.3,4,5

POST SURGICAL CARE INCLUDES:

  • Limit hypertrophic scarring and contractures via: 
    • Anti-deformity orthosis fabrication 
    • Compressive garments made of silicone sheets applied to digits and web spaces help to negate scarring and contracture via tissue hypoxia and must be worn 23 hours a day for 6–12 months for severely burned hands4 
    • Apply topical cream and change dressing daily 
      • Helps to reduce infection, reduce pain, encourages epithelialization, and decrease fluid loss
      • Epinephrine-soaked dressing immediately after debridement.3
      • 5% Sulfamylon solution applied every 8 hours until graft is adhered
      • Non-stick wound veil (DeRoyal, Powell, TN) used with either bacitracin or mupirocin 5
      • For pediatric burns, Acticoat (Smith& Nephew, Memphis TN) and Aquacel Ag (Conva Tec, Inc., Slillman, NJ) are highly recommended because they require fewer dressing changes, have antimicrobial activity, and are pain-sparing 6
    • Elevate arm to prevent edema 
    • After epithelialisation, introduce hypoallergenic lotion to massage scar 3 
    • Initiate supervised hand therapy to include free range of motion (ROM), extension and flexion once safe to do so; early and aggressive therapy is contraindicated for hands that have been more severely burned 4,5 
    • Avoid direct sunlight 4 
    • Intralesional steroid injections 
    • Dermatologist directed light- and laser-based therapies: pulsed dye laser, carbon dioxide laser or pulsed light therapy
  • Treatment of scars and contractures
    • Once formed, usually there are no non-surgical remedies; however; use of the above mentioned light and laser therapies have helped
    • Surgery may be delayed until scar has matured; there are exceptions in cases where contracture is severe
    • Surgical intervention is indicated if function-limiting contractures become apparent after 2 months of therapy 4.   
    • Web-space contractures can be corrected with:
      • Z-plasty
      • Local or distant tissue transfer for rearrangement
      • Artery flap
      • Free tissue transfer
      • Post-operative compression necessary to prevent web-creep or recurrence
    • Management of burn claw deformity 4
      • Identify depth and involvement of joint capsules, tendons and bone
      • Grant generous release by making wide excisions of soft tissue contracture followed by soft tissue coverage
      • Provide residual release of deeper structures (muscles, tendons, and joints) through windows to allow for easy closure:
        • Tenotomy of the terminal extensor tendon
        • Extensor tenolysis
        • Mobilize lateral bands
        • Capsulotomy and wire fixation are reserved as last resort due to subsequent bleeding and pain resulting in delay of ROM therapy, inadvertently resulting in recurrence of contracture
        • Soft tissue coverage such as : random-pattern pedicled flap or free tissue transfer
    • Full-thickness skin grafts are used to fill soft tissue defects
Complications
  • Wound borders become defined as the wound heals; circulation can become compromised, at which time, an escharotomy should be performed using a scalpel or electrocautery, while being mindful of underlying structures.
  • Compartment syndrome may occur concomitantly with fluid resuscitation in cases of deep, partial- or full-thickness burns and may damage intrinsic musculature 3,6). In this event, fasciotomy is indicated.
  • Although split-thickness skin grafts are considered the gold standard, complications include hematoma and/or seroma formation. The success of skin grafts depends on adherence devoid of fluid accumulating beneath the graft. Monitoring for sub-graft fluid accumulation is essential. Fluid evacuation is achieved using a large bore needle or #11 scalpel blade 3.
  • Burn wound sepsis is rare but is still a risk in diabetics and patients compromised by other medical comorbidities.
  • Common bacteria in burn sepsis include pseudomonas and MRSA.
Outcomes
  • Multi-interdisciplinary effort during the course of 1 year can be anticipated
  • Debilitative deformity may be the end result for severely burned hands despite early rehabilitation and scar management 4
  • Early surgical intervention has been shown to negate sepsis-related mortality, decrease chances of hypertrophic scarring, and improve hand function 3
  • After surgery of severely burned hands, the best outcome is achieved by alternating compressive therapy with ROM therapy 4
Key Educational Points
  • Early aggressive hand therapy is reserved for superficial burns; aggressive therapy of hands with deeper burns, particularly over the MCP joints, could damage the extensor slip resulting in a boutonmiere deformity (permanent flexion of the PIP joint with concomitant hyperextension of the distal interphalangeal joint of affected finger(s). Therefore, hand therapy in cases of deep, partial- and full-thickness burns should be counter-balanced with stage of healing 3
  • General rule of thumb pertaining to orthosis fabrication: “For any burned body part, allowing the position of comfort allows for position of contracture” (Richards et al., 2014)
  • Although blisters resulting from frostbite burns are very similar to those occurring with thermal burns, frostbite is progressive in nature leading to dermal ischemia and acute management is entirely different from treatment recommended for thermal burns 5
  • Chemical burns: refer to acute management of chemical burns, dissimilar to that of thermal burns
  • The division between secondary burns which are partial thickness (superficial)  and secondary burns that are partial thickness (deep) represents the dividing line between non-operative and operative burn wound care. Defining this distinction is difficult, requires clinical judgement and may vary from one burned area to another.
References

Cited

  1. Robson MC, Heggers JP. Evaluation of hand frostbite blister fluid as a clue to pathogenesis. The J Hand Surg 1981;6(1):43-7. PMID 7204918
  2. Stewart TL, Ball B, Schembri PJ, et al.  The use of laser Doppler imaging as a predictor of burn depth and hypertrophic scar postburn injury. J Burn Care Res 2012;33(6):764-71. PMID 22955162
  3. Pan BS, Vu AT, Yakuboff KP. Management of the acutely burned hand. J Hand Surg Am 2015;40:1477-84. PMID 26043803
  4. Futa DT, Chuang SS, Yang JY. Postburn contractures of the hand. J Hand Surg Am 2014;39:1869-76. PMID 25154575
  5. Richards, WT, Vergara E, Dalaly DG, et al. Acute surgical management of hand burns. J Hand Surg Am 2014;39(10):2075-85. PMID 25257489
  6. McKee DM. Acute management of burn injuries to the hand and upper extremity. J Hand Surg Am 2010;35:1542-44. PMID 20478666
  7. Wu C, Zhou L, Zhu L, Zheng J. Deep digital burns treated with 2 abdominal flaps: case report. J Hand Surg Am 2013;38:2169-72. PMID 24021738
  8. Germann G, Funk H, Bickert B. The fate of the dorsal metacarpal arterial system following thermal injury to the dorsal hand: a Doppler sonographic study. J Hand Surg Am 2000;25(5):962-68.         PMID 11040314

New Articles

  1. Pan BS, Vu AT, Yakuboff KP. Management of the acutely burned hand. J Hand Surg Am 2015;40:1477-84. PMID 26043803
  2. Wu C, Zhou L, Zhu L, Zheng J. Deep digital burns treated with 2 abdominal flaps: case report. J Hand Surg Am 2013;38:2169-72. PMID 24021738

Reviews

  1. Richards, WT, Vergara E, Dalaly DG, et al. Acute surgical management of hand burns. J Hand Surg Am 2014;39(10):2075-85. PMID 25257489
  2. Futa DT, Chuang SS, Yang JY. Postburn contractures of the hand. J Hand Surg Am 2014;39:1869-76. PMID 25154575

Classics

  1. Germann G, Funk H, Bickert B. The fate of the dorsal metacarpal arterial system following thermal injury to the dorsal hand: a Doppler sonographic study. J Hand Surg Am 2000;25(5):962-68. PMID 11040314
  2. McKee DM. Acute management of burn injuries to the hand and upper extremity. J Hand Surg Am 2010;35:1542-44. PMID 20478666
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