DEFINITION

Thermal injuries of the upper extremity include contact, scald, flame, chemical and electrical burns, and present with both acute and chronic injury that may require surgical intervention.

Despite aggressive acute care, splinting, and therapy, long-term hand and wrist deformities due to burn injuries are common.

Following burn injuries, scar contractures are common due to the loss of normal skin pliability, which often require surgical release.

 

 

ANATOMY

 

 

Burns yield both a local and systemic response. Locally, there are three zones of injury.

 

The zone of coagulation describes the point of maximum damage with irreversible tissue loss.

 

The zone of stasis represents the area of diminished tissue perfusion and is most critical, as it represents the zone of reversible injury with adequate resuscitation and wound care.

 

The zone of hyperemia is most peripheral and typically represents tissue that will recover in the absence of overwhelming infection or hypoperfusion (FIG 1).

 

PATHOGENESIS

 

Systemically, burn injuries result in the release of inflammatory mediators that can cause widespread physiologic changes for those injuries that are more than 30% of the total body surface area. For example, cardiovascular collapse can occur from increased capillary permeability and diminished myocardial contractility.

 

Inhalational injury can result in bronchospasm and acute respiratory distress syndrome. A catabolic state results from an increase in metabolism greater than three times the basal rate. Finally, patients may be relatively immunocompromised from downregulation of the immune response.

 

 

 

FIG 1 • Burn zones of injury.

 

 

Electrical shock produces a complex pattern of injury in which the severity of injury depends on the intensity of the current and duration of contact.

 

 

Electric current travels through the body, creating “entry” and “exit” points, damaging any tissue in between these two points.

 

As the electrical current travels, heat is generated along its path, leading to thermal damage. The amount of heat generated (and tissue damage) is proportional to the voltage of the current as well as the resistance of the tissue.

 

 

Alternating currents can interfere with the cardiac cycle, increasing the risk of arrhythmias. Electrical burns are classified as high voltage (≥1000 V) and low voltage (<1000 V).

 

Electrical injuries often extend far beyond the visible cutaneous burn and involve deeper structures.

 

Tissues with high electrical resistance, such as the skin and bone, generate more heat, causing more damage to both themselves and the surrounding tissues. Therefore, patients with high-voltage electrical burns often sustain extensive deep tissue and muscle injuries that predispose to developing acute compartment syndrome.

 

Despite splinting, range-of-motion exercises, compression, and positioning, 80% of patients will have decreased joint motion and up to 10% have difficulties with activities of daily living.

 

Increased and disorganized deposition of collagen fibers following burn injuries results in compact, foreshortened scars. The amount and severity of hypertrophic scarring and contracture is directly related to the depth of the burn and the time required for wound healing.

 

NATURAL HISTORY

 

Superficial burn injuries involve only the epidermis.

 

 

Partial-thickness burns involve the entire epidermis and varying levels of the dermis and dermal appendages. Full-thickness burns injure all layers of the epidermis and dermis and can extend to deeper structures.

 

Superficial burns are painful and involve only the epidermis, which is erythematous and blanches with pressure. These burns will heal with minimal or no scarring and can be managed with local wound care.

 

Partial-thickness burn injuries involve the epidermis as well as varying degrees of the dermis. These can be considered as either superficial or deep, depending on the degree of injury to the dermis. Superficial partial-thickness burns are typically sensate, moist, weepy, and painful after sloughing of the epidermis and usually heal within 2 weeks of injury. Deep partial-thickness burns extend into the reticular dermis

 

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and typically heal within 3 to 8 weeks and often require excision and grafting (FIG 2).

 

 

Full-thickness burns involve the entire thickness of the skin and are characterized by charred, painless, leathery skin with visible coagulated vessels.

 

PATIENT HISTORY AND PHYSICAL FINDINGS

Assessment of the Burned Patient

 

In addition to routine medical history, it is imperative to obtain the mechanism of burn injury and assess for other concomitant injuries.

 

High-voltage electrical burns, burns that occurred in an enclosed space, or burns from explosions require trauma and critical care to evaluate and treat other potential lifethreatening injuries.

 

Physical examination should focus on determining the extent of burn injury and vascular status.

 

All upper extremities should be assessed for signs of vascular compromise, such as diminished pulses, poor capillary refill, cool skin temperature, and poor turgor.

 

 

Vascular insufficiency is uncommon with superficial and partial-thickness burns. Patients with crush injuries, full-thickness burns, circumferential injuries, and those in association with lacerations or other trauma may be at risk for vascular insufficiency.

 

Classification of Burn Injuries

 

Superficial burn injuries involve only the epidermis. Partial-thickness burns involve the entire epidermis and varying levels of the dermis and dermal appendages. Full-thickness burns injure all layers of the epidermis and dermis and can extend to deeper structures.

 

 

Superficial burns are painful and involve only the epidermis and are erythematous that blanch with pressure. These burns will heal with minimal or no scarring and can be managed with local wound care.

 

Partial-thickness burn injuries involve the epidermis as well as varying degrees of the dermis. Partial-thickness burns can be considered as either superficial or deep partial thickness, depending on the degree of injury to the dermis.

 

 

Superficial partial-thickness burns are typically sensate, moist, weepy, and painful after sloughing of the epidermis and usually heal within 2 weeks of injury.

 

Deep partial-thickness burns extend into the reticular dermis and typically heal within 3 to 8 weeks, often requiring excision and grafting.

 

Full-thickness burns involve the entire thickness of the skin and are characterized by charred, painless, leathery skin with visible coagulated vessels.

 

 

 

FIG 2 • Upper extremity burn injury demonstrating superficial, partial-thickness, and full-thickness burns.

 

Compartment Syndrome

 

Compartment syndrome may result from burn injuries, especially electrical burn injuries.

 

Acute circumferential or near-circumferential full-thickness burns of the extremity may compromise distal perfusion and require escharotomy, in which the unyielding burned tissue is released or excised.

 

 

The inelastic skin in a circumferential burn acts as a tourniquet, which compromises venous return and

capillary perfusion leading to tissue ischemia distal to the burn.

 

The differential diagnosis for compartment syndrome includes nerve injuries causing paresthesias and arterial or venous insufficiency from other causes (eg, trauma).

 

Compartment pressures can be measured with a commercially available pressure transducer or by creating one using an 18- or 20-gauge needle, a syringe containing saline, a pressure transducer, and a three-way stopcock.

 

Treatment for compartment syndrome of the forearm and hand should be initiated based on clinical suspicion. Prompt fasciotomy minimizes functional loss and promotes recovery. Fasciotomy should be performed if compartment pressures are higher than 30 mm Hg for normotensive patients or within 20 mm Hg of the diastolic pressure for hypotensive patients.

 

IMAGING AND OTHER DIAGNOSTIC STUDIES

 

In addition to routine medical history, the mechanism of burn injury and assessment for concomitant injuries is sought. High-voltage electrical burns, burns that occurred in an enclosed space, or burns associated with explosions and inhalation injury require further consultation.

 

Plain radiographs are obtained if hand reconstruction for scar contractures is planned to assess for heterotopic ossification or arthritic changes that may require additional treatment, such as capsulotomy and ligamentous releases.

 

DIFFERENTIAL DIAGNOSIS

Allergic reactions Pressure-induced injury Compartment syndrome

Dermatologic conditions resulting in desquamation or tissue loss (eg, toxic epidermal necrolysis, erythema multiforme)

 

 

NONOPERATIVE MANAGEMENT

 

Acute superficial or partial-thickness burns over noncritically functioning areas that are expected to heal within 2 to 3 weeks may be managed with dressing changes. Typical options for topical wound care are detailed in Table 1.

 

 

Topical antibiotic agents (eg, Bacitracin, Silvadene, Sulfamylon, Mepilex Ag, Acticoat) are applied and changed regularly as the burn heals.

 

Empiric systemic antibiotics are not indicated for burn injuries.

 

Burns should be cleaned with soap and water daily and covered with topical antimicrobial agents.

 

For early, immature scarring within 6 months of injury, conservative measures can dramatically improve scar appearance through collagen remodeling.

 

 

Examples include pressure garments, silicone gel/sheeting, and physical therapy. All have been shown to control hypertrophic scarring with full-time use over several months.

 

 

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Table 1 Topical Agents and Dressings for Burn Treatment

 

 

Description

Application

Pros

Cons

 

 

Acticoat Silver-coated polyethylene net dressing

Change every 3-7 d

Few dressing changes, painless, large antimicrobial spectrum

Cost

 

Adaptic Impregnated mesh

Once daily Painless, nonadherent, good moisture

No antimicrobial effect, may dry out

 

Aquacel Ag Silver rayon

mesh dressing

Change every 1-14 d

Painless, large antimicrobial spectrum

Difficult patient maintenance

 

Bacitracin Topical agent 1-4 times

daily

Painless, inexpensive, uncommon incidence of bacterial resistance

Antibiotic resistance and dermatitis with long-term use

 

Silvadene (silver sulfadiazine)

Topical agent 1-2 times

daily

Painless, cooling effect; fight gram-negative bacteria

Poor deep eschar penetration, daily dressing changes, leukopenia

 

Mepilex Ag Silver-impregnated foam dressing

Every few days

Ease of application and excellent patient tolerance

Requires clean, noncontaminated wound bed; not effective for full-thickness injury

 

Sulfamylon (mafenide acetate)

Topical agent Daily Bacteriostatic action Application may be painful.

 

Xeroform Impregnated mesh

Once daily Nonadherent,

bacteriostatic activity

Dessication

 

SURGICAL MANAGEMENT

Preoperative Planning

 

Extent of the burn injury and vascular status is assessed for signs of vascular compromise, such as diminished pulses, poor capillary refill, cool skin temperature, and poor turgor.

 

Crush injuries, full-thickness burns, circumferential injuries, and those in association with lacerations are at highest risk for vascular insufficiency.

 

 

 

FIG 3 • Lund-Browder diagram to estimate burn wound size.

 

 

The “rule of nines” is useful to estimate the total percentage of body surface area involved (FIG 3).

 

 

Alternatively, the area can be estimated using the patient's palm, which is approximately 1% of the total body surface area.

 

Resuscitation is guided by the total body surface area involved, patient weight, and urine output, with adjustment made for pediatric patients.

 

Because burns may continue to evolve over 48 to 72 hours following injury, serial examinations are required to adequately determine burn depth.

 

 

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Infection, inadequate resuscitation, poor wound care, and malnutrition can result in burns progressing from superficial to deep partial-thickness or full-thickness burn injuries. Close attention to nutrition and resuscitation are imperative.

 

In general, burns that are not anticipated to heal within 3 weeks should undergo operative excision and grafting within the first few days of the burn injury.

 

 

Early tangential excision of the burn is indicated within the first few days of injury and is performed in the operating room under general anesthesia.

 

Scar maturation continues for approximately 1 year.

 

 

True keloid formation is rare; however, hypertrophic burn scars are common and can be managed by the conservative measures listed earlier.

 

Positioning

 

Supine position is used for upper extremity burns, with the arm extended on a hand table and a tourniquet available.

 

 

Donor sites should be accessible; most commonly the ipsilateral upper thigh.

 

Approach

 

Depending on the size and depth of the burn and the clinical status, burn wounds may undergo débridement and coverage with autologous skin (meshed vs. nonmeshed), cadaveric skin substitutes, or xenograft substitutes (eg, Integra).

 

 

 

FIG 4 • A-C. Classic deformities associated with severe hand burn, with flexed PIP joint and extended MCP and DIP joints.

 

 

Even without scar resection, surgical release of burn scars often result in large soft tissue defects due to tissue deficiency.

 

Thick split- or full-thickness skin grafts can be used to resurface the soft tissue defect, but flap coverage may be necessary if contracture release or scar excision leads to exposure of joint structures, tendons, or neurovascular bundles.

 

Burn scar contractures can result in secondary joint contractures and tendon damage requiring release or reconstruction.

 

Burn scar contractures in the hand cause a “claw” deformity with flexed wrist and proximal interphalangeal (PIP) joints, extended distal interphalangeal (DIP) and metacarpophalangeal (MCP) joints, and adducted web spaces (FIG 4A-C). These contractures should be differentiated from other causes of stiffness, such as intrinsic joint disease or Dupuytren disease.

 

Flaps can include local pedicled flaps (eg, radial or ulnar forearm flap), regional pedicled flap (groin flap), or free flap (eg, lateral arm or anterolateral thigh).

 

Scar is excised through an incision around the contracted scar and through the subcutaneous fat and underlying structures. Scar is often adherent to underlying fascia, tendons, and joints.

 

 

Traction is applied to assist in identifying the areolar plane between scar and normal tissue. Scar is lifted in its entirety and tight underlying fibrous bands are broken up with blunt and sharp dissection.

 

After complete excision of scar, affected joints are stretched to evaluate the need for capsulotomy or ligamentous release.

 

 

TECHNIQUE

• Burn Wound Débridement

 

 

Tangential excision of the burn is performed sharply with specialized blades set to the depth of desired excision (eg, Goulian knives). Alternatively, pressurized knives such as a dermatome or using hydro-débridement instruments such as the Versajet.

 

Débridement is completed down through the layers of burn to rid the wound surface of necrotic nonviable debris down to punctate bleeding.

 

Inadequate débridement will lead to graft failure and increase the infection risk.

 

If the burn wound is limited to an extremity, débridement may be performed under tourniquet control. The tourniquet is released to confirm adequate débridement prior to coverage.

 

Hemostasis is achieved using epinephrine-soaked dressings applied topically and using adjuncts such as thrombin spray. Maintain normotensive and normothermic to prevent intraoperative coagulopathy.

 

For clean, adequately débrided burn wounds without exposed vital structures, autologous skin grafting is ideal coverage. Large burn wounds with exposed deep structures or exposed neurovascular bundles are temporarily covered with moist dressing changes and will require local flap, distant flap, or free tissue coverage within 48 to 72 hours.

 

Autologous skin can be harvested using either a dermatome or a Goulian blade at approximately 0.012 to

0.018 inch.

 

Thinner skin grafts are preferred for those patients with extensive burn injuries in whom donor sites may need to be used several times.

 

Full-thickness skins grafts are preferred in areas of high function or high aesthetic value but are difficult to obtain in an extensively injured patient.

 

Nonmeshed grafts are preferred over the hands and joints to prevent scar contracture (TECH FIG 1). Grafts meshed at 1:1.5 to 1:3 provide fluid egress, prevent seroma formation, and provide greater coverage over nonjoint areas, such as the forearm.

 

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TECH FIG 1 • Split-thickness autograft to dorsal hand burn.

 

 

Grafts are fixed in place with either absorbable sutures (4-0 chromic or Monocryl) or staples. Fibrin glue (eg, Artiss) can be used and diminishes graft loss due to shear.

 

For patients with inadequate donor skin, or who are hemodynamically unstable, temporary wound coverage can be achieved with cadaveric skin substitutes or dermal skin substitutes (eg, Integra). Autologous skin grafting can be performed later when donor sites are available and grafting is more favorable.

 

Grafted wounds are dressed using antibiotic ointment and antibiotic-impregnated gauze applied with light compression over grafts to reduce shear injury. The hand is splinted in a functional position. Dressings are left in place for approximately 3 to 5 days.

 

Donor skin sites are dressed with either occlusive dressings or with antibiotic-impregnated gauze. These wounds typically reepithelize within 1 to 2 weeks and can be reharvested for skin grafts as needed.

 

The grafted wounds are inspected in approximately 5 days to assess early graft take, and gentle active and passive range of motion can be initiated. Grafts are then redressed with antibiotic dressings until complete healing (approximately 10 to 14 days).

 

For burn wounds that are not amenable to early autologous skin grafting, temporary skin substitutes are available. Cadaveric skin (homograft), porcine xenograft, or dermal skin substitutes (eg, Integra) can affixed to the wound similar to a split-thickness skin autograft. In a healthy wound bed, cadaveric skin will incorporate and provide temporary coverage for 2 to 3 weeks as the wound continues to heal underneath.

• Escharotomy

   

  Escharotomy can be performed at the bedside using electrocautery with the patient under sedation.

   

  A full-thickness skin incision is made at the length of the full-thickness burn on the radial aspect of the forearm along a line connecting the lateral end of the antecubital flexion crease and radial styloid (TECH FIG 2).

   

  The incision is deepened until viable tissue is encountered. The incision spans the entire burn, from normal skin to normal skin.

   

  If the hand and the forearm are still tight after a radial release, a second escharotomy incision is made along a line just volar to the ulna, spanning the entire burn.

   

  To perform escharotomy of the hand, extend the radial incision onto the hand with the radial incision along the midaxial line of the thenar eminence. The radial sensory nerve will lie along this incision and must be protected.

   

  The ulnar incision can be carried onto the hypothenar eminence as needed.

   

  Circumferential finger burns are treated with a digital escharotomy. A midlateral incision down into subcutaneous fat is made along one side of the finger, from the MCP joint to the fingertip.

   

  Escharotomy wounds are dressed with a moist dressing.

   

   

   

  TECH FIG 2 • Escharotomy release.

• Fasciotomy of the Hand and Forearm with Carpal Tunnel Release

   

  Two dorsal incisions, centered over the index and ring metacarpals, are used to release the interosseous

  muscles and the thumb adductor muscle compartments (TECH FIG 3A).

   

  Incisions are made ulnar and radial to the index and ring extensors. Dissection is continued until the fascia of the dorsal interosseous muscles is reached. The fascia is opened sharply.

   

  Blunt dissection is performed along the ulnar and radial side of the index finger metacarpal to open the first volar interosseous and adductor pollicis muscles.

   

  The second volar interosseous muscle is opened with deep blunt dissection along the radial border of the ring finger metacarpal.

   

  Through the ring finger metacarpal incision, deep blunt dissection along the radial border of the small finger metacarpal releases the third volar interosseous muscle.

   

  Thenar muscles are released through an incision on the radial border of the thumb metacarpal between the volar glabrous and dorsal pliable skin. The dissection is volar to the metacarpal to expose the fascia of the thenar muscles, which is sharply opened (TECH FIG 3B).

   

  The hypothenar muscles are released similarly with an incision on the ulnar aspect of the small finger metacarpal (TECH FIG 3C).

   

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  The carpal tunnel is released through a standard incision in the palm in line with the ring metacarpal. See TECH FIG 3B for the technique.

   

  We perform fasciotomy of all three forearm compartments to avoid lingering doubts regarding inadequate release.

   

  For uncomplicated fasciotomy wounds, once adequate débridement has been achieved, moist dressing changes are performed for 7 to 14 days in preparation for primary closure or skin grafting. Large wounds with exposed deep structures or exposed neurovascular structures are temporarily covered with moist dressing changes and will require local flap, distant flap, or free tissue transfer coverage within 48 to 72 hours.

   

   

   

  TECH FIG 3 • A. Dorsal fasciotomy release. B. Thenar muscle release and carpal tunnel release. C.

  Hypothenar release.

   

   

  Negative-pressure dressings can be used for postfasciotomy defects as an alternative to traditional wound care; edema often subsides and allows for primary wound closure. Open defects are covered with a 0.012-inch split-thickness skin graft.

• Scar Contracture Release with Local Tissue Rearrangement

 

 

Mild linear scar bands can be corrected with scar release and local tissue rearrangement. A basic Z-plasty can be used (TECH FIG 4A) to interrupt and lengthen a scar.

 

The central limb of the Z is planned along the axis of the scar band, and the angle of the Z-plasty can be varied, with a larger angle providing more release. We prefer 45-degree flaps.

 

The theoretical gain in length is proportional to the angle of the Z-plasty (Table 2).

 

One or multiple Z-plasty flaps are used to break up mild to moderate linear contractures (TECH FIG 4B).

 

The Z-plasty flaps are elevated just below the dermis, preserving a small cuff of subcutaneous fat on the underside of the flaps.

 

Foreshortened fibrous bands that require release with scissors or a knife often are present in the underlying soft tissue.

 

Care is taken to protect the neurovascular bundle.

 

 

 

TECH FIG 4 • A. Two-flap Z-plasty. B. Repeating flap, multiple Z-plasty. C. Five-flap jumping man Z-plasty.

 

 

After release of underlying tissue and extension of the joint, the Z-plasty flaps should fall naturally into a transposed position.

 

The flaps are sutured in place with absorbable sutures.

 

Antibiotic ointment is placed on the incision, followed by soft bulky dressings, which remain for 2 days.

 

Patients are allowed progressive gentle range of motion. Stretching and scar massage are encouraged to begin 2 to 3 weeks postoperatively.

 

Abduction or extension splints may be used at night to maintain posture.

 

Variations on the basic Z-plasty can be performed to accommodate specific areas.

 

For example, a five-flap “jumping man” Z-plasty (combination of two Z-plasty flaps with a V-Y advancement flap) works well to release web space contractures.

 

Compared to a basic Z-plasty, the additional flaps maximize gain in length and the V-Y flap introduces unscarred skin into the reconstruction, providing more pliability and elasticity to the reconstructed web space (TECH FIG 4C).

 

 

 

Table 2 Z-Plasty Angles for Burn Scar Contracture Release

 

 

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Z-Plasty Angles (Degrees)	Theoretical Gain in Length
30	25
45	50
60	75

75

100

 

Laser Therapy for Burn Scars

 

In recent years, laser therapy for scar conditions have evolved substantially and can be applied to burn scar injuries to improve scar pliability, symptoms (pain, pruritis), and appearance.

 

Laser therapy stimulates scar remodeling through microscopic thermal injury, which causes an acute inflammatory reaction resulting in metalloproteinase-mediated turnover of extracellular matrix proteins, increased cell proliferation in the dermis and epidermis, recruitment of stem and precursor cells, and sustained production of new dermal matrix proteins including collagen types I and III and elastin.

 

Pulsed dye laser treatment at 585 to 595 nm targets hemoglobin and causes selective damage to cutaneous microvessels.

 

It is useful to improve erythematous scars with telangiectasias or inflammatory scars with pruritis and pain.

 

Fractional lasers use an array of thin, deep columns of thermal injury by laser microbeam exposures.

 

Treatment can be tailored by modifying the depth of penetration (energy delivered), the width of penetration (duration of the laser delivery), and the density of the area treated.

 

Common ablative fractional lasers include carbon dioxide lasers, erbium:YAG, and thulium.

 

Benefits of laser therapy include minimal recovery periods and short, outpatient procedures. However, scars may require multiple treatments to achieve remodeling and complications include pigmentation changes, pain, blistering, bruising, and swelling.

Groin Flap Coverage for Burn Scar Contracture

 

An ipsilateral groin flaps can be harvested based on the superficial circumflex iliac artery.

 

A line between the anterior superior iliac spine (ASIS) and pubic tubercle is drawn, identifying the inguinal ligament. A second parallel line is drawn 2 to 3 cm below the midaxis of the flap and corresponds to the course of the superficial circumflex iliac artery.

 

Using a pattern of the defect, a flap is designed inferior to the ASIS to lie along the previously marked midaxis. If necessary, the flap can be extended lateral to the ASIS for additional length.

 

 

A flap up to 20 × 10 cm can be closed primarily and is sufficient for most hand and wrist defects. The flap is oriented to minimize kinking and twisting of the pedicle after inset.

 

The flap is incised down to the underlying fascia.

 

Inferiorly, the fascia lata and sartorius fascia are identified. The flap is elevated tangentially off the fascia in a lateral to medial fashion until the lateral aspect of the sartorius fascia is encountered.

 

The sartorius fascia is incised at its lateral margin and elevated from the underlying muscle, with care taken to avoid injuring the lateral femoral cutaneous nerve. The dissection concludes at the medial edge of the sartorius.

 

Although the vascular pedicle is not typically identified, it traverses out of the femoral triangle and through the sartorius fascia at the medial edge of the muscle.

 

The proximal portion of the flap is tubularized if possible around the vascular pedicle.

 

The donor defect is closed primarily, including countouring the cutaneous deformity at the lateral aspect; however, a small open area may be left at the base of the flap.

The flap is gently thinned along the margins. The defect is brought into the field, and the flap is inset using nonabsorbable sutures. The forearm is secured to the abdominal skin with several large nonabsorbable sutures.

Soft bulky dressings are used, followed by an elastic bandage wrapped around the hip to further stabilize the reconstruction.

Members of the surgical team must be present at the time of recovery from anesthesia to mitigate the chance of accidental flap avulsion.

The flap is divided, thinned, and inset in 3 to 4 weeks at an additional operation.

 

 

POSTOPERATIVE CARE

 

Aggressive range of motion therapy should be initiated following injury to optimize outcome. Patients are encouraged to use their hands for activities of daily living. An occupational therapists who specialize in burn injuries is very helpful.

Splints are used to maintain the hand in the intrinsic-plus position, with the MCP joints at 70 to 90 degrees of flexion, PIP joints at full extension, and the wrist in 10 degrees of extension to reduce clawing. Clawing yields tension over the PIP joint, resulting in chronic central slip injuries and late boutonnière deformities.

 

COMPLICATIONS

Complications following acute burn treatment include graft loss, burn wound progression, and development of scar contractures that limit function.

Complications of local tissue rearrangement used for contracture release include partial skin flap necrosis, dehiscence, scar recurrence, and neurovascular bundle injury.

 

 

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SUGGESTED READINGS

1. Dente CJ, Feliciano DV, Rozycki GS, et al. A review of upper extremity fasciotomies in a level I trauma center. Am Surg 2004;70:1088-1093.

    

2. Esselman PC, Thombs BD, Magyar-Russell G, et al. Burn rehabilitation: state of the science. Am J Phys Med Rehabil 2006;85:383-413.

    

3. Graham TJ, Stern PJ, True MS. Classification and treatment of post-burn metacarpophalangeal joint extension contractures in children. J Hand Surg Am 1990;15:450-456.

    

4. Hargens AR, Romine JS, Sipe JC, et al. Peripheral nerve-conduction block by high muscle-compartment pressure. J Bone Joint Surg Am 1979;61(2):192-200.

    

5. Larson DL, Abston S, Willis B, et al. Contracture and scar formation in the burn patient. Clin Plast Surg 1974;1:653-666.

    

6. Lee RC, Zhang D, Hannig J. Biophysical injury mechanism in electrical shock trauma. Annu Rev Biomed

Eng 2000;2:477-509.

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