Hand
Burn injuries to the hand require special attention due to the hand's crucial role in daily functioning. The specific characteristics of hand burns, such as the thinner dorsal skin and thicker palmar skin, influence the choice of treatment. Skillful dressing techniques and recognizing the importance of the thumb are essential in managing hand burns effectively.
Medical history
This case focuses on a 2-year-old boy from Mbulu, Tanzania, who sustained a burn injury from hot porridge. As the local hospital lacked the capability for skin grafting, the boy was transferred to Haydom Hospital after ten days via a public Landcruiser (Photo 1).
Physical examination
Upon admission to Haydom Hospital, a physical examination revealed a full-thickness burn affecting approximately 1.5 percent of the total body surface area (TBSA) on the right hand. The burn was located on the wrist and dorsum of the hand, extending towards the base of the thumb as well as the middle and ring fingers. The eschar had been removed, and signs of healing were observed in certain areas of the wound bed, indicating some potential for recovery (Photo 2).
Conservative management
The patient's hand was managed conservatively, employing Vaseline gauzes with silver sulphadiazine cream (SSD) and daily soaking for one week. During the dressing process, certain guidelines were followed:
Finger Separation: Vaseline gauzes were used to separate the fingers in the web spaces, helping to prevent web space contractures.
Avoiding Constriction: Circular gauzes were avoided to prevent constriction, and loose crepe bandages were used instead.
Proper Layering: The gauzes and bandages were layered thinly, avoiding excessive thickness.
Open Finger Tips: The finger tips were left open to allow for circulation monitoring.
After seventeen days, a decision was made by the medical team to perform a graft on the remaining defect, which accounted for approximately 1 percent of the total body surface area (TBSA) (Photo 3).
Surgery
Under general anesthesia, the contaminated granulation tissue on the surface of the wound was carefully scraped off. Subsequently, a split skin graft was harvested from the left upper leg. The graft was meshed using a scalpel and securely sutured in place on the burn wound. To ensure the success of the graft and prevent movement-related complications of the fingers, K-wires were utilized (Photo 4).
Postoperative care
Following the surgery, the wounds were carefully dressed using tetracycline ointment on Vaseline gauzes, covered with dry gauzes, and secured with a circular bandage. Additional gauzes were used to protect the K-wires in the hand. It is crucial to emphasize to both the patient and parents the importance of avoiding friction, as it can jeopardize the viability of the skin graft.
Four days after the procedure, the wound was inspected (Photo 5), and after seven days, the K-wires were safely removed (Photo 6). Regular monitoring and follow-up are essential during the postoperative period.
After a two-week recovery period, the patient was discharged from the hospital.
Outcome
The split skin graft in this case showed good take, indicating successful grafting. However, it is important to note that infection, hematoma, and friction can potentially lead to partial or complete failure of the graft.
The mother was provided with detailed instructions on how to protect the graft during the initial four weeks. After this period, the boy was encouraged to gradually resume normal use of the hand. During follow-up appointments, it was observed that the hand regained its normal function, indicating a positive outcome (Photos 7, 8, 9).
Regular monitoring and continued care are necessary to ensure the long-term success of the graft and to address any potential complications that may arise.
Lessons learned
A comprehensive physical examination is essential during the acute phase of burn injuries, with a focus on estimating wound depth and assessing the circulation of the digit tips. It is important to evaluate each digit separately, particularly in cases of full-thickness circumferential burns, as they are at a higher risk of perfusion loss and may require escharotomy.
The assessment of burns should continue over a period of 7 to 14 days, as the wound depth may progress from superficial to deep. In the case described, a split-thickness skin graft (SSG) was chosen as the suitable method to cover the wound. Another viable option for smaller burn wounds, especially on joints, is a full-thickness graft (FTG). FTGs offer advantages such as less shrinkage and improved skin quality, which can contribute to better joint mobility. However, it is important to note that FTGs carry a higher risk of graft failure compared to SSGs.
Proper conservative management plays a significant role in facilitating re-epithelialization and favorable outcomes. In the presented case, diligent conservative measures, including dressings with tetracycline ointment, careful wound protection, and regular follow-up, contributed to the successful healing of a substantial portion of the burn without significant contractures.
The feedback from the patient's mother expressed satisfaction with the care provided and the resulting outcome. It is crucial to prioritize patient satisfaction and ensure effective communication and support throughout the treatment process. By implementing these lessons learned, healthcare professionals can improve their approach to burn management and optimize patient outcomes.
