Functional and Aesthetic Reconstruction of Burn Patients

432
Functional and Aes thetic Recons truction of Burned Patients
Figure 32.8
Inadequate proximal interphalangeal joint cover-
age is a common problem, particularly in young children, and can
lead to the “burn boutonnière” deformity if not recognized and
addressed early. This deformity can be very difficult to address
subsequently.
placing and axial Kischner wire across the joint for 2-3
weeks may facilitate healing, with resulting stability. If
the overlying extensor mechanism is frankly destroyed,
with joint being open, sometimes a partially functional
joint can be salvaged by Kischner wire fixation for 2-3
weeks, which may facilitate granulation tissue bridging
the open joint which can subsequently be autografted.
Such joint need to be closely watched in the weeks and
months after recovery for the development of a “burn bou-
tonnière” deformity. Reconstruction of the extensor appar-
atus in this situation is rarely successful. However,
arthrodesis may provide a very functional result.
Close follow-up after initial discharge is essential to
ensure that early rehabilitation and reconstruction are ade-
quate. It is quite common for patients to lose range and
function after their hand therapy is transferred from the
experienced inpatient team to an outpatient therapist
who may not be as familiar with burned hands. Monitoring
this aspect of recovery is essential to facilitate early
intervention.
VI.
NURSING CONSIDERATIONS
During initial evaluation, a decision must be made about
managing the patient as an inpatient or an outpatient
(11). Daily dressing changes with wound inspection and
passive ranging by an experienced examiner constitute
ideal outpatient management. Patients with small super-
ficial hand bums who have adequate home support and
no other significant injuries are good candidates for outpa-
tient management as long as they are able to maintain good
follow-up. The complications associated with poor outpa-
tient management, such as infection, contractures, and
pain, make inpatient management the cost-effective
alternatives for all other patients.
Most dressing changes are done by nurses. Frequency is
debated, but a daily change is generally considered reason-
able. These are complex and important activities. The
essential aspects of dressing changes are (1) pain and
anxiety control, (2) emotional support, (3) would cleans-
ing, (4) wound inspection, (5) passive ranging, (6)
choice and application of topical agent, (7) ensuring
splint fit, and (8) teaching.
Before any hand dressing can be changed, pain and
anxiety must be adequately addressed. This is a compli-
cated issue. The degree of pain and anxiety will vary
widely from patient to patient and will vary from day to
day in the same patient. Having a clear unit protocol
helps a lot, but there is no pharmacologic substitute for
patience and a caring manner (12). Dressings should be
removed gently and only as fast as the patient can tolerate,
after administration of any needed medication.
Even a burn that seems totally mundane to experienced
staff is a major issue for the patient. A calm and caring atti-
tude is better than most pain medications. Genuine support
and patience are essential. Dressing changes should not be
rushed.
Wounds should be gently cleansed of dried topical
agent, loose debris, tattered blister remnants, and fibrinous
exudate. This should be done gently using a wet technique.
There is no place for rough blunt debridement as this will
cause unnecessary pain and may disrupt fragile new epi-
thelium, while being ineffective in removing real eschar.
Clean intact blisters may be left alone as they will
provide excellent pain control while the underlying
dermis resurfaces.
After the dressing has been removed, the wound should
be inspected for depth and signs suggesting infection.
Increased swelling, tenderness, drainage, or malodor
should prompt a consultation with the bum team and poss-
ible treatment for infection. Digital perfusion should be
noted, looking for brisk capillary refill and warm digits.
If the bum appears full thickness, the burn team should
be consulted, as early surgery, particularly if it is inevit-
able, may truncate disability and improve functional
outcome.
After the wound has been cleansed, it is ideal to take the
hand through a range of motion, either by coaching the
patient to perform it actively or by passive ranging. This
will help to reduce edema and will help to ease rehabilita-
tion when healing is complete. Ideally, this is repeated
frequently by co-operative and motivated patients.
After this, a topical agent and a protective dressing
should be applied. There is a wide choice or reasonable
agents. Topical agents are applied to control pain, decrease
vapor loss, prevent desiccation, and slow down bacterial
growth. The agent chosen should be based on the

Management of Acutely Burned Hand
433
experience of the individual practitioner. A protective
dressing is then commonly applied, care being taken to
prevent constriction. If splints are applied, ensuring
proper splint fit is very important. Splints should maintain
a proper position (see earlier) without applying undue
pressure in any area.
Finally, it is essential that the patient and their family be
taught about the bum and its plan of care in a clear and
patient way. This may have to be repeated more than
once. Taking the time to do this will help to optimize
results by enhancing understanding and compliance. It
will improve the patient’s overall experience and can be
a source of genuine satisfaction to the bum care provider.
VII.
REHABILITATION ISSUES
Hand therapy is central to an optimal outcome, no mater
how good the topical care and surgery (13). During resus-
citation and initial stabilization, the hands are elevated to
minimize edema and splinted in a functional position.
The optimal position is debated, but consensus includes
the interphalangeal joints in extension and the metarcarpo-
phalangeal joints at 70°-90° of flexion to maximize
collateral ligament length. The wrist is kept at about 20°
or 30° of extension and the thumb in a neutral position
with the first web space open. Splints must be custom
fitted to ensure a proper fit and are placed within 24-
48 h after injury. Hands with deep palmar bums are
splinted in extension. Even when critically ill, it is advisa-
ble to passively range hands twice daily except during
periods immediately after grafting. Active therapy is prac-
ticed as soon as practical. Continuous passive motion
can be useful in selected patients, but an interested
occupational therapist is more effective, particularly in
children. Progressive active therapy, massage, and com-
pression become increasingly important after the initial
phase of healing is complete. Close follow-up in the
bum clinic is important to ensure that ongoing therapy is
adequate and any needed reconstructive procedures are
done in a timely fashion.
It is quite common, especially in growing young chil-
dren, for function to be compromised within the first one
or two postinjury years, by one or more stereotypical
hand contractures. It is ideal if these are identified and
operated early, to ensure normal development and opti-
mize long-term function. These typical contractures
include dorsal web space contractures [Fig. 32.9(A)],
Figure 32.9
(A) Dorsal web space contracture. (B ) Dorsal extension contracture. (C ) First web space contracture.

434
Functional and Aesthetic Reconstruction of Burned Patients
dorsal extension contractures [Fig. 32.9(B)], first web
space contractures [Fig. 32.9(C)], and digital flexion con-
tractures, particularly of the fifth finger (Fig. 32.7). These
deformities can be easily corrected, especially if addressed
early. These operations should be done to ensure optimal
function.
VIII.
LONG-TERM OUTCOMES
There have been three studies published describing the
long-term outcomes of serious hand bums. All have docu-
mented that acceptable function is achievable in most
patients, but that this requires effective surgery and hand
therapy.
In a 1985, functional results in 478 adults with 786
burned hands were reported (14). Long-term evaluation
showed that early excision and immediate autografting
of deep second-degree, mixed second- and third-degree,
and third-degree full-thickness hand burns resulted in
over 90% acceptable functional results. There were no sig-
nificant differences in results in patients with superficial
second-degree burns treated nonsurgically with early
physical therapy compared with results in patients with
deep second-degree, mixed second- and third-degree,
and third-degree hand burns treated with early excision
and grafting. No patient with fourth-degree burns had
excellent to good results. Permanent damage was related
to the extent of original injury to the extensor tendons
and joint capsules.
In a more recent report, long-term functional results in
659 adults with 1047 burned hands were reported (15).
The patients were both treated and followed up in a
single facility and the injuries were divided into three
injury and three functional categories. Injury category I
(305 hands/47%) was superficial injuries that required
no surgery. Injury category II (309 hands/48%) had
deep dermal or full-thickness injuries that required graft-
ing. Injury category III (32 hands/5%) had injuries that
involved underlying tendon, joint capsule, and usually
bone (fourth-degree injuries). The resulting function was
classified using the rehabilitation frame of reference
concept in which outcome is based on performance
rather than on isolated components of function (16). Func-
tional category A included those hands with normal or
near-normal postinjury function. Functional category B
hands had abnormal function, but were able to perform
activities of daily living, although they might require the
assistance of adaptive devices such as padded eating
utensil handles. Functional category C hands could not
perform activities of daily living even with the assistance
of adaptive devices. The authors reported normal function
in 97% of those with superficial injuries and 81% of those
with deep dermal and full-thickness injuries requiring
surgery. Although only 9% of those with injuries involving
the extensor mechanism, joint capsule, or bone had normal
functional outcomes, 90% were able to independently
perform activities of daily living.
There has been only one report of long-term functional
outcome in a large cohort of children with serious hand
burns. In this study of 495 children with 698 acutely
burned hands managed over a 10-year period, normal
function was found in 85% of hands after third-degree
burn (17). In those children with fourth-degree injuries
involving bone, 70% had the ability to perform activities
of daily living with the hand. Reconstructive hand
surgery was required in 4.4% of second-degree burns,
32% of third-degree burns, and 65% of injuries involving
underlying bone and tendon, this need being presumably
greater than that in the adults.
Hand function is a central component of the quality of
life in those suffering serious burns. These outcome
studies have demonstrated that very acceptable functional
outcomes are possible in those with serious hand burns,
but only if the injuries are managed in a skillful and
timely fashion.
REFERENCES
1.
Rodeberg DA, Easter AJ, Washam MA, Housinger TA,
Greenhalgh DG, Warden GD. Use of a helium-oxygen
mixture in the treatment of postextubation stridor in pedi-
atric patients with bums. J Burn Care Rehabil 1995;
16(5):476-480.
2.
Moon RE. Treatment of diving emergencies. Crit Care Clin
1999; 15(2):429-456.
3.
Braithwaite F. Treatment of dorsal burns of the hand. Br J
Plast Surg 1949; 2:1-31.
4.
Burke JF, Bondoc CC, Quinby WC Jr, Remensnyder JP.
Primary surgical management of the deeply burned hand.
Trauma 1976; 16(8):593-598.
5.
Heimbach D, Engrav L, Grube B, Marvin J. Burn depth: a
review. World J Surg 1992; 16(1): 10-15.
6.
Coffee T, Yurko L, Fratianne RB. Mixing inpatient with
outpatient care: establishing an outpatient clinic on a burn
unit. J Burn Care Rehabil 1992; 13(5):587-589.
7.
Levine BA, Sirinek ICR, Peterson HD, Pruitt BA Jr. Effi-
cacy of tangential excision and immediate auto grafting of
deep second-degree burns of the hand. J Trauma 1979;
19(9):670-673.
8.
Goodwin CW, Maguire MS, McManus WF, Pruitt BA Jr.
Prospective study of burn wound excision of the hands.
J Trauma 1983; 23(6):510-517.
9.
Salisbury RE, Taylor JW, Levine NS. Evaluation of digital
escharotomy in burned hands. Plast Reconstr Surg 1976;
58(4):440-443.

Management of Acutely Burned Hand
435
10.
Hanumadass M, Kagan R, Matsuda T. Early coverage of
deep hand burns with groin flaps. J Trauma 1987;
27(2): 109-114.
11.
Mertens DM, Jenkins ME, Warden GD. Outpatient
burn management. Nurs Clin North Am 1997; 32(2):
343-364.
12.
Sheridan RL, Hinson M, Nackel A, Blaquiere M, Daley W,
Querzoli B. Development of a pediatric burn pain and
anxiety management program. J Burn Care Rehabil 1997;
18(5):455-459; discussion 453-454.
13.
Barillo DJ, Harvey KD, Hobbs CL, Mozingo DW,
Cioffi WG, Pruitt BA Jr. Prospective outcome analysis of
a protocol for the surgical and rehabilitative management
of bums to the hands. Plast Reconstr Surge 1997;
100(6): 1442-1451.
14.
First W, Ackroyd F, Burke J, Bondoc C. Long-term func-
tional results of selective treatment of hand bums. Am J
Surg 1985; 149(4):516-521.
15.
Sheridan RL, Hurley J, Smith MA, Ryan CM, Bondoc CC,
Quinby WC Jr. The acutely burned hand: management and
outcome based on a ten-year experience with 1047 acute
hand burns. J Trauma 1995; 38(3):406-411.
16.
Dutton R. Rehabilitation frame of reference. In: Hopkins HL,
Smith HD, eds. Willard and Spackman’s Occupational
Therapy. Philadelphia: J.B. Lippincott Co, 1993;79—81.
17.
Sheridan RL, Baryza MJ, Pessina MA, O’Neill KM,
Cipullo HM, Donelan MB, et al. Acute hand burns in
children: management and long-tern outcome based on a
10-year experience with 698 injured hands. Ann Surg
1999; 229(4):558-564.

(Trang không có chữ)

33
Recons truction of the Burned Hand
MALACHY E. ASUKU
Ahm adu Bello University Teaching Hospital', Kaduna, Nigeria
ROBERT L. McCAULEY
University of Texas Medical Branch and Shriners Hospital for Children— Galveston Unit, Galveston, Texas, USA
ROCCO C. PIAZZA II
University of Texas Medical Branch School of Medicine, Galveston, Texas, USA
I.
INTRODUCTION
Reconstmction of the burned hand is key to the overall
functional rehabilitation of the burned patient. Whether
the burned hand is an isolated injury or part of a large
total body surface area bum, its loss represents a major
functional impairment. The American Bum Association
recognizes the importance of the burned hand by
designating it a major injury (1). In addition, loss of the
hand constitutes a 57% loss of function for the whole
person (2,3). Thus, successful management of the burned
hand is important.
The incidence of hand bum has been extensively
reported (4,5). Tredget (4) reported more than 1700 bums
during a 10-year period. In patients with a mean total
body surface area (TBSA) bum of 15%, 54% of the
437
I.
Introduction
437
B. Joint Deformities
450
II
Skin Grafts
438
^ Metacarpophalangeal Joint
451
ttt
ni • o
i-'À. i.
o
2. Proximal Interphalangeal Joint
452
III.
Skm Substitutes
438
, T
* ,
Tx .
a
t t
®
¿HQ
Distal Interphalangeal Joint
453
T if? ?
®
a a 1
c - Amputations
454
B. AlloDerm
441
,
^ ,
1. Phalangization
454
IV.
Reconstruction of the Burned Hand
441
2 Pollicization
454
A .
S o ft Tis s u e De fo rm itie s
441
3 \
Dis tra c tio n Le n g th e n in g
455
L
Scars
4 4 2
4.
To e to Th u m b Tra n s fe r
455
2.
Co rre c tio n o f Bu rn Sc a r
5
Os te o p la s tic Th u m b
Co n tra c tu re s
4 4 2
Re c o n s tru c tio n
455
3. Dorsal and Volar Contractures
444
t
,
t 0
^
V.
Electrical Bums
455
4.
Web Space Contractures
T .. .
(Ad d u c tio n Co n tra c tu re s )
4 4 8
£
^ M a n a g e m e n t
45 6
5.
Firs t W e b Space Co n tra c tu re s
'
u tc o m e
/AJJ
A
^
C. Reconstruction
458
(Adduction Contractures
o f the Th u m b )
4 4 9
VL
Co n c lu s io n
45 9
6.
Second to Fourth Web Space
References
460
Contractures
450

438
Functional and Aes thetic Recons truction of Burned Patients
patients sustained burns to the hand and upper extremity.
However, 75% of the burned hands were noted in patients
with <20% TBS A bums. Yet, the importance of the sever-
ity of hand burn with functional outcome was not addres-
sed until Sheridan et al. (5) reviewed 1047 burned hands.
In this classification scheme, patients with category I
injuries required no surgical intervention in the manage-
ment of superficial partial-thickness burns; 97% of these
patients demonstrated complete functional return. Patients
with category II injuries required skin grafts for closure;
81 % of these patients were able to achieve nearly complete
functional recovery. Patients with the most severe injuries
involving tendons, joints, or bone were assigned to cat-
egory III; only 9% of patients were noted to have return
to normal function (Table 33.1). Thus, it is clear that the
initial management of the acute burned hand along with
the depth of injury can impact functional outcome.
II.
SKIN GRAFT S
It is clear that early closure of the burn wound minimizes
edema, decrease pain, and promotes earlier functional
rehabilitation. With respect to the hand, the decreased
amount of fibrosis with earlier range of motion should
decrease the possibility of joint contractures and tendon
adhesions. Early closure of bums to the hand is key to
the long-term outcome of hand function. The use of
meshed grafts vs. sheet grafts for coverage of the burned
hand has received some attention. Although no random-
ized trials exist, it is generally accepted that unexpanded
meshed grafts (1:1.5) may have the same functional
outcome as sheet grafts (Fig. 33.1). Also of concern has
been the use of split-thickness skin grafts (STSG) vs.
full-thickness skin grafts (FTSG) to resurface burned hands.
Several studies have examined the concept that FTSG are
better than STSG. In the acute setting, Schwanholt et al.
(6) also showed improved function and a decreased need
for reconstructive procedures when FTSGs are used
Table 33.1
Burn Injury and Outcome Categories
Injury Category
I
Second-degree burn that healed without surgery
II
Deep burn that required surgery but did not involve
III
Deep burn involving bone and requiring Kirschner
wire fixation
Outcome Category
A
Normal function
B
Abnormal function but able to perform activities of
daily living
C
Hand cannot perform activities of daily living, such
as feeding and toileting
Source: Reprinted with permission from Sheridan et al. (5).
for the treatment of acute deep palmar burns in children.
In reconstruction, Pensler et al. (7) examined the long-
term effects of STSG vs. FTSG in the reconstruction of
postbum palmar contractures in children. These authors
showed that with at least 3-year follow-up, no functional
differences were noted between the two groups. Even in
cases in which at least 75% of the palmar surface required
skin grafting, no functional disparities were noted. It is
clear that the thickness of the STSG can have an impact
on functional outcome. Although Pensler et al. (7) did
not address the issue of graft thickness, Schwanholt et al.
(6) compared 0.012-0.015 in. STSG with FTSG. Under-
standably, grafts of thin to moderate thickness such as
these would produce inferior results compared with
FTSG. But how do thick STSG (0.20 in.) compare with
FTSG? Also, is there a difference in their use in the
acutely burned hand vs. their use in reconstructive pro-
cedures? These issues have yet to be resolved. The
exposure of nerves or tendons in the burned hand constitu-
tes a separate problem. Whether this occurs acutely as in
electrical injuries after debridement or after scar releases
for severe contractures, skin grafts may not be the best
option.
III.
SKIN S UBSTITUTES
Inadequate skin coverage or delay in coverage of the
burned hand can lead to the development of unstable
scars, hypertrophic burn scars, and scar contractures (8).
In severe cases, these patients require complete scar exci-
sion, placing the metacarpophalangeal joints in flexion
and the interphalangeal joints in extension with subsequent
resurfacing of the hand. Such interventions are a prelude to
physical therapy to restore form and function to the
deformed burned hand. Kucan observed that stable and
durable skin cover is the first priority in the reconstruction
of the burned hand (9). The ability of the hand to withstand
the functional demands of everyday life is key. Tradition-
ally, resurfacing of the hand has been guided by the prin-
ciples of the reconstructive ladder. STSGs are considered
before the use of FTSG. When exposure of a nonvascular-
ized bed, nerves, or tendons precludes the use of skin
grafts, local uninjured flaps may not be available in the
burned hand because of adjacent injury. At the same
time, regional and free flaps may be unavailable in patients
surviving large TBS A burns. These limitations have stimu-
lated the search for alternative methods of resurfacing in
the reconstruction of the burned hand. The use of tissue
expansion, to increase donor areas of full-thickness grafts
and to improve the availability of flaps while minimizing
the donor site morbidity, has received some attention
(10). Unfortunately, this technique is not without its own
shortcomings. The procedure is a two-stage process that

Reconstruction of Burned Hand
439
Figure 33.1
(A) Early excision of deep partial-thickness burns of the hand. (B) Result at 6 months after coverage with 1:1.5
unexpanded meshed skin grafts. (C) Excellent flexion noted at 6 months after coverage. (D) Excellent extension noted at 6 months
after coverage. [Reprinted from: McCauley RL, Asuku ME. Upper extremity burn reconstruction. In: Mathes S, ed. Plastic Surgery.
2nd ed. Philadelphia: W.B. Saunders (in press).]
requires several months of expansion and may be compli-
cated by problems of infection, exposure, and rupture (10).
Skin substitutes have long been of interest in acute cov-
erage of burn patients. Presently, many products and tech-
niques are available for temporary coverage of burn
wounds, but only those methods that offer possibility of
permanent wound coverage can be referred to as skin sub-
stitutes (11). The ideal skin substitute must possess the
physicochemical properties of the skin (Fig. 33.2)
(Table 33.2). The use of skin substitutes in upper extremity
burns was initially limited to cases in which the lack of
skin graft donor sites dictates coverage by other means.
Recent clinical reports, however, have suggested that
skin substitutes may heal with less scarring than conven-
tional skin grafts. This is a desirable outcome in upper
extremity burns. Less scarring may translate into less sec-
ondary contractures and fewer indications for reconstruc-
tion. Consequently, the last decade has witnessed
anecdotal reports of successes in the use of skin substitutes
in burn reconstruction (12,13).
A.
Integra®
Integra® was designed by Burke et al. (14). It is a bilamin-
ary acellular matrix consisting of an outer silastic sheet
and an inner layer of highly porous structure composed
of cross-linked coprecipitate of bovine collagen and chon-
droitin 6-sulfate derived from shark cartilage. As a skin
substitute, the recipient fibroblasts infiltrate the matrix
network and synthesize a neo-dermis that is histologically
close to normal human dermis while the artificial dermis
undergoes biodégradation. Adequate revascularization
requires 2-3 weeks, at which time the silastic membrane
is removed and replaced by an ultrathin (usually
<0.001 in.) epidermal overlay. The resulting coverage is
reportedly pliable and nonadherent to deeper structures,

440
Functional and Aes thetic Recons truction of Burned Patients
while the donor site heals satisfactorily within 1 week
(15-18).
In 2001, Dantzer and Braye (12), reported a series
of 31 patients who had placed for reconstruction of
39 different sites. Thirty-one of these sites were postbum
deformities, with 10 in the upper limb and hands.
They emphasized the need to provide a well-vascularized
bed with perfect homeostasis for Integra® to take satisfac-
torily. They noted that the outcome in the reconstmction of
the burned hand was excellent as long as complete con-
tracture release with restoration of full range of motion
was achieved intraoperatively and an intensive physical
therapy program was instituted in the immediate post-
operative period. They were particularly impressed by
the fact that when it was used over tendons on the
Table 33.2
Properties of Ideal Skin Substitutes
Nonantigenic, nonallergenic, nontoxic, nonirritating
Water vapor transmission similar to that of normal skin
Impermeable to exogenous microorganisms
Prevents proliferation of wound surface flora
Sufficiently thin and pliable to conform to irregular wound
surface
Adheres rapidly and permanently to wound surface
Adequate tensile strength to withstand linear and shear stresses
Elastic enough to permit motion of underlying structures
Inner surface structure that permits ingrowth of fibrovascular
tissues
Biodegradable
Minimal storage requirements, indefinite shelf life
Source: Modified from Pruitt BA Jr, Levine NS. Characteristics and uses
of biologic dressings and skin substitutes. Arch Surg 1984; 19:312.
dorsum of the hand, Integra® provided pliable skin with
no adherence to the deeper structures. Other reported
advantages of Integra® included immediate availability,
simplicity, and reliability. In addition, minimal donor
site morbidity is noted with the use of an ultrathin epider-
mal graft. The disadvantages of use of Integra® for recon-
structive surgery include the necessity of two operations,
the risk of infection, early detachment of the silastic
layer, recurrence of contractures, and cost. They con-
cluded that in light of their preliminary results, Integra®
appears to be an alternative to skin grafts and possibly
skin flaps in reconstructive surgery.
In the same year, Chou et al. (13) reported the use of
Integra® for the reconstmction of bum scar deformities
of the upper extremities in 13 severely burned patients.
A 2-year follow-up showed increased range of motion in
the upper extremity joints, good appearance, and pliable
skin using the Vancouver Scar Scale. They advocated
the use of Integra® in severely burned patients with insuf-
ficient donor sites for full thickness grafts and in whom
suitable flaps are not available. Heimbach et al. (15)
noted that Integra® which has been available in the
United States for life-threatening acute bum care since
1995, has found an “off-label” use in reconstructive
surgery. He also noted that Integra® may be as good as
an intermediate to thick split-thickness graft. However,
Heimbach et al. (15) questioned the use of Integra® in
the presence of normal skin. Shakespeare and Shakespeare
(19), in a survey of the use of skin substitutes in bum
centers in the United Kingdom, found only two units
where Integra® was used for the reconstmction of
burned patients with satisfactory outcome (19). The
Figure 33.2
Classification of potential skin substitutes. CEA, cultured epithelial autografts; STSG, split-thickness skin grafts. (Modi-
fied from Cairns BA, deSerres S, Peterson HD, Meyer AA. Skin replacements: the biotechnological quest for optimal wound closure.
Arch Surg 1993; 128:1246-1252. Reprinted with permission.)

Recons truction of Burned Hand
441
survey revealed that the other centers in the United
Kingdom were reluctant to use skin substitutes in recon-
structive procedures, because clinical evidence supporting
such use was still scanty.
B.
AlloDerm®
The potential use of allograft donor skin as a permanent
skin replacement in full thickness bums is limited by its
immunogenic properties. Although allograft skin will rou-
tinely take onto a full-thickness wound, it will ultimately
be rejected. This immune response to allograft skin is
directed primarily against Langhans cells, epidermal
cells, endothelial cells, and dermal fibroblasts. The noncel-
lular component of the dermis consisting mainly of intra-
cellular matrix protein and collagen has been shown to
be nonimmunogenic (20-22). AlloDerm® is the product
of a complex biotechnological process that succeeded in
removing the immunogenic cells from the nonimmuno-
genic dermis of allograft skin, making it possible for it
to be used as a permanent skin replacement (22).
AlloDerm® is an acellular allogenic dermal matrix pro-
cessed from human allograft skin with preservation of the
type IV and type V collagen. The final product is devoid
of type I and type II major histocompatibility antigens. It
is intended to provide a permanent nonimmunogenic tem-
plate to augment the dermal component of a meshed or
sheet split-thickness skin graft when used on a full-thickness
wound (21-23). This concept addresses the fact that the
degree of scarring and contraction that follow autografting
of bum wound with STSGs grafts correlates inversely
with the amount of dermis delivered in the graft. Unfortu-
nately, dermal cropping is preferably kept to a minimum
to permit repeated harvesting in patients with limited
donor sites as a result of massive bums. In addition, harvest-
ing of thicker grafts may result in increased morbidity at the
donor site. Unlike Integra®, AlloDerm® allows the success-
ful use of ultrathin autografts that can be applied simul-
taneously while maximizing the amount of dermis
delivered to the burn wound (20,21). Lattari et al. (21), in
1979, reported satisfactory results with the use of Allo-
Derm® in acute hand bums. They observed that it permitted
early restoration of normal hand function and exhibited
excellent elasticity, good pigmentation, and excellent satis-
faction with the patients. They concluded, thus, “the high
frequency and reproducibility of excellent results with this
composite graft, coupled with the reduced trauma and
rapid healing of donor sites associated with the ultrathin
autografts, has made composite grafting with the use of
AlloDerm® their new method of choice for the treatment
of full-thickness bums of the hand and feet.” A number of
authors who advocate the use of AlloDerm® in acute bum
care have agreed that its full potential have not yet been rea-
lized (21-24). It appears that AlloDerm® may be a viable
alternative in the reconstruction of the burned hand. Its
ability to immediately support autografts makes it an attrac-
tive alternative to Integra®.
IV.
RECONSTRUCTION OF THE
BURNED HAND
Reconstmction of the burned hand is a challenging
problem. Optimal results depend on many factors, including
the extent and depth of soft tissue damage, the immediate
postburn care, operative intervention, and subsequent phys-
ical therapy. Unfortunately, reconstmctive surgeons may
have control of only one-third of these factors (25).
Whitson and Allen (8) summarized the factors that contrib-
ute to deformities of the hand as persistent edema, wound
infection, poor positioning, prolonged immobilization, and
delayed or inadequate skin coverage. Although successful
acute management of the burned hand has reduced the
need for subsequent reconstruction, bum scar contractures
associated with compromised hand functions still occur
(26-30). The majority of these cases may be related to
the severity of the initial injury. However, some cases
may have been prevented by appropriate acute care.
Peacock et al. (31) noted that the need for secondary
reconstmctive procedures is decreased by proper attention
to positioning and ranging of joints during the acute phase
of wound care. The success rates of such procedures
increase in direct proportion to the degree of motion pre-
served before reconstruction. Reconstmctive goals are
easily attained if all the members of the bum team pursue
them from the outset. Parry (25) noted that in the delayed
evaluation of burned patients, reconstmctive goals center
on the restoration of function and form. Although many sur-
geons recognize the difficulties associated with the correc-
tion of bum hand deformities, Donelan (32) observed that
postbum hand deformities could be confusing to analyze
because acute injuries and their methods of treatment vary
so widely. In addition, multiple problems can exist in
each postbum hand. However, Donelan was able to divide
the deformities into three general categories. He commen-
ted that all of these might be present in a single hand: soft
tissue deformities, joint deformities, and amputations.
A.
Soft T is sue Deformitie s
The soft tissue deformities that commonly occur in the
burned hand include unstable scars, hypertrophic scars,
and contractures. Brown (33) observed that the difference
in the quality between palmar and dorsal skin surfaces of
the hand explain the more frequent crippling effects of
bums on the dorsal surface as opposed to a palmar
surface of the hand. The palmar surface is more protected
by the thicker nature of the superficial layer of its

442
Functional and Aes thetic Reconstruction of Burned Patients
epidermis and by the instinctive mechanism of self-protec-
tion in which the hands are placed over the face at the time
of burning thereby exposing the thin dorsal surface with its
sparse subcutaneous tissue. Consequently, most of the
interests in burns of the hand and most of the deformities
have been noted to occur with dorsal injuries.
1.
Scars
Spontaneous healing after deep second-degree bums in
which the dermis has been partially destroyed, can result
in unstable coverage that is susceptible to recurrent ulcera-
tions and hypertrophic scars. Resurfacing of the burned
hand with widely expanded mesh may produce unstable
scars. This may ultimately inhibit function. Donelan obser-
ved that meshed skin grafts result in permanently abnormal
skin texture that does not improve significantly with time.
Some authors, however, believe that the use of 1:1.5 unex-
panded meshed grafts give satisfactory long-term coverage
(34,35). It is known that with expansion of meshed grafts
1:4 and greater, healing in the interstices of the mesh is
essentially by secondary intention. This increases the like-
lihood of both unstable scar function and hypertrophic scar
development. Such grafts may fail to provide either the
necessary pliability to accommodate the increased range
of motion in the multiple joints of the hand or the durability
to withstand the stress and strain imposed on the hand by
the activities of daily living (ADL).
The healing of superficial partial thickness burns to the
hand is usually completed within 2-3 weeks after injury
and occurs by re-epithelialization. On the other hand, in
deep partial thickness or full thickness burns, healing
occurs by secondarily intention. Under such conditions,
there is a significant development of granulation tissue,
which is a precursor to the development of hypertrophic
scars. Magliani et al. (36), in 1979, reported more scar
complications in hand burn patients undergoing surgery
after 21 days compared with those treated at an earlier
stage. Deitch et al. (37), in 1983, noted that a major
problem in patients surviving thermal injuries is the devel-
opment of hypertrophic burn scars. They felt that the most
important indicator of hypertrophic scar formation is the
time required for the burn to heal. In a series of 100
patients, they observed hypertrophic scar formation in
33% of the patients when the wound healed between 14
and 21 days. Yet, 78% of burn sites that healed after 21
days developed hypertrophic scars. Similarly, Cole et al.
(38), in 1992, reported a 79% incidence of hypertrophic
scars in patients with deep partial-thickness hand burns
who were managed conservatively. All their patients
responded to pressure therapy; however, no scarring per-
sisted beyond a mean of 19 months in their series. Hyper-
trophic scar formation over the dorsum of the hand still
occurs despite continuing emphasis on splinting, early
excision and grafting, pressure therapy, and physical
therapy.
Parks et al. (39) and Larson et al. (40) popularized the
use of pressure garments in the control and prevention of
hypertrophic scars. The measures consisted of continuous
controlled pressure of the magnitude of 25 mmHg above
the capillary pressure, which could be provided by elastic
wraps and pressure gloves. These must be worn continu-
ously for several months to be effective in controlling
hypertrophic scars. Frequent careful evaluation is necess-
ary to ensure the effectiveness of the program. The
patient and family members must be adequately educated
about the importance of consistent home care and compli-
ance. Hypertrophic scars are believed to be most respon-
sive to treatment during the first 3 -6 months. However,
the role of pressure in controlling hypertrophic burn scars
came under scrutiny when the use of silicone gel for the
same purpose started appearing in the literature (41).
Perkins et al. (41) described a patient who rapidly recov-
ered complete active flexion at the metacarpophalangeal
joints after application of silicone gel to his dorsal hand
scars. They went on to make a number of interesting obser-
vations. The mode of action of the silicone gel is unknown.
It does not reply on pressure. Over joints, where tight
painful scars restrict movement, silicone gel sheets will
allow early pain-free movements. When applied over
healed skin grafts, silicone gel prevents contraction of
the graft. In addition, when applied to advanced hypertro-
phied scar tissue, the area will soften, thus allowing it to be
more easily controlled by pressure therapy. Silicone sheets
used alone or in conjunction with accepted pressure and
pressure insert techniques allow treatment to be tailored
to a patient’s needs. Such an option allows a more flexible
approach in burn scar management. They concluded that
the full potential of silicone gel is probably yet to be rea-
lized as newer products are continuously being developed.
2.
Correction of Burn Scar Contractures
Achauer et al. (42) noted that surgery on immature hyper-
trophied scar requires careful consideration because of the
possibility of recurrence. It is believed that in many cases
the deformity is not usually completely corrected. This
group advocated a conservative approach to all such
active scars. On the other hand, the mature contracted
hypertrophic scar will not respond to conservative
measures. Thus, surgical intervention to improve function
and appearance becomes necessary. Incisional release and
resurfacing with skin grafts may be all that is required
(32). Elimination of tension after incisional release can
favorably influence the maturity of the residual scar.
This decreases the morbidity and complexity of surgery
as well as minimizes the requirements for skin graft
donor site. Although focal hypertrophic and linear scars

Recons truction of Burned Hand
443
can be incised or revised, massive diffuse hypertrophic
scars of the hand require complete excision with preser-
vation of as much subcutaneous tissue as possible to be
able to provide resurfacing with STSG or FTSG. Elastic
compression gloves and splints are usually worn in the
postoperative period to prevent recurrence of scar hyper-
trophy (39,40).
Burn scar contractures are perhaps the most frequent
and most frustrating sequela of thermal injuries to the
hand. A major contributing factor to the development of
contractures correlates with a delay in initiation of appro-
priate and adequate hand care in the presence of life-
threatening issues in patients with large TBS A bums.
Unfortunately, stiffness occurs in the burned hand quickly.
A week of neglect in the burned hand can lead to mal-
positioning and distortion that may be difficult to correct
(25). Today, even with large TBSA burns, biologic dres-
sings and skin substitutes may assist in the resurfacing of
large areas so that the hand can still receive the attention
it deserves. In addition, compliance with a postacute
care physical therapy program aimed at minimizing scar
hypertrophy and contractures plays an equally important
role in functional rehabilitation. This is particularly
important in children, who may not be able to cooperate
with such programs. Although the causes of burn scar con-
tractures are numerous, Larson et al. (40) noted that the
burn wound would shorten until it meets an opposing
force of at least equal magnitude. In addition, the position
of comfort is the position of contracture (40). They further
observed that the severity of these effects is directly related
to the depth of the initial injury. It suffices to say that con-
traction within the substance of the scar is a continuing
event. The net effect is the consolidation and shortening
of the scar resulting in a restrictive scar. This paves the
way for the development of contractures. Brown (33)
noted that a healed deep partial-thickness burn wound of
the dorsum of the hand would almost universally result
in the production of hypertrophic scar. Also, secondary
contraction of collagen during the remodeling phase pro-
duces restrictive scarring in the hand, adding to the defor-
mity (33). Such deformities may be treated clinically by
graded traction, serial splinting, and programmed exer-
cises. The timing of these measures is equally important,
and any combination may be indicated concurrently or
sequentially. Exercise may be effective, but during rest and
sleep, some method of positioning and splinting should be
used to preserve any function that has been gained (40).
The untreated severely burned hand is susceptible to the
development of contractures. Many patients instinctively
assume a position that is least painful. Described as the
position of comfort, it is diametrically opposed to that of
function (33). The position is one of volar flexion at the
wrist, hyperextension at the metacarpophalangeal joints,
and variable degrees of flexion at the interphalangeal
joints with adduction and extension of the thumb. The
transverse metacarpal arch is usually undisturbed at the
onset. In fact, in most patients, the initial thermal injury
is limited to the skin, with the underlying tendons, joints,
and joint capsules being spared. These structures,
however, tend to be secondarily affected by prolonged
healing. The position of the wrist has been described as
one of the key factors in the development of deformity
in the burned hand (33). The synergistic effects of extrin-
sic extensors, resulting in metacarpophalangeal joint
extension with wrist flexion, allow laxity of the collateral
ligaments in the early stage, and within a short while, these
become shortened and contracted, producing the extension
deformity that cannot be overcome by the flexor muscles.
The transverse intermetacarpal ligaments become shor-
tened and thickened, resulting in loss of the arch. Simi-
larly, the proximal interphalangeal joints assume a
position of moderate flexion immediately after burning,
and if uninhibited, this progresses to extreme flexion
(33). Prevention of the development of this deformity
requires splinting of the hand in an anticlaw or “safe” pos-
ition in the immediate postinjury period. It is, therefore,
important that a therapist familiar with burned hands
become an active member of the burn team from the
outset. Parry (25) emphasized that to achieve the safe pos-
ition, the interphalangeal joint should be maintained in
extension because these joints have no secondary lateral
support system if surgical releases are required. Further-
more, the volar plate may become fixed in flexion, increas-
ing the risk of rupture of the central slip of the extensor
tendon, resulting in boutonniere deformities. The metacar-
pophalangeal joints should be placed at 40-70° of flexion
to prevent the collateral ligaments from shortening and
contracting, as occurs when the joint is extended. The
thumb should be abducted and rotated toward the palm
to prevent the contraction and fibrosis of its muscles.
Finally, the wrist should be at 35° of extension. In
severe deformities, maintaining the hand in the safe pos-
ition may require percutaneous fixation of multiple joints
with Kirschner wires for a variable time. McCauley (27)
noted that in the correction of severe contractures in chil-
dren, pinning of the metacarpophalangeal joints for 4 -6
weeks resulted in satisfactory outcomes. In adults,
however, the fear of joint stiffness calls for caution in
deciding the optimal period of immobilization required
for the hand.
Burn scar contractures of the hand present a wide spec-
trum of anatomic distortions and functional disabilities.
This makes the development of a universal system of
classification difficult and elusive. Such a declassification
is necessary since it allows comparison of different treat-
ment modalities and subsequent long-term outcomes
from the various centers involved in the complex recon-
struction of burned hand. However, burn scar contractures

444
Functional and Aes thetic Recons truction of Burned Patients
of the hand can be divided into the clinical entities com-
monly encountered. These are the web space contractures,
dorsal contractures, and volar contractures.
3.
Dorsal and Volar Contractures
Dorsal contractures of the hand are the most common of all
the complications of the burned hand. It is the result of
damage to the thin dorsal skin and scant subcutaneous
tissue, which offers little protection to the deeper
structures. Consequently, these injuries are often deep,
resulting in a spectrum of deformities (Figs. 33.3 and
33.4). On the other hand, volar contractures are less
common. The relatively thick layer of epidermis, in
addition to the reflexive closure of the hand at the time
of injury, provides adequate protection for the deeper
structures. Deep volar hand injuries, however, can occur
after direct contact with flame or a hot object of prolonged
duration (Figs. 33.5 and 33.6). Children with poor reflexes
and unconscious adults can be susceptible to such injuries.
Figure 33. 3
(A) Lateral view of neglected bum scar contracture in a 2-year-old. (B) Dorsal view of the same hand. (C) After excisional
release, metacarpophalangeal joint immobilization with k-wires and resurfacing with split-thickness sheet graft. (D) Flexion demon-
strated at 4 months. (E) Extension demonstrated at 4 months. [Reprinted with permission from McCauley (27).]

Recons truction of Burned Hand
445
Figure 33. 4
(A) Severe dorsal contracture of the right hand (grade IV) in a 13-year-old boy who was burned at 6 months of age.
(B) Lateral view showing complete fusion of the entire dorsal of the hand and wrist to the distal portion of the forearm. (C) Release
of the wrist contracture and resurfacing with a groin flap. (D) Postoperative appearance after division of the groin flap. (E) Excision
of dorsal hand scars with pinning of the metacarpophalangeal joint with k-wires. (F) Elevation of reverse radial artery forearm flap.
(G) Fingers are syndactalyzed and the dorsum of the hand resurfaced with the reverse radial artery forearm flap. (H) Appearance of
the hand after release of the fingers. (I) Appearance of the hand lateral view of the hand and key pinch noted 6 months after surgery.

446
Functional and Aes thetic Reconstruction of Burned Patients
Figure 33. 5
(A) Lateral view of severe volar contracture. (B) Volar view showing severe contracture and dislocation of the thumb and
index finger. (C) Release of the volar contracture accomplished with split-thickness skin grafts and k-wire fixation of the thumb and index
finger followed by splinting. (D) Pinch function demonstrated at 1year. (E) Grasp function demonstrated at 1year. [Reprinted from McCauley
RL, Asuku ME. Upper extremity bum reconstmction. In: Mathes S, ed. Plastic Surgery. 2nd ed. Philadelphia: W.B. Saunders (in press).]

Recons truction of Burned Hand
447
Figure 33. 6
(A, B) A 13-year-old boy who stained flame burns to the volar surface of the hand with contracture formation for 7 years.
(C) Extension of hand after two operations for release and resurfacing with full-thickness skin grafts. (D) Function after 9 months.
Although the management of such injuries may be con-
troversial, the issue of management both acutely and in the
reconstructive phase of care, is still under scrutiny. Pensler
et al. (7) favor the use of STSG in palmar burns, whereas
Schwanholt et al. (6) are strongly opposed to it, advocating
FTSG instead.
McCauley (27) proposed a classification system which
correlates the severity of burn scar contractures to hand
function (Table 33.3). The grade I and grade II
Table 33. 3 Classification of Bum Scar Contractures
Grade I
Symptomatic tightness but no limitation in range
of motion, normal architecture
Grade II
Mild decrease in range of motion without
significant impact on activities of daily living,
no distortion of normal architecture
Grade III
Functional deficit noted, with early changes
in
normal architecture of hand
Grade IV
Loss of hand function with significant distortion of
normal architecture of the hand
Subset classification for Grade III and Grade IV contracture:
A: Flexion contractures
B: Extension contractures
C: Combination of flexion and extension contractures
Source: Reprinted with permission from McCauley (27).
contractures are likely to respond to conservative
measures, provided the scars are immature, whereas
grade III and grade IV contractures will require surgical
intervention to achieve maximum functional outcome.
Restoration of function to the grade IV burn scar contrac-
tures of the hand is a major undertaking (Fig. 33.4). This
group also noted that anatomic restoration of the trans-
verse and longitudinal arches through adequate excisional
release is key to satisfactory functional outcome (27).
Internal fixation with Kirschner wires to maintain the
metacarpophalangeal joints at 70-90° of flexion and the
interphalangeal joints at 180° of extension is essential.
Resurfacing with thick STSG or FTSG will usually
suffice. However, flap coverage will be required in the
event of the exposure of joints or tendons (Fig. 33.7).
For severe volar contractures, McCauley (27) advocated
excisional release and resurfacing with skin grafts or
flaps. The metacarpophalangeal joints are kept in exten-
sion to maximize the extent of soft tissue release while bol-
sters are used for immobilization. He reported satisfactory
results even in children with the most severe of contrac-
tures, concluding that the functional outcome appeared
to be maximized with the extended period of Kirschner
wire fixation. Donelan (32) observed that timely release
of dorsal soft tissue contractures can greatly improve the
effect of physical therapy and may prevent the develop-
ment of permanent joint contractures.

448
Functional and Aes thetic Reconstruction of Burned Patients
Figure 33. 7 (A) Burn scar contracture of the hand of a 12-year-old. Loss of longitudinal and transverse arches as well as subluxation of
the metacarpophalangeal joints is noted at 7 years after bum. (B) Excisional release and pinning of the metacarpophalangeal joints at 90°.
(C) Elevation of superficial temporoparietal fascial free flap. (D) One week after dorsal resurfacing with superficial temporoparietal
fascial free flap and coverage with a split-thickness skin graft. (E) Outcome at 2 months after coverage. (F-H) Functional outcome
4 months after reconstruction. [Reprinted with permission from McCauley (27).]
4.
Web Space Contractures (Adduction Contractures)
Postbum syndactyly or interdigital web contractures are
common sequelae of thermal injuries involving the
dorsum of the hand and digits (43-45). Groenevelt et al.
(43) described syndactyly one of the most common post-
bum deformities of the hand (43). They previewed 180
burned hands requiring secondary reconstructive surgery.
Two hundred and eighty dorsal interdigital contractures
distributed
unevenly
over
the
four
web
spaces
(Table 33.4). Interdigital web contractures commonly
occur as a result of fusion of adjacent burned digits
during the healing process. Less commonly, burn syndac-
tyly results from dorsal web scars pulled distally by con-
traction of healing tissues, leading to dorsal hooding. In
these instances, the deformity is usually only mild to mod-
erate. True postbum syndactyly with varying degrees of
fusion of the fingers and complete obliteration of the
web space results from dorsal hand bums that extend
Table 33. 4 Distribution of Syndactyly
and Adduction Contractures
Web I
34%
Web II
24%
Web III
24%
Web IV
18%
Source: Reprinted
with
permission
from
Groenevelt et al. (43).

Recons truction of Burned Hand
449
beyond the web space. It is often associated with hyertro-
phied scarring due to healing over a protected period (32).
Krizek et al. (44) observed that despite careful adherence
to the basic principles of management of the severely
burned hand, webbing may still develop. They proposed
that the preservation of web spaces should be incorporated
into the basic principles of management of the burned
hand. Attention should be directed to spacing between
the digits whenever the burned hand is splinted in the
safe position. The flexion imposed on the metacarpopha-
langeal joints places the digits in marked adduction, favor-
ing the development of interdigital webbing. It is,
therefore, essential to incorporate spacers between the
digits and to encourage frequent abduction. In addition,
spreading exercises along with the usual flexion and exten-
sion exercises are emphasized (44). When the burn wound
of the hand requires operative treatment, the wound should
be excised completely and resurfaced with a sheet of graft,
avoiding curved uninterrupted lines between the graft and
the intact skin around the web space. This can be achieved
by placing darts along the line of the skin-graft junction or
by bringing normal unburned skin into the web space com-
misure (44).
5.
F irst Web Space Contractures (Adduction
Contractures o f the Thumb)
Interdigital contractures can be divided functionally into
two groups, first web space contractures and second to
fourth web space contractures. Adduction contractures of
the first web space can have a significant impact on
overall hand function because thumb abduction and oppo-
sition are either impaired or lost. Some of the functional
deficiencies include loss of grasp and loss of key pinch.
Various measures, including skeletal tractions, have been
employed in a bid to preserve this important web space
(44). When a first web space adduction contracture
occurs, it justifies surgical intervention and physical
therapy to maintain anatomy and restore function.
Larson et al. (46) observed that if the web space con-
tracture is not mature, the use of pressure might help
remodel the wound to overcome the problem. However,
for all matured first web space contractures, surgical cor-
rection is required. Krizek et al. (44) noted that surgery
in these instances is designed to accomplish one of three
goals: to break up and add length to a straight line contrac-
ture; to re-form the web space by employing local flaps; or
for the severely scarred web, to add skin from outside the
local area. When the contracture is limited to the leading
edge of the web space with adequate adjacent nonscarred
tissue, some form of local tissue rearrangement with or
without supplemental skin grafts may be all that is
required. Krizek et al. (44) noted that the simplest pro-
cedure to lengthen the straight-line contracture is the
Z-plasty. First described by Homer in 1837 for use in
burned patients, it breaks up the line of the scar and
lengthens the scar. Several authors believe that the 60°
Z-plasty given optimal results (25,44). When the
webbing is over a longer distance, double or multiple
Z-plasties side to side or in tandem may give better
results because lateral tension is less with two small
Z-plasties than with a single large one. The four-flap
Z-plasty described by Limberg has been found to increase
the net gain in length with satisfactory outcome (47,48).
Similarly, the five-flap Z-plasty, which is a combination
of double opposed Z-plasties and a Y-V advancement
flap, has been used in the release of severe first web
space contractures (Fig. 33.8). Other local flaps that have
been successfully used in web space contracture releases
include the Y-V and the V-M advancement flaps and the
dorsally based hourglass flap technique described by Salis-
bury, Bevin, and Parry (49-51). Krizek et al. (44)
observed that the use of local flaps requires meticulous
attention to detail in keeping the flaps as short and thick
as possible to ensure a better blood supply. When there
is a deficiency of tissues, these procedures may have to
Figure 33.8
Methods for correction of first web space con-
tractures. (A) Four-limb Z-plasty. (B) Five-limb Z-plasty.
[Reprinted with permission from Strock et al. (28).]

450
Functional and Aes thetic Recons truction of Burned Patients
be combined with supplemental skin grafts. Donelan (32)
questioned the rationale of using local flaps where skin
grafts have to be used as well. Apparently, it seems to
add little to improved function or aesthetics. When the
web space contracture is due to extensive dorsal scarring
or involvement of both the palmar and dorsal sides of
the web space, there is significant deficiency tissue. The
introduction of tissue from outside the local area may be
necessary to obtain a satisfactory release (32). The import-
ant landmarks at surgery are the metacarpophalangeal
joints, the proximal interphalangeal joints, and the mid-
point between these as the proposed level of the volar
edge of the web space. The contracture is then carefully
released, preserving the normal slope of the web space.
The incisions may extend to normal skin through the
full-thickness of the scar to afford complete release. The
resulting defect is resurfaced with a thick STSG or a
FTSG anchored over bolster dressings with the fingers in
abduction and extension. The bolster dressings are
usually removed on the fifth to seventh postoperative
day for graft inspection. It is advisable to begin aggressive
physiotherapy when the skin graft has stabilized. Mainten-
ance of night splints with the thumb in abduction and
extension and daytime compressive wraps and gloves with
interdigital web space inserts and conformers such as
molded silicone elastomer is continued for several months.
Donelan (32) observed that skin grafts could provide satis-
factory functional and aesthetic results in addition to
allowing simultaneous correction of multiple web spaces
because the blood supply of adjacent fingers is not com-
promised. In severe first web space contractures, an ade-
quate release may be compromised by tightness of the
underlying adductor pollicis and first dorsal interosseous
muscles. A staged release with preservation of muscle
function maybe necessary. Some authors have recommen-
ded that multiple skin releases with or without skin grafts
separated by 6 months or more of intensive physical
therapy in order to obtain the desired result (32). In exten-
sive contractures where there is damage to deeper struc-
tures, flap coverage of the web space may be the initial
procedure.
Spinner (52) described a transpositional flap obtained
from the radial side of the index finger for the release of
soft tissue adduction contracture of the thumb. The flap
donor site is resurfaced with STSGs. They demonstrated
satisfactory results with this procedure and concluded
that the advantages of the procedure are two-fold. First,
local tissue is used, and second, the exposure is excellent
for the performance of any other procedures simul-
taneously. Housinger et al. (53) described the use of a rec-
tangular flap, which they called the goal-post procedure,
for the release of first web space adduction contractures
in pediatric patients. The rectangular flap is based proxi-
mally on the palmar or dorsal surface of the web and is
inserted directly into the contracture band. Lateral flaps
are then raised along the borders of the post incision and
secured to the base of the rectangular flap. A bulky dressing
is applied after closure, and physiotherapy is started as
early as the second week after surgery. They reported
satisfactory results in a series of 31 first web space contrac-
tures. There were no wound complications, and none of the
patients had redevelopment of contracture in the follow-up
period that averaged 20 months.
On occasion, the restoration of the first web space has
required the use of distant flaps. Beasley (54) noted that
the most widely used design is a superiorly based
random flap from the contralateral epigastrium, which is
shaped like a parallelogram folded at the point of
maximum distance between the first and second meta-
carpals to provide palmar and dorsal triangles of tissue.
A variety of other random flaps from the trunk and contral-
ateral arm have also been used. Although rarely indicated,
the possibility of designing and tailoring free flaps to meet
specific circumstances must always be kept in mind.
6.
Second to F ourth Web Space Contractures
Although interdigital contractures of the second to fourth
web spaces may be disfiguring, unless they are extensive,
the impact on function may be relatively minimal
(Fig. 33.9). However, the presence of interdigital
pockets, the inability to wear gloves and difficulties in
maintenance of good hygiene may constitute an indication
for surgical correction of these problems (45). In addition,
many patients will seek surgical correction for aesthetic
reasons. Although the principles of surgical correction
are similar to those for first web space adduction contrac-
tures, the recurrence rate may be higher. Mancoll et al.
(55), in a series of 38 patients who underwent surgical cor-
rection of web space contractures, reported the use of local
flaps in 57%, split-thickness grafts in 24%, full-thickness
grafts in 8%, and a combination of local flaps and skin
grafts in 11% of the patients. In this series, best results
were obtained with the use of local flaps, which had a
recurrence rate of 64% during a follow-up period that
spanned 1-18 years (mean, 7 years). The multiplicity of
approaches and techniques for correction web space con-
tractures is perhaps a reflection of the fact that none is
infallible. Flexibility may, therefore, continue to be the
key in this area of surgical uncertainty.
B.
Jo int De formitie s
The joints of the hand may be affected in deep thermal
injuries either directly by the effect of heat or secondarily
by complications of ischemic changes, infection, or the
persistence of contracted inflexible scars over the joints
(56). The management of the resultant postburn joint

Recons truction of Burned Hand
451
Figure 33. 9 (A) Dorsal view of second to fourth web space contractures; note that the first web space is spared. (B) Hand function
preserved despite web space contracture. [Reprinted from: McCauley RL, Asuku ME. Upper extremity burn reconstruction. In:
Mathes S, ed. Plastic Surgery. 2nd ed. Philadelphia: W.B. Saunders (in press).]
deformities requires a thorough preoperative evaluation,
including active and passive range of motion measure-
ments and triplanar radiography, as a prelude to successful
therapeutic interventions.
1.
Metacarpophalangeal Joint
Thermal injury to the dorsum of the hand can progress to
affect the metacarpophalangeal joints, leading to severe
compromise in hand function (57). Extension and hyper-
extension contractures due to scarring of the dorsal skin,
extensor mechanism, or joint capsule are the most debili-
tating complications occurring at this joint (57).
Graham et al. (57) proposed a classification system for
the evaluation of metacarpophalangeal joint extension
contractures in the burned hand based on the limitation
of passive flexion a the joint with the wrist joint maximally
extended to eliminate the effect of tenodesis (57). The
classification, devised to reflect burn severity and ana-
tomic involvement, is aimed at directing surgical interven-
tion and assessing postoperative results (Fig. 33.10). By
this classification, type I deformity is one in which at
least 30° of flexion is preserved at the metacarpophalan-
geal joint; scarring here is limited to the dorsal skin and
is described as the dermodesis effect. Type II deformity
demonstrates <30° of flexion at the metacarpophalangeal
Figure 33. 10 (A) Type I metacarpophalangeal joint contracture. (B) Type II metacarpophalangeal joint contracture. (C) Type III
metacarpophalangeal joint contracture. [Reprinted with permission from Graham et al. (57).]

452
Functional and Aesthetic Reconstruction of Burned Patients
joint. Here scarring typically involves the skin, dorsal
apparatus, dorsal capsule, and collateral ligaments. In the
type III deformity, passive flexion >30° of hyperextension
at the metacarpophalangeal joint cannot be attained
regardless of wrist position. These hands may reveal
extensive dorsal scarring, atrophy of the intrinsic hand
muscle, and joint incongruity with dorsal subluxation or
dislocation at the metacarpophalangeal joint.
Surgical management of type I deformity may require
only a release of the scarred skin and resurfacing with
thick STSG or FTSG. The joint, itself, appears to be pre-
served. Type II deformity, however, requires not only
release of the skin on the dorsum of the hand but also
release of the deeper tissues with simultaneous capsulo-
tomies. Flap coverage is indicated when the resultant bed
is unsuitable for resurfacing with skin grafts. It is desirable
to achieve metacarpophalangeal joint flexion of 90°, intrao-
peratively, and to maintain this by means of external splints
or K-wire fixation. In the type III deformity, the joint is
severely affected with limited range of motion and narrow-
ing of the joint space on radiographic examination. The role
of joint reconstruction is therefore limited. Arthrodesis of
the joint may offer the best option for improving function.
Ideally, arthrodesis of the metacarpophalangeal joints is
performed at an angle of 10-45° of flexion (Table 33.5).
In severe cases in which multiple joints are involved, the
final therapeutic option may be amputation of the digit.
Graham et al. (57) reported a series consisting of 278 surgi-
cally treated postbum metacarpophalangeal joint extension
contractures. Forty-seven percent were type I deformities.
Within this group, 95% had satisfactory improvement in
range of motion after surgical intervention. Of the 34%
that were type II deformities, 73% had satisfactory
outcome. In type III deformities (19%), only 47% had sat-
isfactory surgical outcome. Their armamentarium of recon-
structive procedures included dorsal scar releases and
coverage with skin grafts, capsulotomies, arthrodesis, and
digital amputations. They concluded that with this classifi-
cation as well as radiographic analysis guiding the choice of
reconstructive procedure, the potential for satisfactory
results could be optimized.
2.
Proximal Interphalangeal Joint
The proximal interphalangeal joint may be the most fre-
quently affected deep structure in the burned hand
(56,58). Most proximal interphalangeal joint contractures
are usually flexion contractures. In dorsal burns, the over-
lying central slip may be destroyed by direct thermal
injury or secondary to edema and constricting scar. This
results in a boutonniere deformity. The flexion deformity
may also arise from scar contracture of the palmar digital
skin. Ulnar nerve palsy arising from heterotopic ossification
at the elbow or from an electrical bum injury may also
produce proximal interphalangeal joint flexion deformities
(45). Stern et al. (59) classified these deformities due to
flexion contracture of the palmar digital skin into three cat-
egories based on location and severity. In this classification,
type I contractures are limited to the skin. In type II contrac-
tures, additional capsular shortening exists, requiring a cap-
sulotomy for complete release. Type III contractures have
accompanying narrowing of the joint space and articular
incongruity, requiring bone shortening or arthrodesis to
improve function. The classification also correlated directly
with the outcome of surgical treatment. The poorest results
are more commonly associated with type III contractures.
Proximal interphalangeal flexion contractures arising
from the destruction of the dorsal skin and extensor
tendon are most formidable deformities seen in these
joints (60). Groenevelt and Schoorl (60) noted that when
deeper structures of the dorsum of the hand are involved
primarily by thermal injury or by subsequent infection,
the most affected area is the proximal interphalangeal
joint. This is because the thin overlying skin and scanty
subcutaneous tissue confer little protection to the struc-
tures of the joint. In addition, metacarpophalangeal joint
hyperextension contractures, can lead to flexion at the
proximal interphalangeal joint as a result of the effect of
tenodesis. Prolonged immobilization of the proximal inter-
phaleangeal joint in flexion during the acute bum period is
potentially detrimental. Acute therapy is usually limited to
maintaining the proximal interphalangeal joint in exten-
sion through external splinting or K-wire fixation. This
minimizes tension on the central slip of the extensor
tendon and the transverse retinacular ligaments (32).
This approach is successful in preserving proximal inter-
phalangeal joint function in mild cases. However, the
more severe cases go on to develop early postburn bouton-
nière deformities, with a fraction progressing to the highly
debilitating chronic postbum boutonnière deformities.
Larson et al. (56), observed that the early postbum bou-
tonnière deformity responds satisfactorily to splinting (56).
They, therefore, advocated splinting for early cases even if
Table 33.5
Recommended Angles for Arthrodesis
MCP
PIP/IP
DIP
Thumb
10-20
10-20
N/A
Index
20-30
25-35
5-15
Middle
25-35
30-40
5-15
Ring
30-40
35-45
5-15
Little
35-45
40-50
5-15
Note: A range is given because the exact angle of fusion will depend on
the individual hand with digit length and expected function. MCP, meta-
carpophalangeal; PIP/IP, proximal interphalangeal/interphalangeal;
DIP, distal interphalangeal.
Source: Reprinted with permission from: Smith MA, Spence RJ. Bums
of the hand and upper limb: a review. Bums 1998; 24:493-505.

Recons tructio n of Burned Hand
453
the joint is exposed with the central part of the dorsal hood
destroyed. They also noted that splinting might allow the
open areas to fill in with scar tissue. Groenevelt and
Schoorl (60) supported Larson et al.’s observation but
made the distinction between early cases and long-standing
boutonnière deformities (60). For the patients with a long-
standing or chronic bountonnière deformity, there is
rupture of the central slip and the transverse ligaments
have given way with volar subluxation of the lateral
bands. Here, surgical correction is required. The potential
for reconstruction is deemed slim, however, because of
the myriad of problems accompanying the deformity.
These include the scarred poor quality skin overlying the
dorsum of the joint, the damaged articular surfaces of the
joint, and the contractures of the capsuloligamentous struc-
tures that preclude a delicate and sophisticated reconstruc-
tion (32,60). Elliot (61) observed that reconstruction of
the proximal interphalangeal joint extensor mechanism in
the context of a postbum boutonnière deformity is difficult
and rarely successful. Consequently, he recommended
arthrodesis. However, reconstructive procedures may be
offered to a select few in whom the dorsal tissues are of
good quality, the articular surfaces are undamaged, and
full passive range of motion is restored through preoperative
physical therapy. Groenevelt and Schoorl (60) observed that
the reconstructive procedure consists of two parts, correc-
tion of the deformity and repair of the extensor mechanism.
Correction of the deformity involves freeing the lateral
bands from their volar attachment and placing them in
their normal positions. A capsulotomy to release the collat-
eral ligaments and occasionally a release of the volar plate
may be required. The extensor mechanism is repaired by
reattachment of the central slip to restore extension of the
middle phalanx and to provide a stabilizing action of the
middle phalanx during finger flexion (62). This can be
achieved through tendon advancement procedures, depend-
ing on the availability and state of the proximal and distal
stumps of the central slip (51,63,64). The lateral bands,
flexor tendons, or free tendon grafts could also be used in
repair of the central slip (63,65-67). Larson et al. (56), in
1970, described the use of free tendon grafts through four
short midlateral incisions in place of the popular dorsal
approach. This approach avoided postoperative wound
breakdown, which can occur with the dorsal approach.
They obtained satisfactory results with the approach and
concluded that some chronic boutonniere deformities can
be corrected satisfactorily by avoidance of dorsal incisions
and use of free tendon grafts. Clearly, there are a number
of methods to address the correction of boutonnière deform-
ities. However, a mobile joint is crucial in the use of splint-
ing, lateral band transposition or the use of tendon grafts to
correct this problem (Fig. 33.11) (Table 33.6). The use of
prosthetic implants for joint replacement in the management
of these injuries is still in a stage of infancy. Groenevelt and
Schoorl have reported the use of resection implant arthro-
plasty with the Swanson prosthesis on two occasions for
postbum bountonnière deformities with ankylosed joints
(43,60). They readily admit, however, that the functional
outcome with use of the joint prostheses was disappointing
in spite of good skin coverage and sufficient extensor
mechanisms.
3.
Distal Interphalangeal Joint
Deep dorsal bums over the distal interphalangeal joint can
lead to rupture or weakening of the extensor tendon at its
insertion into the base of the distal phalanx (43). The resul-
tant defect is a mallet finger. If this is associated with
hyperextension at the proximal interphalangeal joint, a
swan-neck deformity is possible. The articular surfaces
of the distal interphalangeal joints can be completely
destroyed in these deformities with no residual motion
(32,43). Surgical correction by wedge excision arthrodesis
in a functional position is often the only option for func-
tional rehabilitation. Digital amputations might have to
be considered. A stiff, malpositioned, and painful digit,
particularly on the ulnar boarder of the hand, is only a nui-
sance to the overall function and appearance of the hand.
Figure 33.11
(A) Postbum boutonnière deformities of the middle and fifth fingers. (B) Demonstrating joint flexibility, which makes
this deformity suitable for surgical correction. [Reprinted from: McCauley RL, Asuku ME. Upper extremity bum reconstruction. In:
Mathes S, ed. Plastic Surgery. 2nd ed. Philadelphia: W.B. Saunders (in press).]

454
Functional and Aes thetic Reconstruction of Burned Patients
Table 33.6
Methods for
Correction of Boutonniere
Deformities
I.
Splinting
II. Lateral band transposition
III. Tendon grafts
IV. Arthrodesis
C.
Amputations
Digital losses after vascular compromise can result from
severe thermal injuries to the hand. It is crucial that the
vascular status of the digit be assessed early in the acute
phase of injury. Maneuvers aimed at improving the circu-
lation of the digits such as the elimination of edema,
escharotomies, and fasciotomies are important in preser-
ving perfusion to the digits. When the postbum deformed
hand is characterized by digital losses, it constitutes a
major problem to the reconstructive hand surgeon. The
most severe of such injuries result in multiple digital
amputations producing a paddle hand. On occasion, with
the resultant scars, the remaining phalanges may be
hidden and malpositioned. Radiographic examination is
therefore essential in the assessment of the patient and is
a useful tool in decision-making (32).
In reconstruction of the digits, the thumb and index
finger are the most important. Because the thumb accounts
for 40-50% of the total function of the hand, it is usually
the first to be addressed (68). Diminished thumb function
represents a severe handicap to the patient, and this is
made worse if the remaining portion of the hand is com-
promised by heavy scarring, contractures, joint stiffness,
and shortened digits (69,70). Ward et al. (71) noted that
the absence of the thumb in severe burns poses reconstruc-
tive problems not seen in other types of trauma. They
observed that there is usually loss of additional digits as
well as soft tissue injury to the remainder of the hand. It
is believed that the potential for flap loss is markedly
increased when local flaps are elevated acutely in
scarred and skin-grafted areas. In addition, scar contrac-
tures across joints and web spaces are usually present.
Burn scars on the trunk may decrease the amount of
donor sites available for the use of pedicled flaps. When
both hands are involved, the problem is compounded.
The goal of reconstruction is to restore adequate thumb
function. Adequate thumb function requires the presence
of a tactile digit capable of being opposed to at least one
other digit or in the hand. The level of amputation, the
degree of function, and the status of the remainder of the
hand will determine the most suitable reconstructive pro-
cedure. The objective of thumb-index finger reconstruc-
tion is to provide lateral pinch or key pinch. Of concern
are the issues of length, strength, stability, sensibility,
and mobility (72). The methods of reconstructing the
thumb range in complexity from first web space releases
to the technically complex microvascular toe to thumb
transfer (25). The choice of reconstruction of those must
be governed by its ability to maximize functional return.
On occasion, the burned hand may be so extensively
damaged that reconstruction may not be considered. Yet,
such drastic decisions are rarely considered even in the
most devastatingly deformed cases. In such cases, amputa-
tion and fitting of prosthesis may offer overall improve-
ment. This recommendation, however, requires the most
careful consideration for the patient. Factors such as age,
sex, vocation and avocation, hand dominance, and status
of the contralateral hand must be carefully analyzed
(54). When the need for amputation is limited to the
digits, consideration must be given to any amputation for
improvement of overall functional and aesthetic outcome.
1.
Phalangization
Described by Huguier, phalangealization is one of the ear-
liest techniques of thumb reconstruction (72). It is indi-
cated in the severely burned hand with multiple
proximal digit loss resulting in the paddle or mitten
hand. The goal of thumb reconstruction is to achieve
gross pinch between the first ray and the reachable remain-
ing ulnar portion of the hand (72). The procedure consists
of first web space deepening, transfer of the adductor pol-
licis tendon more proximally on the thumb metacarpal
shaft, and excision of the index metacarpal shaft. The pro-
cedure minimizes the risk of flap elevation and extensive
dissections in areas of deep scarring. The result is an
apparent increase in thumb length and an increase in the
width and depth of the web space. It is a one-stage oper-
ation capable of producing excellent functional results as
well as an acceptable aesthetic outcome. This technique,
however, often produces insufficient thumb length made
worse if there is concomitant contracture of the web
space. It has generally been replaced by pollicization pro-
cedures, which in such a severely burned hand may simply
be a second to first metacarpal transfer.
2.
Pollicization
Littler (73) popularized the advancement pollicization
after World War II. It involves the vascularized osteocuta-
neous transfer of the remnant of the index metacarpal ray
onto the thumb metacarpal stump to produce increased
length of the thumb with increased functional capabilities.
It is indicated when severe thumb and index finger are ren-
dered relatively useless and the two are converted into a
single functional thumb. Best results are obtained when
a mobile trapeziometacarpal joint exists, thenar muscula-
ture remains functional, and good sensibility of the digit
to be pollicized remains (68). May et al. (72) also made

Recons truction of Burned Hand
455
several technical observations that are important in achiev-
ing satisfactory outcome. They noted that in the presence
of severe scarring, flap resurfacing of the burned hand
carried out as a preliminary procedure would improve
soft tissue quality at the time of pollicization. They also
noted that proximal identification of the neurovascular
structures at the initial stage of dissection would ensure
that the palmar skin island selected for transfer with the
index metacarpal is accompanied by the appropriate neu-
rovascular structures. They advocated proximal division
of the index metacarpal bone to obtain complete mobiliz-
ation. However, the wrist flexor and extensor tendons as
well as the volar neurovascular pedicle should be pre-
served. Adduction of the thumb ray as well as splitting
the common digital nerve to the second web longitudinally
allows maximal advancement. They suggested the use of
longitudinal Kirschner wire and interosseous wiring to
achieve osteosynthesis. The Kirschner wire is removed
in 6-8 weeks after boney union is confirmed by X-rays.
The newly created web space should be draped with the
available flap and resurfaced with a thick STSG. Progress-
ive first web splinting is used to expand the web for at least
6 weeks, and the splint is then worn as a night splint for up
to 6 months postoperatively. Several authors have reported
satisfactory functional results in terms of range of motion
of the reconstructed thumb and two-pointed discrimi-
nation. Single-hand prehensions through the assessments
of tip and lateral pinch strengths have been shown to
improve with advancement pollicization procedures
(68-72) (Figs. 33.12 and 33.13).
3.
Distraction Lengthening
Matev (74) introduced metacarpal lengthening by use of a
distraction device to increase the length of a shortened
thumb. The prerequisites for this procedure include the
presence of all or most of the metacarpal, a functional tra-
peziometacarpal joint, functional muscles of the thumb and
adequate soft tissue over the thumb and in the web space.
Predistraction soft tissue transfer in the form of a flap
may be indicated if the thumb is involved in a dense
unyielding scar (75). The technique initially involved the
insertion of pins above and below the osteotomy site. A
subperiosteal transverse osteotomy at the middle third of
the first metacarpal is performed. Distraction is started
within a week of the operation. The distraction is done at
the rate of 1-1.5 mm daily for 25-40 days, depending
on the amount of lengthening required. Matev reported
obtaining length increment of up to 38 mm in a 12-year-
old boy without significant decrease in sensibility and
without injury to the remaining open thumb epiphysis
(74). However, he observed that for successful outcome,
at least most of first metacarpal must be present and skin
coverage of the amputation stump should be adequate.
Immobilization begins after cessation of the distraction
and is continued until ossification of the interfragmental
gap is complete and there is solid fusion of the bone.
Stern et al. used this technique in the reconstruction of
bum deformed thumb in a 10-year-old boy. They achieved
25 mm of lengthening during 4 weeks of distraction
(76,77). Satisfactory functional and aesthetic results were
obtained and they concluded that the procedure is simple
and effective and does not risk the loss of an adjacent digit.
4.
Toe to Thumb Transfer
The development of microsurgical techniques permitted
the single-stage transplantation of tissues and added a
new dimension to thumb reconstruction. The great toe to
thumb free tissue transfer was first performed experimen-
tally by Buncke and clinically by Cobbett (70). Toe to
thumb transplantation is indicated for reconstruction of
thumb amputations distal to the proximal third of the first
metacarpal. It allows replacement of the missing metacar-
pophalangeal and interphalangeal joints as well as the nail
and specialized cutaneous structures of the thumb (70).
Preparatory flap transfer to ensure adequate coverage of
vital structures and to provide tissue for a pliable thumb
web may be required. Toe to thumb transfer can provide
excellent aesthetic and functional rehabilitation of the
burned hand when pollicization is not possible. It is
limited by problems of availability. In patients who have
survived large TBS A burns, the feet may be part of the
injury. It is otherwise a safe, reliable, and efficient means
of thumb reconstruction that offers significant advantages
over other techniques. In the words of Buncke, great toes
make great thumbs (70). The subsequent introduction of
the use of second toe for transfer has made the procedure
possible even when the big toes are unsuitable for transfer.
Again, it is emphasized that in patients with large TBSA
bums, multiple digits of the hands as well as the feet
may be involved with severe burn injury. In cases of mul-
tiple digital loss along with toe amputations, this method of
reconstruction is not possible.
5.
Osteoplastic Thumb Reconstruction
This is a multistaged procedure consisting of lengthening
of the thumb remnant with a bone graft placed into a
tubed pedicle flap. Later restoration of sensation with a
neurovascular island transfer wrap completes the recon-
struction. It is often bulky, poorly functional, and aestheti-
cally unacceptable. It has therefore largely been abandoned
and is mentioned only for historical interest (68).
V.
ELECTRICAL BURNS
Burns resulting from the passage of electric current are
among the most devastating of injuries (78,79). Although

456
Functional and Aes thetic Recons truction of Burned Patients
Figure 33. 12
(A) A 10-year-old patient with multiple digital amputations. Note loss of thumb. (B) Seven years after first to second
metacarpal transfer with growth of amputated stumps and metacarpal transfer. (C) Excellent opposition noted. (D) Functional result also
acceptable.
they account for only 3-12% of all bum injuries, electrical
bums are associated with multiple complex operative pro-
cedures and high amputation rates. Whereas most low-
voltage injuries (< 1000 V) occur in the home, high-
voltage injuries (> 1000 V) occur as industrial accidents
and are characterized by high morbidity and mortality
rates (79). The upper extremity is the most frequently
involved region of the body in electrical bum injuries
(32,79-84). Most series have reported upper extremity
involvement in high-voltage electrical injuries to be as
high as 60-80%. This is to be expected because the
hands are usually the entry points in a majority of these
injuries that occur as occupational hazards (81,82).
A.
Initial Management
Immediate treatment is aimed at resuscitation of the
patient and then salvage of the affected limb. The key to
the acute management of electrical injuries to the upper
extremity is to have a high index of suspicion for potential
damage to deeper tissues (32). The initial clinical presen-
tation largely determines the ultimate outcome in the

Recons truction of Burned Hand
457
Figure 33. 13 (A) A 7-year-old patient with multiple digital amputations. (B) Bilateral metacarpal transfers noted with hands closed.
(C) Bilateral metacarpal transfers noted with hands open.
extremity (78,79). The contracted charred extremity with
no distal pulses may require amputation and fitting with
a prosthesis. In less severe injuries, the ultimate goal is
limb salvage to maximize upper extremity function.
Early exploration and debridement is usually carried
out to remove necrotic tissue. Hunt et al. (85) observed
that escharotomy and fasciotomy in the management of
electrical injuries are not only therapeutic but also diag-
nostic. Carpal tunnel release to minimize median nerve
compression is often essential at exploration. Subsequent
debridement within a few days after injury may be
useful in ensuring complete excision of all devitalized
tissues (86). Mann et al. (79) observed that serial debride-
ment has been the historic key to successful management
of these injuries. The precise delineation of viable tissue
may be difficult to determine during the first 24-72 h
(79). They advocate immediate decompression in only a
select few who exhibit progressive peripheral nerve dys-
function, clinical manifestation of compartment syndrome,
or injury sufficient to cause difficulty in resuscitating the
patient. They also suggested that other patients are better
served by a more conservative approach. This means
delaying the initial operation for a few days until the
necrotic tissue can be recognized with subsequent excision
and closure of the wound. It is of paramount importance to
ensure adequate debridement before closure is pursued.
Technetium Tc99M stannous pyrophosphate scintigraphy
has been found to be a useful tool in aiding the diagnosis
of focal areas of skeletal muscle necrosis (78,83,87).
Yet, it is not a substitute for adequate surgery. In the
acute stage, closure with skin grafts to protect vital struc-
tures from desiccation may be indicated. However, repla-
cement with flap coverage may subsequently be required
as a prelude to reconstruction.
B.
Outcome
The outcome of immediate treatment is two-fold. The
limbs that have suffered major vascular damage will pro-
gress and may require late amputations. On the other
hand, other limbs may be deemed salvageable. Yet, in
most series the incidence of amputations remain high.
Achauer et al. (78) documented a 40% amputation rate
in the upper extremity of 22 patients with high-voltage
injuries. Salisbury et al. (88) reported an amputation rate
of 37% in a series of 76 patients. Mann et al. (79),
however, advocated immediate selective compression for
high-voltage electrical injuries (79). Their overall amputa-
tion rate was reported to be only 10%. Although this is
considerably lower than reported rates in most series,
43% of their patients did not require any form of
surgery. This suggests that the injuries were less severe.

458
Functional and Aes thetic Recons truction of Burned Patients
After severe high-voltage electrical injuries, most salvage
limbs suffer variable degrees of deficit that may require
reconstruction to maximize hand function. While waiting
for reconstruction, these limbs must be adequately
managed to prevent progressive disabilities. Neurologic
deficits may require physical therapy to maintain muscle
bulk and supple joints. The loss of protective sensation
is an indication for measures to protect against trauma.
C.
Recons truction
The general principles of staged reconstruction have
remained dependable (78,89). Soft tissue deficits are
addressed ahead of nerve repairs, and then tendon and
muscle transfers when indicated. Adequate soft tissue
cover is a primary concern and often requires the use of
flaps. The types of flaps available for coverage of these
injuries are numerous. However, fasciocutaneous flaps
are primarily used for reconstruction. The use of free
flaps in an extremity that has suffered significant electrical
injury calls for the utmost in caution (78). The vascular
status of the ulnar and radial arteries needs to be assessed
in the event that the hand is surviving on one damaged
vessel. Although muscle flaps have been used, the goal
of the reconstructive effort should match the necessary
soft tissue coverage. Flap coverage allows for later evalu-
ation and deeper reconstruction of vessels, nerves, or
tendons. Once coverage is completed, nerve grafts, if indi-
cated, are performed by use of sural nerve cable grafts. In a
series of six patients who suffered high-voltage electrical
injuries involving the upper extremities, McCauley and
Barret (89) reported the use of sural nerve cable grafts of
9-10 cm mean length in repair of the median and ulnar
nerves in seven extremities (Fig. 33.14). Soft tissue
Figure 33. 14 (A) A 13-year-old patient with extensive loss of musculature and poor volar surface skin graft coverage 1 month after
high-voltage electrical injury. The hand is insensate. (B) Excision of skin graft and coverage with an abdominal flap prior to further recon-
struction. (C) Elevation of flap and identification of proximal and distal stumps of the median and ulnar nerves. (D) Reconstruction of the
median and ulnar nerves with sural nerve cable grafts. (E) Flexion 1 year after reconstruction. (F) Extension 1 year after reconstruction.
(G) Demonstrating hand function 1 year after reconstruction. (H) Analysis of response to temperature changes at 1 year after reconstruc-
tion. [Reprinted with permission from McCauley and Barret (89).]

Recons truction of Burned Hand
459
cover was required in five extremitites as a prelude to
nerve grafting. The outcome was satisfactory as all six
patients developed protective sensation within a few
months. After nerve repairs, tendon injuries are then
addressed. Operations include tendon grafts and tendon
transfers. However, supple joints must be considered pre-
requisites to these procedures. Staged tendon grafts with
silicone spacers may also be used successfully. Tendon
transfers from a relatively spared compartment may, gen-
erally, give better functional outcome (78).
Engrav et al. (90), reported the results of a survey on the
outcome of treatment of upper extremity electrical inju-
ries. This group documented the total return of function
in 6%, partial return of function in 53%, and no functional
return in 28% of the patients (90). They concluded that the
potentials for maximizing hand function depend on the
degree of initial injury and the salvage efforts instituted
in the immediate post injury period. Achauer et al. (78)
observed that reconstruction of the severely damaged
hand might take several months and still leave significant
loss of strength, agility, and sensitivity. They further
noted that rehabilitation for many occupations might be
more rapid with amputation and prosthesis. Similarly,
McCauley and Barret (89) noted that the neurologic seque-
lae of high-voltage electrical injuries remain significant,
with <6% of adult patients returning to their jobs.
Despite this outlook, optimism on the part of the recon-
structive team and the patient can yield satisfactory results
in even the most severe of these injuries (Fig. 33.15).
VI.
CONCLUSION
Reconstruction of the burned hand starts with the acute
stage of injury. The elimination of edema, adequate posi-
tioning, adequate early resurfacing, and prompt physical
therapy are crucial in maintaining hand function (91).
The management of the postburn deformities may
Figure 33. 15
(A) Electrical burn with full-thickness burns to the radial aspect of the thumb and dorsal aspect of the third finger. (B)
Debridement showing full-thickness injury to the radial aspect of the thumb. (C) Exposure of the extensor tendon and proximal interpha-
langeal joint. (D) Coverage with a groin flap, split longitudinally to cover both defects. (E) Flap division and insetting. (F) Final outcome,
demonstrating flexion. (G) Final outcome, demonstrating extension. [Reprinted from: McCauley RL, Asuku ME. Upper extremity burn
reconstruction. In: Mathes S, ed. Plastic Surgery. 2nd ed. Philadelphia: W.B. Saunders (in press).]

460
Functional and Aes thetic Reconstruction of Burned Patients
require a multidisciplinary approach to address encoun-
tered problems. Treatment options must be based on
detailed functional assessment and the formulation of rea-
listic goals appropriate for the patient’s needs (30,92). The
ultimate outcome of treatment is related to function and
appearance. It is clear that motivation and optimism are
essential in the relationship between the reconstructive
team and the patient, a relationship that may span years
or decades.
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Finger Lengthening of the Burned Hand by
Dis traction Os teos ynthes is
34
DAVID WAINWRIGHT, DONALD H. PARKS
University of Texas— Houston Medical S chool, Houston, Texas, USA
I.
Introduction
463
II.
History
464
III.
Etiology
465
IV.
Goals
465
V.
Overview of Technique
465
VI.
Indications / Considerations
466
A.
Level of Amputation
466
B.
Length of Bone
466
C.
Number of Digits Injured
466
D.
Specific Digits
466
E.
Patient Compliance
467
F.
Timing
467
G. Tissue Condition
467
H. Age
467
VII.
Contraindications
467
VIII.
Technique
467
A.
Preparation
467
B.
Apparatus
468
C.
Surgery
468
D. Postoperative Care/Lengthening
469
E.
Removal
470
IX.
Modifications
470
X.
Rehabilitation and Occupational Therapy
470
XI.
Additional Procedures
471
A. Webspace
471
B.
Intrinsic Release/Tendon Lengthening
471
XII.
Complications
471
XIII.
Advantages
471
XIV.
Disadvantages /Limitations
472
XV.
Results
472
XVI.
Alternatives
472
A.
Alternate Lengthening Techniques
B.
Alternate Procedures for
472
Shortened Digits
472
XVII.
Summary
473
References
473
I.
INTRODUCTION
The hand is commonly involved in thermal injuries, with an
incidence of up to 89% of burn patient admissions (1).
Sheridan et al. (2) has reported that when tissue destruction
is severe (Class C injury—fourth-degree bums), significant
functional deficits are observed in > 90% of patients. This is
particularly tme when amputations are necessary. In this
situation, very few, if any, reconstructive options
are available. Although adaptation to distal, limited ampu-
tations is generally satisfactory, more proximal amputa-
tions are poorly tolerated, especially if the injury involves
the thumb or multiple digits. The effect on pinch and
grasp significantly impacts the patient’s ability to perform
basic acitivites of daily living (ADLs) such as dressing,
feeding, and personal hygiene. To address this difficult
problem, finger lengthening can serve as an option to
improve overall hand function.
463

464
Functional and Aes thetic Recons truction of Burned Patients
The development of finger lengthening techniques has pri-
marily focused on the management of congenitally short
fingers (especially thumbs) and, to a lesser degree, trau-
matic amputations. The thumb has enjoyed particular
emphasis secondary to its importance to overall hand func-
tion, and even construction of a simple, stable post can be
very useful.
The approach has been one of either distal augmenta-
tion or interpositional distraction. “Pseudolengthening”
techniques have also been described, which do not actually
produce an increase in length but an increase in “func-
tional length.” These include phalangization or simple
first webspace deepening techniques. These may also
serve as an adjuvant to certain lengthening procedures to
increase their effectiveness.
Distal augmentation techniques involve the addition of
both bone and soft tissue to the end of the amputated
digit and are generally used for very proximal amputations
that require greater length or need the function of a digit
capable of active motion. This can take the form of tech-
niques where the bone graft and soft tissue flaps for cover
are supplied independently (Gilles cocked hat osteoplastic
reconstruction toe wrap-around flap) or composite flaps
containing all of the required components (osteocutaneous
flaps pollicization of an adjacent digit toe to hand transfer)
(3-9). Although technically more demanding, the compo-
site flap techniques have the potential for restoring both
movement and the most complete and precise sensation.
The latter is the most important factor in determining the
ultimate use and function of the reconstructed digit.
The Gilles cocked hat technique uses a proximal, volar-
based flap of the thumb, which is elevated to surround a
free bone graft (generally iliac) that is secured in longitudi-
nal fashion to the bony remnant of the thumb. This is a
relatively simple, dependable, one-stage procedure which
preserves sensation by using local tissue with the digital
nerves intact. There is a limit on the length of bone graft
the flap can cover, and the technique is only applicable
to reconstruction of the thumb, producing a stable post.
Bone graft survival and union can be inconsistent.
Osteoplastic reconstruction involves placement of a
pedicled flap (groin, tubed abdominal) around a free
bone graft with secondary division of the flap once it has
established a blood supply from the hand. Although it
has the potential for producing a stable functional post
for the thumb, it has the disadvantage of a two-staged pro-
cedure and can be overly bulky. Perhaps more importantly,
the flap is insensate, diminishing its usefulness, and has
generally been combined with a second procedure of a
digital neurovascular island flap to provide sensation.
The toe wrap-around technique transfers the skin, nail,
pulp, and a variable amount of phalangeal bone from the
II.
HISTORY
great toe by microvascular technique to the thumb, often
surrounding a free bone graft that provides additional
length. It has the advantages of a thumb with good soft
tissue bulk, sensation, and cosmesis, and avoids the sacri-
fice of an entire toe. The microsurgical technique is more
demanding and the reconstruction serves as a post only.
Composite techniques can serve as an alternative tech-
nique to producing a post or potentially restore a func-
tional digit. A variety of osteocutaneous flaps (rib,
radius, iliac crest, scapula, fibula, first metatarsal) are
available to the reconstructive surgeon, some of which
are applicable to the reconstruction of the thumb. Since
the bone is part of the flap and therefore vascularized,
bone survival and union are more dependable and success-
ful. It produces a post and, like the osteoplastic technique,
has the similar disadvantages of being bulky and insensate.
It requires a microsurgical technique and if this is to be
used, perhaps a functioning digit would be a better choice.
Pollicization can restore active movement and excellent
sensation by transposing an adjacent digit (usually the
index) to the thumb for proximal amputation levels. It is
particularly useful if there is only an index remnant, as
this will salvage use from a digit with suboptimal function.
This technique has the added advantage of widening the
first webspace.
The toe to hand transfer is the “ultimate composite
flap,” having the potential for the most precise reconstruc-
tion of an amputated digit. The great toe has been used for
thumb reconstruction and the second toe has been
described for replacing either the thumb or the other
digits. This method can restore soft tissue bulk, sensation,
active motion, and supplies an intact, mobile joint. It can
also provide the best cosmetic result. The procedure is
technically demanding and the recipient site must be suit-
able to accept this transfer. Sacrifice of the great toe may
affect the performance of some athletic activities, and
some patients dislike the cosmetic result.
While distal augmentation methods attempt to replace the
missing bone and soft tissue with additional tissue, interpo-
sition techniques focus on the addition of hard tissue and rely
on the soft tissue’s ability to stretch and expand. This tech-
nique was first applied to the lengthening of long bones as
described by Codivilla (10) for the lengthening of the
lower limb. Interposition techniques in the hand were first
described by Matev (11) for the lengthening of a traumati-
cally short thumb. This has also been used for other appli-
cations (12,13). An osteotomy was first performed in the
bone to be lengthened and the fragments were immediately
separated to a specific distance to achieve the desired length.
An external fixator was applied which held the fragments in
position and permitted further lengthening while new bone
developed across the gap. Although this was successful in
children, many adults were not capable of forming sufficient
osseous tissue across large gaps (>2.5-3.0cm ) and

Finger Lengthening of the Burned Hand by Distraction Osteosynthes is
465
developed a nonunion. Kessler et al. (12) modified this tech-
nique to include a bone graft for the adult population or when
long distraction gaps were created (13). Manktelow and
Wainwright (14) modified the osteotomy design in an
effort to obtain primary bone healing and avoid the use of
a bone graft. Their step osteotomy was effective; however,
this technique required a longer length of residual bone to
accommodate the step portion of the osteotomy. Periosteal
flaps over the gap section facilitated new bone growth and
eventual healing.
To avoid the problems with nonunion experienced when
the fragments were immediately distracted, the hand sur-
geons looked to the orthopedic literature. Putti (15) was
the first to propose that lengthening be performed using con-
tinuous traction but it is the technical refinements developed
by Ilizarov (16,17) which are the basis of most clinical prac-
tice today. His technique, often called “callotasis,” lengthens
the bone after the healing process has been initiated at the
osteotomy site. The osteotomy involves the cortex only, pre-
serving the overlying periosteum and the inner endosteum.
These undamaged structures are available to participate in
the healing process and the generation of new bone. An
external fixation device is placed which holds the fracture
fragments in their preosteotomy position with no separation
at the osteotomy site. There is a 2-week lag period before
lengthening begins. This allows new oseous tissue to be
formed at the site of injury, forming an early callus. At
approximately 2 weeks, lengthening of the bone is initiated.
This involves gradual widening of the osteotomy gap by a
specific amount each day. Once the desired length is
achieved, the external fixation device remains in place to
provide immobilization and stability. The interfragmentary
gap, now filled with osteoid tissue, is allowed to solidify
by calcification.
Application of the Ilizarov technique for hand recon-
struction has been described for both congenital and trau-
matic deformities (13,18-21). In the bum population, this
technique has primarily been used for thumb reconstruc-
tion to compliment older techniques, although in selected
cases it has been applied to other digits (22-24).
III.
ETIOLOGY
Shortened digits following bum injury are most commonly
a result of a deep fourth-degree injury, necessitating ampu-
tations. In children, other mechanisms can be responsible.
The bum can retard growth by affecting epiphyseal viabi-
lity, causing joint destruction, or the restricting effect of a
tight scar contracture can modify bone growth.
IV.
GOALS
The goal of surgery is not simply to produce a longer
finger. In addition to length, finger function, particularly
as it applies to the thumb, is dependent on optimizing
mobility, sensation, and stability. Therefore, lengthening
the finger cannot compromise these other considerations.
Patients with digital amputations will present with
specific functional deficits that lengthening of the finger
will address. The functions that can be improved by this
technique include:
1.
improved first web space opening for holding
objects
2.
standard pinch
3.
key pinch
4.
increased security and power of holding large
objects.
These particular functions have a corresponding effect
on ADLs and other specific tasks. The thumb and index
finger are primarily involved with pinch and holding
objects in the first webspace while the remaining digits
afford security and power to holding larger objects.
Feeding and hygiene tasks primarily require a “holding”
function while pinch is important for dressing. Although
more complex tasks such as buttoning garments and
tying shoes are not realistic, holding small (pinch) and
large (grasp) objects can be improved.
V.
OVERVIEW OF TECHNIQUE
This technique is a modification of a standard distraction
osteosynthesis technique used for long bone lengthening. If
a sufficient bony remnant exists following digit amputation
as a result of bum injury, this procedure can be considered.
There are two important technical aspects that signifi-
cantly influence the success of this technique. First,
ideally a corticotomy, rather than an osteotomy, is per-
formed. This minimizes dismption of the periosteum and
the endosteal tissue within the marrow cavity. These struc-
tures are therefore available to participate in bone healing
with the generation of callus at the corticotomy site.
Second, distraction is delayed by several weeks to
allow an early callus to form that contains immature
woven bone and more importantly a significant number
of osteoprogenitor cells. Therefore, it is actually this
healing fracture callus which is lengthened, and so the
term “callotasis” (Fig. 34.1). The rate of lengthening is
important. Too rapid lengthening may lead to nonunion
since the bone forming tissues cannot produce sufficient
matrix to fill the gap. In contrast, if distraction is too
slow, calcification may occur with early union across the
distraction gap, preventing further lengthening.
The standard time course is 2 weeks of stabilization fol-
lowing the corticotomy, gradual, continuous lengthening
over 4 -6 weeks, followed by a 2-4-week period of stabil-
ization to allow the new bone to calcify and solidify.

466
Functional and Aes thetic Reconstruction of Burned Patients
Figure 34.1
Callotasis/callus distraction-callus forms within
interfragmentary gap and is lengthened by gradual distraction
across the corticotomy site.
VI.
INDICATIONS/CONSIDERATIONS
The decision to reconstruct, and the choice of method to
accomplish this, is not a simple one. The patient’s needs,
desires, the specifics of the injury and anatomic deficit,
and the available donor tissues (both local and distant)
all have to be considered. This complex decision is par-
ticularly true for the thumb, as evidenced by the numerous
articles attempting to provide objective criteria and algor-
ithms for determining the most suitable procedure for an
individual patient and injury.
A.
Level of Am putation
Not all digital amputation can be managed appropriately
with this lengthening technique. Loss of length distal to
the mid middle phalanx does not generally require recon-
struction since adequate function is usually present at that
level of loss. Finger loss at or proximal to the metacarpo-
phalangeal (MCP) joint is generally too severe to permit
meaningful reconstruction using a distraction lengthening
technique; however, this has been attempted in one case.
The majority of our experience has been with amputations
at the level of mid-proximal phalanx (Fig. 34.2).
Figure 34. 2
Level of amputation-distal amputations do not
require reconstruction while very proximal amputation levels
will not be adequately managed by distraction lengthening alone.
The thumb is the most important digit for hand func-
tion, and preserving its length is critical. Amputations
distal to the mid distal phalanx are generally well toler-
ated. In contrast, when the loss is proximal to the MCP
joint, this technique is unlikely to provide a functionally
important increase in length and distal augmentation
methods should be considered.
Although this technique has recently been applied to
traumatic distal phalangeal amputation stumps, the
author feels this is unlikely to find application in the
burn population (25).
B.
Length of Bone
Sufficient bone must be available to provide room for the
placement of the external fixation pins and the osteotomy
site. The Mini Hoffman device has two longitudinally
oriented pins on either side of the osteotomy. These are
0.5 cm apart and therefore the minimal workable length
of the phalangeal remnant is about 1.5 cm.
C.
Number of Digits Injured
Only in exceptional circumstances would one consider
lengthening a single shortened digit. Generally, if unin-
jured or minimally injured digits are present, the patient
will adapt to this deficit and the lengthened digits will be
ignored, not be used, or possibly get in the way and inter-
fere with function. With isolated finger amputations, alter-
nate approaches should be considered. For example, an
isolated index finger amputation at the proximal phalanx
may best be managed by ray amputation rather than by
lengthening with the uninjured middle finger, assuming
the functions of the index. The exception to this single-
finger exclusion is when the thumb has been amputated
since it contributes substantially to hand function and
can provide great benefit when acting simply as a post.
The author has generally reserved the distraction lengthen-
ing technique for either a shortened thumb or patients with
burn amputations of all four fingers.
A relative indication would be an isolated index finger.
This may be considered if the third finger is not suitable as
a substitute for index function. Since the remaining digits
are often injured, lengthening of an isolated index finger
may be more appropriate as the number of amputations
and severity of associated injury to the other digits
increase.
D.
Specific Digits
Since the thumb is such a functionally important digit,
lengthening should always be considered. Even as a
simple post, the thumb can supply many of the required
functions. Lengthening of shortened index and middle

Finger Lengthening of the Burned Hand by Dis traction Os teos ynthes is
467
fingers can also be helpful since they contribute to standard
and key pinch, by acting as posts in combination with the
thumb. Lengthening of the ulnar digits is less useful
since a “post” will not contribute significantly to grasp,
although the “security” and power of holding large
objects might be improved. On the ulnar side of the
hand, one might consider a secondary wedge osteotomy
of a lengthened phalanx to produce an “arthrodesis” in a
functional position but the author has not attempted this.
E.
Patient Compliance
Patient cooperation is critical for this technique to be suc-
cessful. The patient is expected to maintain and care for
the apparatus during the lengthening period and will be
responsible for the day-to-day lengthening. They also
must be willing and capable of participating in an
intense occupational therapy program following com-
pletion of the lengthening process.
F.
Timing
This is not a procedure to be considered during the acute
phase of bum management. All tissues must be completely
matured and there should be no residual hypertrophic scar-
ring or burn contracture of the involved digits.
G.
Tis s ue Condition
Although uninjured skin of the digital remnant is prefer-
able, it is not essential. Stern (22) advocates excising the
burn scar and resurfacing the digit, ideally with a flap.
The author has not found this to be necessary in all cases
as mature scar tissue is capable of stretching. However,
if the skin cover is atrophic or unstable and/or little to
no soft tissue padding exists over the distal bone, this
should be considered. Adequate sensation is crucial so
that the patient will and can use the reconstmcted digit
effectively. Resurfacing with a skin graft or a conventional
local flap may diminish this and limit the usefulness of the
reconstruction.
The joint proximal to the bone to be lengthened should
be stable with an intact ligamentous structure and an
acceptable range of motion. In addition, there should be
adequately functioning motors, both flexor and extensor,
across this joint.
H.
Age
Special considerations in the child include the size of the
bone structures to be lengthened, and the presence and
location of the epiphyseal growth center. The ability of
the parents to manage the child’s care and comply with
the lengthening program also needs to be evaluated.
In the older patient, compliance issues are again import-
ant, as they may be unable to tolerate the surgery, distrac-
tion, or rehabilitation necessary for the procedure to be
successful. Pre-existing problems (e.g., arthritis, trauma)
are also more likely to be seen in this population.
VII.
CONTRAINDICATIONS
There are a number of clinical situations in which this
technique is either not applicable or not advisable. When
confronted with an amputation of a single digit, excluding
the thumb, lengthening is unlikely to be a benefit and the
process involved may ultimately compromise hand func-
tion further if the amputated digit interferes with overall
hand function. Often a ray amputation may be the best sol-
ution in this clinical situation.
Since one of the primary goals of digital lengthening is
to restore adequate pinch, amputations on the ulnar side of
the hand are less likely to be improved with lengthening
since the grasping function of this side of the hand requires
effective finger flexion and not simply a static, stable post.
Small residual bone fragments cannot be lengthened since
there is insufficient bone for placement of the distracting
apparatus. Also, amputations proximal to MCP joints gen-
erally cannot be lengthened sufficiently to provide an ade-
quate post for pinch. Perhaps most importantly, since the
patient needs to participate in the lengthening process
and protect the external fixation apparatus, compliance is
of paramount importance. If the patient demonstrates an
inability to dependably participate in their care, the tech-
nique of distraction osteosynthesis of the amputated digit
is not an appropriate choice.
VIII.
TECHNIQUE
A.
Preparation
An aggressive preoperative occupational therapy program
is essential to maximize the range of motion of the joint
proximal to the bone to be lengthened. In addition, all
scar therapy should be completed to include compression
therapy and scar release or resurfacing where necessary.
In the thumb, an adduction contracture can exist from
muscle shortening and/or scarring as a result of direct
thermal injury or inability to maintain the thumb in an
abducted position during the acute burn care phase. If a
degree of intrinsic tightness exists preoperatively in a
digit, it may result in a flexion contracture at the MCP
joint proximal to the lengthened bone. Occupational
therapy techniques such as passive stretching and dynamic
splinting can be used to help rectify these problems. If
these measures are unsuccessful, the release of an adductor
or an intrinsic muscle will need to be considered.

468
Functional and Aes thetic Recons truction of Burned Patients
The patient should be thoroughly educated on the pro-
cedure to be undertaken and understand the goals of the
reconstruction, their role in the lengthening process, and
the need for their strict compliance with postreconstruc-
tion therapy.
Anterior-posterior (an X-ray view) and lateral radio-
graphs of the bone to be lengthened are necessary to
confirm that adequate length and bone quality are avail-
able to perform this procedure. A “mock” surgery can be
drawn on the radiograph to confirm this.
B. Apparatus
The apparatus used by the author is the Hoffman® mini-
lengthening and external fixation device (Howmedica,
Switzerland) (Fig. 34.3). This technique employs two fix-
ation pins in both the proximal and the distal bone fragments.
Although transfixing pins are available, generally threaded,
2.0 mm diameter, self-tapping half pins have been used for
distraction lengthening. These are available in a variety of
lengths to provide versatility in clinical application.
The pins allow purchase of the lengthening device onto
the bone fragments. Although three planes of movement
are available with this apparatus, longitudinal lengthening
of digits rarely necessitates this feature. Mobility of one of
the sliding blocks along the central shaft of the apparatus
provides some versatility between pin pairs. A measuring
scale from 0 to 25 mm is engraved on the inner shaft of
the lengthening device to accurately monitor the lengthening
process. Length adjustment of the apparatus is accomplished
by rotating and adjusting a nut on one end of the apparatus.
There is an additional locking nut at this location to prevent
inadvertent movement between adjustment events.
A variety of hand chucks, socket wrenches, and span-
ners are available for stabilization and adjustment of the
apparatus. A drill guide is also available to ensure that
Figure 34. 3
Hoffman® mini-lengthening device (A) Distal
pin site. (B) Point for distraction wrench. (C) Measurements of
distraction length.
the two pins on each bone fragment are a precise distance
apart, so that they can be secured to the pin clamps of the
external distraction device.
C.
Surgery
The surgery is performed under either general or block
anesthesia and under tourniquet control. The outline of
the phalangeal remnant is drawn on the dorsum of the
amputated digit and the proposed transverse corticotomy
is marked in the center of the phalangeal remnant
(Fig. 34.4). A longitudinal line is also drawn perpendicular
to the corticotomy line, in the center of the bony fragment.
This represents the axis of the pin placement. The pro-
posed pin sites are then marked. The pins are located as
far away from the osteotomy site as the length and
quality of the bony remnant will permit. The author has
found that placement of the pins is much easier if per-
formed prior to the corticotomy. This provides a larger
bony fragment to secure while drilling the pin holes and
facilitates the accurate placement of the pins along the
longitudinal axis of the bone.
Two pins are placed on either side of the corticotomy
site in a longitudinal fashion. The first pin to be placed
is that furthest away from the corticotomy site. This
should be placed as far away from the corticotomy site
Figure 34.4
Preoperative planning surface markings.

Finger Lengthening of the Burned Hand by Distraction Os teosynthes is
469
as possible but far enough from the end of the bony frag-
ment so that there will be adequate bone for pin purchase
and there is no risk of entering the joint. A stab incision is
made at the proposed pin location and this is extended
down to the bone. Using a fine periosteal elevator, the peri-
osteum is cleared over a small area of bone that is to be
drilled. Using a drill guide to protect the skin, a bicortical
drill hole is performed using a 1.5 mm drill bit. Care
should be taken that this and all subsequent drill holes
are placed perpendicular to the dorsal surface of the
bone (Fig. 34.5).
Using the special pin insertion hand chuck, a 2.0 mm
threaded half pin is placed in this hole. It should be inserted
to the entire thickness of bone and one can palpate on the
volar surface to feel for the tip as it exits the volar surface
of the bone. Once this pin is in place, the two-hole drill
guide is placed over this pin. The second hole of the drill
guide is placed along the longitudinal axis line and a
second 1.5 mm hole is drilled. A second 2.0 mm pin is
then inserted at this site. Two pins are then placed by the
same technique into the opposite end of the bone fragment.
Once the two fixations pins are placed at either end of the
bone fragment, the corticotomy can be performed (Fig. 34.6).
It should be noted that in Ilizarov’s original description, a
corticotomy was performed which preserved the periosteal
and endosteal structures for bony generation. Although this
is the ideal and should be strived for, it may not be practical.
With the small diameter of the phalanx, completely preser-
ving the endosteal structures may not be possible.
An incision is made along the longitudinal axis on the
dorsum of the bone. This is taken down to and through
the periosteum. A periosteal dissector is then used to sep-
arate the periosteum from the phalanx, around its circum-
ference at the proposed corticotomy site. The corticotomy
is performed using a small 1 or 2 mm sharp osteotome.
This method is more precise and results in less heat and
mechanical injury to the surrounding tissues than with
the use of powered instruments. This is angulated to the
sides, in an attempt to cut the cortical bone only and pre-
serve as much of the internal endosteal tissue as possible.
These details minimize the injury to the adjacent tissues
and hence, optimize healing. Once the corticotomy is com-
pleted, the two ends of the phalangeal fragment should be
separated and the surgeon should be able to rotate them
slightly in relation to one another. The external apparatus
is then applied making sure that the two phalangeal frag-
ments maintain precisely the same orientation that they
did preoperatively (Fig. 34.7). The lengthening appliance
needs to be positioned, so that it is not protruding
unnecessarily and run the risk of damage or hitting it.
The latter can cause malalignment of the fragments and
also lead to pin loosening. The lengthening apparatus
also needs to be positioned, so that it can be accessed
easily for subsequent lengthening.
The small dorsal incision is closed and the pin sites
wrapped with 0.5 in. antibiotic impregnated gauze. Appli-
cation of a protective splint completes the procedure.
D.
Pos toperative Ca re/Le ng the n in g
The apparatus remains stationary and the wounds per-
mitted to heal over the following 2 weeks. At this stage
the repair process has begun at the corticotomy site and
early callus has been formed. The apparatus and pins
Figure 34.5
Correct pin placement confirm ed by X-ray.
Figure 34.6
Bon e exposed for planned corticotom y.

470
Functional and Aes thetic Recons truction of Burned Patients
need to be reinspected to make sure that the longitudinal
axis in both the dorsal-volar and the radial-ulnar directions
has been preserved. If the two fragments are not aligned
correctly, there may be problematic deviation and angula-
tion of the future lengthened bone.
Lengthening is initiated at 2 weeks. This is generally
begun at half a turn of the lengthening apparatus (1/2 mm)
per day and is soon increased to half a turn twice per day
for a total of 1 mm of lengthening per day. This lengthening
process is continued until the desired length is achieved,
which is generally between 2 and 3 cm. In the authors’
experience this usually takes ~ 1 month (Fig. 34.8).
From this point, the lengthening apparatus takes on the
function of an external fixation device. The distracted
bony fragments are maintained in position, as stable as
possible, to permit new solid bone growth within the dis-
traction gap. Insufficient stabilization can lead to malunion
and nonunion. Solidification of the distraction gap gener-
ally takes 2 -4 weeks.
Figure 34.8
Serial X-rays during distraction illustrating
gradual lengthening and new bone formation within gap.
E.
Removal
At 2 -3 weeks, the authors will loosen the external fixator
and test the lengthened phalanx for stability. If the dis-
tracted bone is deemed solid, the external fixator is
removed. This is generally accomplished in the operating
room since local anesthesia is inadequate. If it is not solid,
the external fixator remains in place for another 2 weeks
and the bone is tested again.
Following removal, the finger is protected for another
week or two until there is radiographic evidence of bony
continuity across the distraction gap. The patient will then
be allowed to use the digit in a normal fashion and an
aggressive occupational therapy program will be initiated.
IX.
MODIFICATIONS
If the digit has been lost with only a small middle phalan-
geal remnant, lengthening of the intact proximal phalanx
can be considered. Since the surgeon is now working at
lengthening an entire intact phalanx, the technique is
often easier, since a longer length of bone is available.
However, in this situation, as the lengthening proceeds
there will be inevitable tethering from the long flexor
tendons and this may result in flexion contracture across
the proximal interphalangeal joint (PIPJ). This can be
avoided by stabilizing the PIPJ prior to distraction.
Crossed Kirschner wires can be placed across the PIPJ
maintaining the middle phalangeal remnant in a neutral
position. In this way, some of the distraction forces are
more directly applied to the long flexor tendon. This modi-
fication is also applicable to the thumb when a small prox-
imal phalangeal remnant is present. Lengthening, in this
instance,"is performed on the metacarpal.
When only a small proximal phalangeal remnant remains,
lengthening of the metacarpal is an option. Once lengthened,
the distal metacarpal fragment can be angled volarly, thus
creating an “arthrodesis” at an acceptable angle at the
MCP joint level. Theoretically, a joint could be transplanted
or a joint implant inserted at this site, to provide mobility at
this site, but the author has not attempted this.
X.
REHABILITATION AND
OCCUPATIONAL THERAPY
The rehabilitation of the patient undergoing distraction
lengthening of the finger involves two phases. The first
phase is during the time the distraction device is in
place. Extreme caution must be exercised to protect the
external fixation device from trauma to the pin sites
since this may result in loosening and/or infection. If
excessive forces are generated in a vector that is not paral-
lel to the axis of lengthening, then malalignment will
Figure 34.7
External fixation device applied to maintain bone
fragments in precorticotomy position.

Finger Lengthening of the Burned Hand by Dis traction Os teos ynthes is
471
occur. The occupational therapists focus on both the digit
being lengthened and the remainder of the hand. They
undertake a maintenance program to preserve mobility
and function of the adjacent digits and the hand. Active
and very gentle passive range of motion exercises can be
performed with the lengthened digit(s) within the pain tol-
erance limit of the patient. Occasionally, the fixation pins
may tether the soft tissue structures, especially a tendon,
which may produce pain and mechanically block full
excursion of the adjacent joints.
Phase 2 of occupational therapy is begun once the
external fixation device is removed and a solid bony
union is present across the distraction gap. There are two
components to this therapy program. First, some tighten-
ing of the periarticular structures (ligaments, intrinsic
muscles) may have occurred during the lengthening
process secondary to immobilization. Once a solid bony
union has been achieved, these can be aggressively
addressed through a program of active and passive range
of motion exercises and possibly dynamic splinting. The
aim is a full active and passive range of motion. Webspace
tightness may occur necessitating use of static (C-bar) and
dynamic splints for the first webspace and soft, custom
inserts held in place by a pressure glove for the other web-
spaces. The second component of occupational therapy at
this time is focused on using the lengthened digits for
specific functional tasks and ADL. Specifically, this
addresses improving pinch function and strength and the
ability to hold and manipulate objects in the hand.
XL
ADDITIONAL PROCEDURES
A.
Webs pace
In instances of a shortened thumb, the first webspace may
become tighter as a result of the distal pull on the tissues
from the lengthening process. If occupational therapy is
unsuccessful, the first webspace may need to be length-
ened or deepened. Depending on the severity, release
with skin grafts or local tissue rearrangement (four flap
Z-plasty), distant flaps, or a second ray amputation may
be necessary to optimize the size of the first webspace.
If two adjacent digits are lengthened, the author has
observed some distal migration of the webspace skin. In
order to maximize individual finger movement it is some-
times necessary to perform a webspace release, using a
standard syndactyly reconstruction technique with a
dorsal flap and full-thickness skin graft.
B.
Intrins ic Releas e/Tendon Lengthening
Mild adduction contractures of the thumb that were initially
missed or clinically insignificant may become more proble-
matic following lengthening and require release.
The inability of the intrinsic hand muscles to lengthen
in concert with the bone can result in a flexion contracture
at the MCP joint proximal to the lengthened bone and
necessitate release.
Occasionally, the flexor tendons will fail to lengthen
adequately, thereby causing a flexion contracture. This
occurs only when there is a joint distal to the lengthened
bone. An example of this is when only a small middle pha-
langeal fragment is present and distraction osteosynthesis
occurs within the proximal phalanx.
XII.
COMPLICATIONS
Pin site infection and/or loosening can occur with impro-
per pin insertion technique, inadequate pin care, or trauma
to the apparatus while it is in place. A small amount of
drainage or minimal loosening might be salvaged with
local pin site care and strict immobilization and protection.
Otherwise, if significant pin loosening occurs, the pro-
cedure will not be successful and needs to be abandoned.
Deviation or malalignment of the distracted bone can
occur through inaccurate pin placement and apparatus
assembly. Small degrees of malalignment can be adjusted
during distraction. Wenner (26) described a case in which
a 90° angulation deformity was noted at the osteotomy site
10 days following the initiation of the distraction process.
The fragments were realigned in the operating room after a
portion of the lengthening was reversed, and held in align-
ment with a longitudinal smooth K-wire. Further lengthen-
ing of the metacarpal proceeded uneventfully with the
longitudinal K-wire both preventing further bending and
“directing” the direction of subsequent lengthening. Late
malunion, occurring once the corticotomy gap has solidi-
fied, will require an osteotomy to reposition the bone frag-
ments and benefit from the application of an internal
fixation device.
Nonunion is generally a result of either too rapid dis-
traction or failure to adequately immobilize the distracted
bone following the completion of lengthening. If identified
early, the lengthened digit can be salvaged with immobil-
ization, otherwise secondary bone grafting may be necess-
ary, with or without the added stability of an internal
fixation method.
XIII.
ADVANTAGES
This technique of distraction osteosynthesis offers certain
advantages. It uses local tissue to provide improved function
and therefore avoids the necessity of a donor defect. Since
the distraction process occurs gradually over a period of
time, soft tissue structures can be successfully stretched
and lengthened and the pain is generally minimal unless
there is movement at the pin site. In addition, since the

472
Functional and Aesthetic Recons truction of Burned Patients
native neural structures to the digits are preserved, sensation
remains intact to the amputation stump. This technique can
provide improved function, particularly pinch, and the
ability to hold larger objects in the hand. Although this
method demands some degree of surgical precision, it is
not as technically demanding as the microvascular anasto-
moses required in toe to hand transfers.
XIV.
DISADVANTAGES/LIMITATIONS
This technique is not applicable in all instances of finger
amputation, as sufficient bone must be available for the
distraction process. There must be a bone fragment of ade-
quate length and quality to achieve reliable, solid purchase
of the threaded pins for placement of the distraction appar-
atus and sufficient room for the corticotomy. There is also
a limitation of
cm in overall lengthening. If more
ambitious lengthening is attempted, the bone separation
may “outstrip” the capacity of the corticotomy gap to
ossify and achieve a solid, stable union. In this situation,
the gap may require autogenous (nonvascularized) bone
graft to facilitate healing. If it is the surgeon’s opinion
that more than 3 cm length is required to restore satisfac-
tory function, then alternative methods may have to be
considered from the outset. This technique simply pro-
vides a solid, static post, which relies on adjacent, unin-
jured joints and tendons for movement. It does not result
in increased total active movement of the finger since
additional motors and/or joints are not supplied by this
method. If additional flexion is necessary for function,
then pollicization or a toe to hand procedure is indicated.
The lengthening process is prolonged and therefore may
run the risk of complications such a malalignment, pin pro-
blems, and nonunion. It also requires strict patient
cooperation for maintenance of the apparatus and
gradual distraction.
XV.
RESULTS
This technique can achieve 2-3 cm increased length of an
amputated digit. Sensation to the tip is preserved which
maximizes the use of the reconstruction. Solid union has
been achieved in all cases without use of a bone graft.
Pinch and holding objects in the first webspace have
been the specific hand functions that are most improved
with this method (Figs. 34.9 and 34.10).
XVI.
ALTERNATIVES
A.
Alternate Lengthening Techniques
There are a number of alternative options for finger
lengthening,
especially
of the
thumb.
Immediate
Figure 34. 9
(A) Mitten hand with short thumb. (B) Thumb
lengthening.
lengthening as described by Matev (27) may be applicable
to the pediatric population or short gaps since there would
be adequate osteogenic tissue to accomplish bony union.
Otherwise, there is a limit in the amount of lengthening
that can be achieved with this method and a bone graft
is required in the adult. The step osteotomy technique
may be possible with larger fragments and be a more
dependable technique applicable for older patients, in
whom the osteogenic potential of the periosteal and endo-
steal tissues may not be ideal.
B.
Alte rna te Procedures for Shortened Digits
With amputations proximal to the MCP joint, the tech-
nique of distraction lengthening will not be effective,
since adequate functional length cannot be achieved with
the bone available. Surgical options in this case include
creation of a functional post with the Gilles cocked hat,
osteoplastic reconstruction, or toe wrap-around procedures
or a mobile digit with pollicization or a toe to hand
transfer.

Finger Lengthening of the Burned Hand by Distraction Osteosynthes is
473
significantly improve the use of an otherwise nonfunction-
ing hand to permit the patient to resume some ADLs and
restore some degree of normalcy to their life.
Figure 34.10
(A) Preoperative index-middle finger leng-
thening. (B) Postoperative index-middle finger lengthening.
(C) Key pinch.
XVII.
SUMMARY
Distraction osteosynthesis for finger lengthening in bum
patients can be an effective tool to improve function in a
hand devastated by bum injury. This technique is demand-
ing on both the surgeon and the patient. Although it will
not produce normally functioning fingers,
it can
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Reid DAC. The Gillies’ thumb lengthening operation. Hand
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Hughes NC, Moore FT. A preliminary report on the use of a
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Br J Plast Surg 1950; 3:34.
5.
Steichen JB, Weiss APC. Reconstmction of traumatic
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Buck-Gramcko D. Pollicization of the index finger. J Bone
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Buck-Gramcko D. Thumb reconstruction by digital trans-
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Cobbett JR. Free digital transfer: report of a case of transfer
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Codivilla A. On the means of lengthening in the lower
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Matev IB. Thumb reconstruction after amputation at the
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Kessler I, Baruch A, Hecht O. Experience with the distrac-
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Manktelow
RT,
Wain wright
DJ.
A
technique
of
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Putti V. The operative lengthening of the femur. J Am Med
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Ilizarov GA. Basic principle of transosseous compression and
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Toh S, Marita A, Arai K, Nakashima K, Tsubo
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Functional and Aes thetic Reconstruction of Burned Patients
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Second Hand Club. British Society for Surgery of the
Hand, 1975:431.

35
Thumb and Finger Recons truction by Microvas cular
Free Tis s ue Transfer
FU-CHAN WEI, TEWODROS M. GEDEBOU
Chang Gung University and Me dical College, Taipei, Taiwan
I.
INTRODUCTION
The hand, and its digital extensions represent one of the
most important and complex “organs” of the human
body. It provides one of the major “senses” and is an
invaluable means for sustenance. As the primary structure
(besides the foot) with which we directly interact with the
external physical world, the hand is prone to injury by
475
I.
Introduction
475
B. Recipient Site Preparation
480
II.
P e rtin e n t An a to m y o f the Ha n d
4 7 6
C
C o m p le tio n o f To e Tra n s fe r
481
t t t
n ,
,
• i
,,
D
, . ,
,
D.
Fu n c tio n a l an d Ae s th e tic
III.
P a th o p h ys io lo g y o r the Bu rn e d Ha n d
4 76
^ J
Mo d ific a tio n s in To e Tra n s fe rs
4 82
IV .
G e n e ra l P rin c ip le s o f Ma n a g e m e n t o f th e
E
Dis ta l D ig it Re c o n s tru c tio n w ith
Bu rn e d Ha n d
4 77
Va rio u s Tis s u es fro m the Fo o t
483
V.
Indications for Microsurgical Free Tissue
1 .
puip
4 8 3
Transfer Reconstruction
477
2.
Nail
484
VI.
Evaluation Before Microsurgical
3.
Composite
484
Reconstruction
477
F.
Thumb Reconstruction
484
VII.
Options in Microsurgical
G.
Metacarpal Hand Reconstruction
485
Reconstruction
478
H.
Clinical Experience with
VIII. General Intraoperative Management of
^ oe Transfers
485
Free Tissue Transfer in Burn Hand
XI.
Postoperative Care
485
Reconstruction
478
XII.
Rehabilitation
485
IX.
Microsurgical Free Tissue Transfer
XIII.
Outcome of Free Tissue
for Resurfacing
478
Transfer in Burned Hand
486
X.
Microsurgical Toe Transfer
A.
Early Period
486
for Digit Reconstruction
479
B.
Long-term
486
A. Toe Dissection
479
C.
Donor Site
486
1. Marking
479
XIV. Conclusion
487
2. Vascular Pedicle Dissection
480
References
487
3. Structural Dissection
480

476
Functional and Aes thetic Recons truction of Burned Patients
various means including burns. Bums of the hand are
classified by the American Bum Association as “major”,
despite its relatively small surface area (3%), in recog-
nition of its central role in human function and appearance.
II.
PERTINENT ANATOMY OF THE HAND
Although the anatomy of the hand is complex and is well
described elsewhere, relevant anatomy with regards to
microsurgical applications in bums is comparatively
simpler. The dorsal skin of the digits is thin, flexible and
has numerous hair follicles, sebaceous glands, and pigment
cells. Resting on a thin layer of subcutaneous tissue, it pro-
vides little protective coverage of the underlying extensor
mechanism, especially at the level of the proximal interpha-
langeal joint (PIP), in lieu of maximizing gliding function. In
contrast, the skin of the volar aspect of the hand is hairless,
unpigmented, and with variable thickness along the axis of
each digit. The surface topography includes multiple
whorls, arches and ridges designed to maximize grip func-
tion and is complemented by underlying retaining ligaments.
The distal digit forms a unique segment beginning
distal to the insertion of the sublimis in the fingers or the
interphalangeal joint in the thumb. With a stable, adherent
nail on the dorsum, volarly it comprises of sensate glabor-
ous pulp skin attached to the underlying distal phalanx by a
network of septae. It has the highest neural density of
any body surface, due to the presence of Pacinian and
Meissner’s corpuscles as well as Merkel cell-neurite
complexes. The nail maximizes the strong pinch surface
area of the finger functions as a platform for the trans-
mission of sensation, and due to its conspicuous location
carries significant aesthetic value (1).
Two lateral proper digital arteries provide blood supply
to the digits. Located dorsally in relation to the corre-
sponding digital nerves, the proper digital arteries are
extensions of the common digital arteries, which in turn
branch off the superficial palmar arch. The ulnar and
radial arteries contribute to this arch, with the former in
dominance in the majority of cases. Multiple veins occur
on the dorsal surface of each digit, superficial to the
dorsal branches of proper digital arteries and nerves.
Proper function of each digit requires the undisturbed
interplay of many critical structures and that of the hand
requires interaction between the thumb and fingers. The
thumb as the prime digit of the hand exhibits a wide
range of circumductal motion at the basal joint, and is
required to be opposable, stable, sensible, and of sufficient
length (2,3). The index finger with its independent motion
and the remaining fingers are important to stabilize objects
for manipulation and power grasp. Therefore, pinch, grip,
fine motor movement, and sensitive tactile feedback are
the basic functions of the hand that require restoration.
III.
PATHOPHYSIOLOGY OF THE
BURNED HAND
The variable depths of injury from thermal or electrical
bums and the anatomic complexity of the hand set the
stage for a wide variety of clinical presentations that
defy simple classification. Beyond the initial injury,
wound healing of the bum goes through different phases
correlating with final outcome of the hand. The initial or
acute phase is marked by the period of inflammation and
ends when epithelialization is complete. During this
stage further extension of injury may develop as a result
of ischemia due to edema, compartment syndrome, vascu-
lar thrombosis, over-zealous debridement and most
notably infection (4,5).
After healing of all open wounds and the inflammatory
phase has subsided, the bum scar undergoes a period of
maturation initially marked by contraction and hypertro-
phy. Wounds in general usually undergo hypertrophy 3
weeks after injury, peaking at about the third month and
stabilizing during the following year. Bum scars,
however, undergo significant contraction and cicatrix for-
mation especially if the wound heals by second intention
or a thin skin graft used for resurfacing. Hypertrophic
wounds overlying areas of motion such as joints develop
into extrinsic contractures. The resulting immobilization
of the joints over time leads to intrinsic contracture due
to fibrosis of underlying ligaments and joint capsules.
During this dynamic phase, wound healing may be
affected by aggressive physical therapeutic maneuvers.
When maturation ceases, the hard and immobile burn
cicatrix becomes a marker for the end-stage burn scar.
Physical therapy is futile at this stage, and even surgical
intervention yields suboptimal results in restoration of a
“normal” digit. The chronic bum wound may develop
into a recalcitrant ulcer, and persist for decades becoming
a risk factor for malignancy. Another common deformity
includes fingers with dorsal burns fixed into the intrinsic
minus position (hyperextension of the metacarpophalan-
geal joint and flexion of the two digital joints) (6-8). Fur-
thermore, if the extensor mechanism has been injured as
well, then a Boutonierre deformity results from the volar
migration of the lateral bands (6). Another common
sequela of burn injury is that of burn syndactyly resulting
from the contraction of injured web spaces. Adduction
contractures of the thumb are particularly disabling by pre-
venting its opposability, and universally require surgical
correction (9). Similarly, flexion contractures of fingers
into the palm impede normal function of the entire hand
and therefore require early restorative measures (5).
Severe injury to the digits may also lead to structural
loss either acutely or secondarily. Fourth degree burns
resulting from thermal, electric, or frostbite injuries may
lead to acute necrosis of the digits. Secondarily, salvaged

Thumb and Finger Recons truction
477
but severely injured or poorly managed digits may develop
into immobile and deformed posts interfering with the
overall function of the hand. If restoration is not possible,
then its removal is necessary for improved function and
even appearance of the hand. If affecting several digits
of the hand, significant disability shall result. The metacar-
pal hand represents the most severe form with variable loss
of digital length as well as number of digits.
IV.
GENERAL PRINCIPLES OF
MANAGEMENT OF THE
BURNED HAND
Outcome of the burned hand is dependent on a complex
interplay between the healing process itself as well as thera-
peutic methods imposed on it. The largest possible impact
in the restoration of function of the hand after a bum is
during the acute stage. Proper wound care, adequate debri-
dement, prevention of edema and infection, proper resurfa-
cing, correct splinting, and early physical therapy, all play a
significant role in the preservation of function. In contrast,
improperly managed deep bums to the hand result in detri-
mental deformities that pose significant challenges to the
reconstructive effort. The adequacy of debridement needs
to be balanced with the necessity for tissue preservation.
Biological dressings can be used and debridement may be
undertaken in a staged fashion to allow excisional accuracy
without compromising the digit to further injury. When the
loss of the digit is inevitable, tissue preservation principles
must override the method of amputation to lessen the diffi-
culty of future restorative surgery. Resurfacing is usually
accomplished during the acute period with either skin
grafts or pedicled flaps such as the groin flap. Local flaps
are avoided to prevent further injury to the hand.
Upon healing and entry of the bum wound into the
dynamic phase, monitoring for scar hypertrophy, contrac-
ture formation, and stability is undertaken and appropriate
therapy is directed. Compression garments, silicone gel,
and massage may reduce the hypertrophy of burn scars
during this period. Physical therapy for improving the
range of motion of the joints is an essential ingredient to
the functional rehabilitation of the hand.
The end-stage wound with contracture, however, will
need release and resurfacing with durable tissue. If the
original injury or resultant contracture is relatively
minimal, resurfacing can be achieved with thick skin
grafts, Z-plasty, or local flaps. If extensive, however,
such as adduction contractures of the first web space or
dorsal metacarpal extension contractures, then such
methods yield suboptimal results. Furthermore, complete
structural loss is best reconstructed with toe transfers.
For example, loss of the thumb at the level of the proximal
phalanx with an adduction contracture will initially require
release and resurfacing of the contracture either with a
groin flap. Toe to thumb reconstruction is then undertaken
secondarily.
V.
INDICATIONS FOR MICROSURGICAL
FREE TISSUE TRANSFER
RECONSTRUCTION
During the acute stage, truly emergent microsurgical
reconstruction is needed only for devascularizing injuries.
Emergent restoration of blood supply with vein grafts is
imperative in segmental devascularization. In complex
cases, a flow-through free flap can be applied to achieve
both circulation and coverage requirements (10,11).
Exposure of or injury to underlying critical structures
requiring resurfacing and conventional flaps are not suit-
able will also necessitate free tissue transfer. The wound
is kept moist with physiological solution wet gauze,
edema reduced by elevation, the zone of injury is clearly
demarked, and the patient condition optimized prior to
undertaking reconstruction. Staged reconstruction with
thin free flaps can then be accomplished safely (4,12-14).
After primary healing of all wounds, worsening con-
tractures of the digits unresponsive to physical therapy
will require early release and resurfacing with durable
tissue to prevent intrinsic contracture formation. Extensive
skin defects following adequate release of burn cicatrix
contractures are managed by thin free flaps. Similarly, in
conditions such as boutonierre deformity of the digit
associated with a dorsal bum cicatrix, a thin tendocuta-
neous free flap can be applied after release.
The most common indication for microsurgical appli-
cations, however, is restoration of composite deficiency
of digits of the hand. Deformed nail beds, inadequate
pulp surfaces, and amputation at various levels of the
digit or digits are best reconstituted with “like” tissue
transfers from the foot. A variety of clinical presentations
exist in this regard. Functional deficit is noted when ampu-
tation level is proximal to the midpoint of the proximal
phalanx of the finger. Loss of multiple digits imposes
even more functional deficit. Both require toe transfers
for ideal reconstruction. Reconstruction of the metacarpal
hand is dictated according to its classification, with the
intent of restoring either triple or pulp-to-pulp pinch for
restoration of prehensile function.
VI.
EVALUATION BEFORE MICROSURGICAL
RECONSTRUCTION
During the acute stage, the extent of the burn injury as well
as the vulnerable marginal zone must be recognized early.
The search for any early signs that could extend the zone
of irreversible injury must be vigilant. The demarcation

478
Functional and Aesthetic Reconstruction of Burned Patients
of viable and nonviable tissue is best evaluated during
serial debridement sessions.
Evaluation of the patient presenting during the matu-
ration phase is more focused on a functional basis. The
character of the “healed” wound as well as the restrictions
it poses to the digits and hand must be recorded in relation
to time since injury. Durability of the skin cover must be
assessed especially over at-risk areas, such as the dorsal
surface overlying the joints of the digits. Photographic or
video documentation is a useful addition to a full physical
examination and history.
Prior to undertaking any reconstructive effort however,
differentiation of the actual disability of the hand from the
restrictions the patient faces in his/her life should be
made. An overall discussion must include the patient and
those supporting him/her so that accurate expectations
are understood and focused management plans set forth
accordingly. Suitability of microsurgical tissue transfer is
determined by evaluating adequacy of recipient as well
as donor structures. Vascular supply is assessed by phys-
ical examination, Doppler flow, and in rare instances
angiography. Most of the microsurgical free tissue trans-
fers can be performed with a two-team approach taking
care of donor and recipient sites, simultaneously.
However, any doubt regarding suitability of the recipient
site requires its exploration prior to free tissue harvest.
VII.
OPTIONS IN MICROSURGICAL
RECONSTRUCTION
Microsurgical techniques provide a “universal passport” into
all areas of the body by transferring a segment of tissue from
one part of the body to another. “Excess,” and even dupli-
cation of various tissues or structures in the human body
allow such autotransplantation without significant sacrifice
to the donor site. Refinements in surgical technique and
knowledge of anatomy continue to add various tissues to
the armamentarium of reconstructive surgeons (Table 35.1).
Table 35.1
Flaps Available for Repair of Various Defects of
the Hand
Defect requirement
Tissue available
Tendocutaneous
Palmaris longus, DP, TFL
Thin dorsal
Venous flaps, ALT, RF,
skin cover
LA, DP, MP
Palmar Skin
1st pedal web space, thenar,
medial plantar
Flow through coverage
RFF, LA, DP, ALT, venous flaps
Vascularized joints
Metatarsophalangeal joint, PIP joint
Distal or entire digits
Toes
Note: RF, radial forearm; LA, lateral arm; TPF, temporoparietal fascia;
TFL, tensor fascia lata; DP, dorsalis pedis; MP, medialis pedis; ALT,
anterolateral thigh; PIP, proximal interphalangeal joint.
VIII.
GENERAL INTRAOPERATIVE
MANAGEMENT OF FREE TISSUE
TRANSFER IN BURN HAND
RECONSTRUCTION
Although general anesthesia is the norm for free flap
reconstruction, regional methods may be applied. Tourni-
quet applied to involved extremities with 2 h limits, facili-
tates preparation of donor and recipient sites. In general, a
well-coordinated two-team approach allows for the expe-
ditious and safe undertaking of microsurgical reconstruc-
tion. The tourniquet can be temporarily released to allow
for reperfusion as well as assessment of sufficient vascu-
larity to the donor structures before division. The free
tissue is then properly inset and microsurgical anastomosis
is undertaken. After re-establishment of adequate vascu-
larity to the transferred tissue, closure of remaining
wounds as well as the donor site is completed. Appropriate
dressings or splinting allows safe transfer of the patient to
the microsurgical intensive care unit.
IX.
MICROSURGICAL FREE TISSUE
TRANSFER FOR RESURFACING
Loss of dorsal skin of the digits entails replacement with
similarly thin tissue that would allow mobility of the
finger. Venous flaps taken from the forearm or calf
provide
the
ideal
thickness
for
smaller
defects
(10,11,13). If multiple digits require dorsal resurfacing,
then the radial forearm, dorsalis pedis, lateral arm, pedal
first web space, medialis pedis, or anterolateral thigh can
provide relatively thin tissue cover. A temporary syndac-
tyly is created, which is divided secondarily in such
cases. If the extensor mechanism is also missing due to
injury or after release, segmental restoration is accom-
plished via a tendo-cutaneous free flap. The radial
forearm with palmaris longus and the dorsalis pedis with
toe extensors are the most commonly used. Venous
forearm palmaris longus tendo-cutaneous flaps have also
been reported, but are occasionally plagued by venous
congestion.
The adduction contracture of the first web space rep-
resents one of the more common clinical entities. Excision
or release of the burn cicatrix, and on occasion, myotomy
of the shortened adductor pollicis is necessary to comple-
tely release the contracture. The resultant defect is resur-
faced with thin, stable, and durable tissue spacer free
flaps as listed earlier (Fig. 35.1). Volar defects pose
specific challenges due to the requirement of restoring sen-
sibility and prehensibility as well as providing coverage.
Although multiple simple procedures have been described
for reconstruction of relatively complex defects of the
hand, the ideal method will have to incorporate restoration
with “like” tissue that is available from the foot. For

Thumb and Finger Reconstruction
479
Figure 35.1
(A) Late presentation of a burned right hand resurfaced with skin grafting. The contracture involved the first web space as
well as the volar surfaces of the ring and small finger. (B) Immediately after contracture release and resurfacing with a thin lateral arm free
flap. (C) Outcome of the hand more than a year following free tissue transfer resulting in excellent return of range of motion of the thumb
and fingers.
example, composite or structural deficits of the digits can
only be replaced by similar tissue from the toes (Figs. 35.2
and 35.3). The nail, pulp, partial or entire digits, and even
combined, adjacent digits are available for transfer (15). A
prerequisite for toe transfer, however, is an adequate soft
tissue base, which can be provided for by a groin flap
(Fig. 35.4).
X. MICROSURGICAL TOE TRANSFER
FOR DIGIT RECONSTRUCTION
A.
Toe Dis s ection
1.
Marking
A small wedge shaped skin island on the dorsum of the
foot is usually designed to facilitate exposure and
Figure 35.2
(A) This patient’s dominant hand suffered a deep burn to the pulp of the thumb as well as to the other digits of the hand.
(B) Design of a partial great toe pulp flap. (C) The great toe partial pulp flap after harvest demonstrating pertinent neurovascular struc-
tures. (D) Appearance of the thumb 1 week postoperatively with complete flap survival. Given the loss of the middle three digits of the
hand, he will undergo finger reconstruction in 1 year.

480
Functional and Aesthetic Recons truction of Burned Patients
Figure 35.3
(A) Fourth degree burn injury to the dorsum of the thumb as well as the first web space. The patient presented after
resurfacing with a groin flap and breakdown of the distal margin. The nail was also obliterated. (B) Designs of a second toe wrap-
around flap for dorsal hemicircumferential reconstruction since the volar aspect of the thumb was intact. (C) Immediately following
transfer of the second toe wrap-around flap to the thumb. (D) Long-term follow-up of the thumb revealing excellent function and
acceptable appearance.
dissection of underlying structures, yet allow primary
closure of the donor site.
2.
Vascular Pedicle Dissection
Dissection of the vascular pedicle is initiated at the first
web space to first identify the junction of the lateral
digital artery of the great toe and the medial digital
artery of the second. Retrograde dissection is undertaken
to delineate arterial anatomy (Fig. 35.5). The first dorsal
metatarsal artery (FDMA) is evaluated in comparison to
the first plantar metatarsal artery (FPMA). The FDMA is
preferred due to its lengthy pedicle and ease of its dissec-
tion compared to the FPMA, which disappears in the
depths of the foot at the level of the middle of the metatar-
sal shaft. Veins are plentiful on the dorsal surface and are
taken in continuity with the saphenous system at any
desired length.
3.
Structural Dissection
Dissection of the corresponding nerves is undertaken, iso-
lated, and ends tagged with sutures for later identification.
Depending on the length requirement, the digital nerve is
lengthened via microscopic fascicular dissection of the
common digital nerve. Both flexor tendons, and the extensor
tendon are dissected and taken at sufficient length. Osteotomy
is carried out at the appropriate level, and the entire donor
tissue is left connected only via its blood supply prior to tour-
niquet release. Of importance, none of the structures are
transected at any point prior to determining adequacy of the
recipient area as well as any length requirements imposed.
B.
Recipient Site Preparation
The digital stump is dissected to allow for coaptation with
the harvested toe. The bony stump is cleared of the