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Chapter 8
Treatment ofHand Burns
TinaL.Palmieri
Introduction
The hands, although comprising <10% of overall body
surface area, are involved in >90% of severe burns [1].
Because people interact with the environment predominantly
via their hands, even a partial loss of hand function can result
in difficulties in performing the simplest tasks. Hands are
particularly important in completing activities of daily living;
loss of hand use is associated with a 57% loss of total function
for an individual [2]. Hands are also visible representations of
our selves. We see our hands more often than our face, and
hands are frequently what is noticed by others. Appearance
has become the focus of outcome research after hand injury
[3]. In children with large burns, the presence of a burn injury
in a visible area, such as the hands, is more strongly associated
with psychological consequences and worse health related
quality of life outcomes than the overall severity of the burn
[4, 5]. Hence, the appearance, as well as the function, of hands
is important. The initial treatment of a hand burn sets the
stage for future hand function; hence, it is important for non-
T. L. Palmieri (*)
Shriners Children’s Northern California, University of California
Davis, Sacramento, CA, USA
e-mail: tlpalmieri@ucdavis.edu
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
J. O. Lee (ed.), Essential Burn Care for Non-Burn Specialists,
https://doi.org/10.1007/978-3-031-28898-2_8
197
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T. L. Palmieri
burn and non-plastic surgery practitioners to understand the
basic principles of management of hand burns. Delayed treatment of a hand burn can result in lifelong disability. The purpose of this chapter is to provide the non-burn physician with
the tools to appropriately evaluate and manage the acute
presentation of a hand burn.
Anatomy ofHand Skin
Understanding skin anatomy is the cornerstone of accurate
diagnosis and management of hand burns. The skin of the
hand is unique anatomically compared to other body regions.
The dorsal hand and palmar hand have different skin structure and function. While the dorsum of the hand has thin,
flexible skin to facilitate movement and joint flexion, the
palmar skin is thicker, attached to the palmar fascia, resistant
to pressure, and contains essential sensory end organs [6]. As
such, the dorsal surface is a motion facilitator, while the palm
is designed structurally and biologically to facilitate grasping
and holding objects. Injuries to the dorsal hand, due to the
proximity of tendons to the skin surface, are prone to motion
deficits, while palm injuries may have long-term impact on
hand sensorium and grasp.
The etiology of burn injuries to the hand varies by
anatomic region, as well as age. Dorsal hand burns are more
commonly caused by scald or flame injuries, while palm
burns, particularly in children, result from contact with a
hot object, such as a curling iron or glass fireplace front [7,
8].Children explore their environment using their hands;
hence, young children, especially toddlers, are at particular
risk of palm injury. Due to the thickness of the palmar skin,
third degree burns of the palm occur less frequently than
dorsal hand burns. Other anatomic locations impose additional risks for long-term sequelae after burn injury. Nail
bed burns can result in nail deviation, cleft, loss, or discoloration and adversely impact hand function [9]. The extensor tendons of the proximal interphalangeal joint (PIP) is
Chapter 8. Treatment ofHand Burns
another area of concern. The central slip of the extensor
tendon inserts at the proximal interphalangeal joint (PIP),
while 2 lateral bands continue distally to the base of the
phalanx. Disruption of this mechanism causes the
Boutonniere deformity. Finally, the fifth finger metacarpophalangeal joint, which is hypermobile, increases the likelihood for development of a boutonniere deformity months
after excision and grafting [10].
199
Aim ofHand Burn Treatment
In general, tenets of hand burn care are to (1) promote a
wound healing environment, (2) maintain circulation, (3)
prevent infection, (4) obtain wound closure, and (5) maintain motion. Appropriate initial wound care relies on
knowledge of the pathophysiology of burn wounds. Because
definitive treatment of the hand burn is complex, requiring
the input of surgeons, physiotherapists, occupational therapists, psychologists, and nursing, national burn treatment
guidelines recommend that hand burns be treated in a burn
center [11]. Due to the limited number of verified burn
centers, most patients are initially evaluated in non-burn
facilities. Timely referral of hand burns to a qualified burn
provider is essential.
Initial Hand Burn Evaluation
The initial priority for burn injury treatment is to remove the
patient from the heat source. This is generally accomplished
at the injury scene. For small burns (less than 10%) immediate irrigation with cool tap water (NOT cold water and NOT
ice) for 20–30min may minimize the damage caused by heat
exposure [12–14]. Initial medical evaluation focuses on
assessment for life-threatening injuries following the guidelines set forth for initial trauma management. Injury history
provides valuable insight into potential associated trauma
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T. L. Palmieri
(such as crush injury during a motor vehicle crash). The etiology of the burn injury (flame, scald, contact, chemical, electrical), duration of contact with the heat source, temperature of
the heat source (if available), first aid applied at the scene,
and prior hand injuries should be recorded. Hand radiographs are generally unnecessary unless there is associated
crush or traumatic injury.
Determination of burn extent and depth is an essential
element of the evaluation. Perhaps the most neglected yet
essential step to enable accurate assessment of burn injury
extent and depth is to wash the wound with soap and water
to remove debris and soot that may obscure visualization
of the wound beneath. Pain associated with the burn
wound will need to be addressed prior to debridement. For
initial burn treatment, patients frequently require intravenous narcotic administration to control pain. Low doses of
short acting narcotics are recommended, as pain decreases
precipitously after dressings are applied. Anxiolytic medications may be required, as well. Appropriate monitoring
should be instituted. After pain is controlled, debridement
can be accomplished by initially rinsing the wound with
cool water, followed by utilization of wet wash rag saturated with room temperature water and soap (such as
chlorhexidine). The rag can then be used to remove loose
tissue and further clean the wound. At times scissors may
be needed to remove adherent skin ends. The final step is
to rinse off the soap and pat the wound dry. This allows for
wound visualization and decreases infection risk.
Burn extent (i.e., how much of the body surface area is
involved in the burn) is generally estimated by applying one
of the three techniques: the palm rule, in which the patient’s
palm (including fingers) is 1% of the patient’s body; the
Rule of Nines, in which each body part is a multiple of 9; or
employing the Lund-Browder chart, which adjusts body
surface area estimates based on age. Upper extremity or
hand burns that encompass the entire circumference of the
arm or hand should be noted and extremity capillary refill
assessed.
Chapter 8. Treatment ofHand Burns
201
Burn depth determination can be particularly challenging
for the hand due to the dynamic nature of the wound. The
burn wound has three injury zones: coagulation, stasis, and
hyperemia. The size of each zone over time is influenced by
tissue perfusion and wound care. The tissue in the zone of
coagulation is damaged beyond repair. The tissue in the
zone of hyperemia, with minimal injury, will heal
spontaneously within a week. The zone most influenced by
initial treatment is the zone of stasis, in which there is
significant, but not complete tissue injury. Appropriate
wound management will allow healing of the zone of stasis,
while inappropriate management or lack of perfusion will
result in extension of the tissue injury. The goal of initial
wound care is to minimize conversion of the zone of stasis
to the zone of coagulation by optimizing the wound healing
environment.
Burn injury depth is divided into three categories: first
(superficial), second (partial-thickness), and third (fullthickness) degrees. First degree burns involve only the
epidermis and do not blister but can be painful. A common
first degree burn scenario is sunburn. A second degree
burn traverses the epidermis and extends a variable distance into the dermis. Superficial second-degree burns are
blistered, painful, moist, pink, and blanch on touch. These
wounds should be managed in a moist environment to
encourage epithelialization [15]. Deep second-degree
burns are generally blistered, deeper red or mottled in
color, have minimal blanching, and are usually somewhat
less painful. These wounds should also initially be managed in a moist environment to encourage epithelialization, but the wounds should be closely monitored by a
burn surgeon. Third-degree flame burns are white or leathery, generally have decreased sensation centrally, while
third-degree scald burns are deep cherry red, dry, and
mottled. Topical antimicrobials or silver dressings should
be placed, and the patient referred to a burn surgeon for
possible excision and grafting. Second and third-degree
hand burns are best treated in a qualified burn center.
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T. L. Palmieri
Most isolated hand burns can be referred for an outpatient
clinic appointment within 1–3 days after injury. To date
visual inspection of the wound for depth determination is
commonplace, although advanced wound imaging modalities such as thermography and laser Doppler are gaining in
popularity [16]. Presence of a blister makes determination
of wound depth problematic, at best, because visualization
of the skin beneath the blister is not possible.
Promote aWound Healing Environment
Loose debris and broken blisters are removed from the wound,
as they are a nidus for infection. Loose fingernails should be
left in place (unless already gone). Loss of fingernails suggests
the presence of a deep third-degree hand burn, and the patient
should be immediately referred to a burn center. Palm blisters
can be left intact; however, if the blister compromises circulation or impedes range of motion, they may require removal.
Blisters contain inflammatory mediators [17]. Any blister
≤2cm in height on the palm can usually be left intact without
adverse outcomes. If the blister ruptures, however, the tissue
pieces should be removed, and the skin beneath washed with
soap and water as described above. Intact blisters should be
wrapped in dry dressings, as topical antimicrobials such as silver sulfadiazine or bacitracin do not penetrate the blister and
will result in skin maceration. Application of topical antimicrobials is appropriate after the blister has ruptured and the
wound cleaned. The topical antimicrobial should be placed
with a thickness of approximately 0.25″ and covered with loose
dressings. Circumferential wrapping of hands should be monitored for impairment of perfusion. Elastic tube netting is the
most efficacious method of holding dressings in place. Dressing
changes depend on the dressing selected. Topical antimicrobials such as silver sulfadiazine and bacitracin should be changed
daily, while silver dressings can be applied for 3—7days. The
patient should be referred to a burn center for outpatient management within the week.
Chapter 8. Treatment ofHand Burns
203
Maintain Circulation
Maintaining circulation in the burned hand is essential to
avoid extension of the zone of stasis to the zone of coagulation. This is particularly important in major burns (>20%
total body surface area). Major burns should receive appropriate intravenous resuscitation. Hand and arm burns should
be elevated above the level of the heart, and dressings placed
loosely to avoid circulatory compromise of the extremity.
Hand escharotomy for burn injury is rarely necessary and
should be performed by a trained burn or hand surgeon, as
they may cause blood loss or injury to underlying structures.
After adequate intravenous sedation is assured, electrocautery is used to incise through burn eschar to pliable nonconstricting tissue or fat. Arm escharotomies consist of
incisions along the medial and lateral aspects of the extremity
with the arm in supination. In the hand, the eschar is released
with 2–3 longitudinal dorsal incisions between the tendons on
the dorsal hand [18]. Digital escharotomies are rarely required
on the lateral and medial aspects of the fingers and should be
above the skin crease formed when the finger is bent at the
DIP joint in order to avoid neurovascular injury. Circulation
should be reassessed frequently after the performance of
escharotomies, and fasciotomy in the operating room may be
necessary if ischemia persists.
Prevent Infection
As emphasized above, burn hand infection is best prevented
by early and complete wound debridement and cleaning with
soap. A partial-thickness wound, which is classically pink,
moist, and painful, will heal within 2weeks and can be treated
with topical bacitracin and Adaptic™ or petroleum gauze such
as Xeroform™ once or twice daily. The advent of silver dressings, which can be applied and kept in place for 5–7days, has
facilitated management. However, proper application of silver dressings is important. The dressing needs to be secured
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T. L. Palmieri
to avoid dislodgement yet allow for movement. In general,
tape should be avoided on burned skin, as it may denude the
epithelial layer. Silver sulfadiazine should be reserved for
third-degree burns. Although silver sulfadiazine has broad
antimicrobial coverage, it leaves a thick residue on wounds
that results in painful dressing changes, and it impedes wound
healing [19]. Other topicals for third-degree wounds include
mafenide acetate (reserved for ears, invasive infections), silver nitrate solution, and silver-containing dressings.
Obtain Wound Closure
Burn wound closure occurs either primarily through wound
healing or secondarily via excision and grafting. The resultant
healed skin or skin graft should be strong and pliable enough
to allow maximal hand function while minimizing unsightly
scar. Burns that heal within 2 weeks do not usually result in
significant scarring or restriction in range of motion. Generally,
all deep partial- or full-thickness burns that are not healing
within 2–3 weeks should be considered for excision of the
burn eschar with skin grafting [20, 21]. It is not necessary to
wait 2weeks prior to referral; the earlier the operative intervention, the less the scarring.
The foundation for surgical treatment of the burned hand
is to perform the simplest technique that allows wound closure and optimized aesthetics without compromising function. Ideally, surgery should be performed as soon as possible
after identification of grafting need to minimize scarring, but
certainly within a week. Early excision decreases infection
risk and facilitates wound excision, as the sub-eschar edema
often separates the eschar from underlying tendons. The burn
eschar is removed by tangentially excising (serial shaving)
nonviable tissue using guarded blade (Goulian knife).
Tourniquets can be employed to decrease blood loss and
improve visualization of vital hand structures during excision.
The wound is reexamined after tourniquet deflation, and
hemostasis is obtained.
Chapter 8. Treatment ofHand Burns
205
Skin grafts are generally either full-thickness or splitthickness. The size of full-thickness skin grafts is limited by
the ability to close the donor site skin with sutures. Splitthickness skin grafts are thus used for larger grafts, such as
grafts encompassing the entire dorsum of the hand and fingers. Because split-thickness skin grafts only contain a portion of the dermis, they may result in greater graft contraction,
increased scarring, and less sensation than full thickness
grafts. As such, the cosmetic outcomes can be compromised.
Full-thickness skin grafts are reserved for smaller vital areas,
such as the palm. In children, full-thickness grafting of the
palm, using a full-thickness donor skin obtained from the
child’s inguinal crease, provides a durable graft that covers
the entire surface of the palm [7]. However, full-thickness
palm grafts will have darker pigmentation than the native
palm skin, which has a paucity of melanocytes. Grafts can be
inserted as sheets of skin (non-meshed) or meshed, in which
holes are placed to extend the skin coverage. Meshed grafts
are used in larger burns where donor sites are limited.
Although meshed skin can cover more surface area, they heal
by scarring of the interstices, resulting in a permanent meshed
pattern that can increase contracture formation, compromising function, and aesthetics. Sheet split- or full-thickness skin
grafts maximize cosmetic and functional outcomes, but the
burn excision should include the dermal elements to prevent
inclusion cyst development. Use of sheet grafts is contingent
upon skin availability and adequacy of the wound bed. It may
be impractical to use sheet grafts for major life-threatening
burns. Allograft or skin substitutes may be used as temporary
coverage when adequate donor site for hand grafts is not
available.
Donor site location in split-thickness skin grafting is an
important consideration for adults and children. In children,
the back has decreased long-term donor site scarring and no
difference in infection rate, pigmentation, or blistering compared to the thigh [22]. The back is our donor site of choice
for split-thickness skin grafts in children. Sheet skin grafting,
which maximizes both function and cosmesis, is advisable.
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T. L. Palmieri
The six-inch dermatome can be used to obtain a graft of sufficient dimensions to completely cover the dorsum of the
hand for most adults and all children without having seams.
This dermatome is particularly suited to the wide flat surface
of the back or transversely on the thigh. However, this dermatome requires additional expertise and should only be
used by trained personnel.
Fourth degree burns (involving tendon, joint, muscle,
bone), often from electrical injury or trauma, may compromise hand viability and function, and should be immediately
referred to a burn center. Wounds are debrided and either
autologous or cadaveric skin grafts or skin substitutes are
used to determine tissue viability. In the event of joint instability, Kirschner wires can be inserted axially to immobilize
the joint in a position of function until autografting is complete. Joint fixation may compromise movement: approximately 25% of patients treated with wire fixation have
significant restriction in activities of daily living [23]. Free
flaps may be required in the case of extensive fourth degree
injury involving multiple fingers. Amputation is reserved for
nonviable and non-salvageable situations.
Maintain Motion
Maintaining range of motion in the burned hand is imperative
to prevent future contractures. Patients with partial- thickness
burns should be instructed on exercises promoting extremity
range of motion. This will both maintain motion and decrease
edema. Splints may be needed to maintain the hand in a
functional position in severe burns and postoperatively. Hand
splints generally use 20 degrees of wrist extension, 70–90
degree metacarpophalangeal joint flexion, and extension of
the interphalangeal joint. Passive range of motion should be
initiated postoperatively as soon as grafts are stable.
Involvement of an occupational therapist is essential to
ensure compliance with strength, range of motion, and
function of the hand. Although pressure garments can
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