Principles and Practice of Burn Care

336
Principles and Practice of Burn Care
victims are children below 15 years of age and young adults.
In US the firecrackers followed by sparklers are the leading
causes of firework injury. In India, especially in Delhi, “anar”
has been incriminated in majority of cases followed by other
firecrackers.1 A study from Ahmedabad reports firecrackers
followed by lighting of powder taken out from firecrackers,
rockets and the ‘anar’ as the commonest causes.2
Fireworks/Firecrackers cause injuries and damage in
the following circumstances:
1. During production: To manufacture fireworks/
firecrackers, one has to obtain a license from the
governmental authorities and comply with the rules and
regulations laid therein. Unfortunately in India, there is
mushrooming of illegal factories even in residential and
thickly populated areas. Safety norms are flouted. When
these factories catch fire, there is not only loss of life
but the adjoining houses also catch fire and collapse
with loss of property. Once these poor quality products
reach the hands of general public, they frequently mal-
function leading to burns and other injuries.
2. Storage: Once out of factory, these products, whether
produced under license or not, are stored illegally in
thickly populated and unlicensed areas and godowns
with great risk of catching fire.
3. Retail sale: During festive season like Diwali, a number
of shops come up in every locality selling crackers in
open spaces as if they are innocuous items, again
endangering the shoppers.
4. Improper and unsafe use of fireworks/firecrackers by
end users (Figs 25.5A and B):
a. Simultaneous igniting of multiple crackers/sparklers.
b. Igniting ‘bombs’ and ‘anar’ in hand in an act of
bravado.
c. Bowing over a firecracker while trying to light it.
d. Unsupervised bursting of firecrackers by small
children.
e. Trying to find out the cause of non-bursting of a
cracker in expected time or relighting it.
f. Collection of the combustible powder out of a number
of crackers and burning them in a heap.
g. Throwing lighted crackers on onlookers or a passerby.
h. Firecrackers exploding earlier or later than expected.
i.
Errant flight paths of ‘rocket’ and spinner.
j.
Sparks or debris from crackers/fireworks causing
house fire.
k. Trying to make crude crackers (e.g., ‘anar’) at home.
l.
Bursting cheap quality crackers.
m. Insufficient open space.
CLINICAL FEATURES OF FIRECRACKERS/
FIREWORKS INJURY
The fireworks/firecracker related injuries3-8 can be divided
into various types, namely, burns, injuries of the ocular globe
and adnexa, lacerations, amputations, noise pollution and
deafness and respiratory illnesses produced/precipitated by
smoke pollution in the environment, etc.
Most of the burn injuries due to firecrackers affect the
hands (Figs 25.6 to 25.10), face (Figs 25.11 to 25.15) and
eyes. However, any part of the body may get burnt especially
when clothes catch fire due to crackers. The feet may get
burnt by stepping on the hot sparkles from ‘phooljhari’ or
‘Zameen chakri’ (Fig. 25.5B). The injuries can be due to
flash, flame, contact and blast. The type of injury varies
Fig. 25.5B: Unsafe use of ‘Zameen Chakri’ by a child who is likely to
get burns of feet
Fig. 25.5A: Unsafe use of ‘Phooljari’ by adults wearing synthetic
clothes and holding a child in the arms

Firework and Firecracker Injuries
337
from place to place depending on the prevalent type of
cracker being used more often. Thus, in Italy, lacerations
and amputations of hand are more common because
explosive devices are used more commonly. In India and
USA, burns are more common. Flash burns are usually
superficial and caused by crackers like ‘anar’, ‘charkhi’
and sparklers affecting bystanders as well.
Facial burns can be complicated by injury to eyeball and
ocular adnexa and account for some of the most disabling
firecracker- related injuries.9-13 They may be penetrating or
non-penetrating. They include eyelid burn/laceration/
hematoma, conjunctival burn/contusion/foreign body and
corneal burn/contusion/foreign body, corneal perforation
or hyphema, traumatic cataract, rupture of iris sphincter or
even globe, vitreous/macular hemorrhage and retinal edema,
etc. There may be a partial or total loss of vision. Most of
these injuries are caused by rockets fired from a bottle.
Fig. 25.7: Laceration of first web space with burns
Figs 25.6A and B: Explosion of ‘Anar’ in hand causing
(A) laceration with burns with stitched wounds. (B) Healed
A
B
Fig. 25.8: Massive lacerations with avulsions and amputations of
thumb and finger due to bomb exploding in hand
Blast injury mainly affects the hands of the operators and
can be contusion, laceration, splitting of web space and even
complete mangling of hand with loss of digits (Figs 25.6A to
25.8). There can be multiple fractures of bones of hand and
even loss of skin and bones. Such severe blast injuries
afflicted to the operator are mostly by powerful bombs and
‘anar’, which burst in the hand. The wounds are extremely
painful as white phosphorus particles are driven into the
skin due to blast effect. These foreign bodies later on lead
to tattooing after healing. The self propelling rockets are
also known to cause severe damage if they are misdirected
accidentally and can be responsible for major fires if they
land up on an inflammable material instead of going up in
the air and bursting in the sky. Flame burn injuries due to
crackers may be extensive if clothes catch fire.

338
Principles and Practice of Burn Care
In addition to fire-related mishaps, the fireworks/
firecrackers also cause noise and air pollution. Infants and
small children do get frightened on hearing the loud sounds
produced.14 Elderly and ill may also not be comfortable
with them. In some bombs, the sound level produced is
more than100 decibels. This is known to cause damage to
the tympanic membrane leading to temporary deafness
which recovers in 7-10 days. If the sound level is more
than 140 decibels, permanent deafness can result. To avoid
this, the regulations do not allow bombs with more than 80
decibels to be manufactured. A lot of smoke is produced
especially on the ‘Diwali’ day and precipitates the attacks
of asthma in susceptible people. The by-products of
combustion contain various toxic and non-toxic chemicals
which can cause inhalational injury. Thus, signs and
symptoms of respiratory tract injury must be looked for in
burns in closed spaces due to firecrackers.
Figs 25.9A to D: Burn due to cracker. Healed after conservative
treatment. Please note the application of “Ratanjyot” (indigenous
medicine) and a “sacred thread” tied on the wrist used in some parts
of our country for faster healing
Figs 25.10A to C: Burns due to firecrackers
A
B
C
A
B
C
D

Firework and Firecracker Injuries
339
Figs 25.11A to C: Superficial burns of face due to cracker injury
being managed conservatively; healed
Fig. 25.13: Cracker injuries to face
Fig. 25.14: Cracker injury to hand and face, a usual combination
Fig. 25.12: Cracker injuries to face and right eye
A
B
C

340
Principles and Practice of Burn Care
MANAGEMENT
Not more than 10% of the firecracker injuries require
admission. Patients are generally treated on outpatient basis.
However, the moderate to extensive burns due to clothes
catching fire need to be admitted. Patients coming with
ocular injuries, blast injuries of hand and facial burns with
edema require admission. Management of burn wound is
the same as for any other minor or major thermal burn
which has been already elaborated elsewhere in this book.
All burns must be thoroughly washed with saline to remove
foreign bodies before dressing. Similarly in cases of ocular
injuries the eyes should be thoroughly irrigated. Phosphorus
particles have to be removed manually followed by saline
irrigation and Fluorescein staining done for corneal
involvement. The management of these injuries is beyond
the realm of a burn surgeon and requires the intervention of
an ophthalmologist.15 For lacerations of the hand, suturing
is done to reposition the tissues back to as normal as possible
(Fig 25.16). The blast injuries of the hand need meticulous
debridement under anesthesia and fixation of fractures by
K-wires or rarely by mini plating and secondary
reconstructive procedure(s) should be planned especially
in case bones are exposed. Various loco-regional or distant
flaps have to be considered. The most commonly used flap
is the groin flap. Severe mutilating blast injuries of the hand
may need amputations at appropriate levels.
Figs 25.15A and B: Cracker injuries to face with cracker
powder causing tattooing
Fig. 25.16: Blast injury of hand due to firecracker leading to multiple
lacerations and loss of soft tissue in the finger tips–managed by
reposition of tissue and local advancement flaps and skin grafting
PREVENTION
Although firecrackers/fireworks lead to a lot of morbidity
and mortality and destruction of property, a complete ban
is not feasible because of the pressure of a large and growing
firework industry and the socio-religious nature of the
festivals.
Over the years, with sustained education of school
children about the harm caused by firecrackers coupled
with the slogan, say ‘NO’ to crackers, the incidence of
these injuries has declined. In Safdarjung Hospital, Delhi,
the number of patients presenting to Burns Casualty on
Diwali night has fallen to 131 in 2008 from over four hundred
cases two decades back (authors’ personal unpublished
data) despite a manifold increase in the city population.
A number of recommendations have been made to
prevent fireworks/firecracker-related injuries. The most
important consideration is the recognition by the general
public as well as the authorities the fact that these innocuous
A
B

Firework and Firecracker Injuries
341
looking toys in various shapes and sizes covered in attractive,
multi-colored paper have the full potential of harm as we
relate with the military combat ammunitions. Hence, the
laws with respect to their manufacture, quality control,
transportation, storage and retail sale must be stringent,
modified and upgraded from time to time and strictly
enforced. As far as possible, there should be community
display of fireworks in open areas by experts and individual
use of crackers by one and all should be discouraged.
A number of unsafe practices at end user level have
already been enumerated above and one must avoid them.
Some other precautions to be observed are listed below:
1. Ensure that other people are out of range and warned
before lighting fireworks.
2. While firing rockets ensure that it is upright in a stable
bottle.
3. Keep a bucket of water ready in the area where crackers
are burst. In case of any mishap, pour water.
4. Wear tight fitting thick cotton dresses.
5. Store firecrackers in a safe place until they are needed,
away from risk of fire.
6. Always use a long ‘phooljhari’ or a candle to ignite
crackers keeping the elbow joint straight to maximize
the distance between cracker and the body.
7. Do not apply oil, toothpaste or any other home made
remedies/ointment on burnt area.
8. Do not panic and drive recklessly while transporting the
victim to medical services. A delay of up to one hour
does not matter.
SUMMARY
The fireworks/firecrackers are more than two millennia old
and have become a source of recreation for people all over
the world breaking the barriers of varied cultures, religion,
literacy, urban-rural, rich-poor, developed-under developed
etc. They are associated with religious festivals, national
state functions, different New Year’s Day of various
countries, sports, marriages, etc. They are billions of dollar
industry. They are also associated with large morbidity,
disablement and mortality apart from economic loss and
loss to property. The World Health Organization16 called
for a worldwide ban on manufacture of all fireworks to
prevent blindness from this cause in 1984. Quarter of a
century later in 2009, we know that their total ban is not
possible. The only solution lies in their manufacture and
sale as per governmental regulations, strict enforcement of
laws related to them and proper precautions being observed
by the end user. Various studies17,18 conducted in different
countries have demonstrated the positive effect of such
measures in minimizing the ‘death’ and destruction
commonly associated with their use. Thus, during
“Dussehera-Diwali” days in India, around Independence Day
in USA, New Year Day in Italy, China and everywhere else,
the incidence of these injuries has certainly come down due
to concerted efforts of the various governmental/non-
governmental agencies, schools and media participation in
teaching the public about dangers of firecracker use, using
only ‘safe and sane’ crackers, precautions and safety
measures to be taken etc.
The festivals are occasions of joy and firecrackers/
fireworks are an enjoyable spectacle. They must not be
turned into ‘unfortunate dates’ to be remembered for the
rest of one’s life.
REFERENCES
1. Mohan D, Varghese M. Fireworks cast a shadow on India’s festival
of lights World Health Forum 1990; 11:323-26.
2. Mehta DR, Suri MP, Patel CK, Agrawal AB, Vora HJ, Raibagkar SC
Firework Injuries-Epidemiology and Prevention Indian J of Burns
2004;12:48-50.
3. Kobayashi J. Injuries from fireworks JAMA 1983; 249:2460.
4. Kobayashi J. Fireworks-Related injuries-Washington State JAMA
1983;250:25-6.
5. Berger LR, Kalishman S, Rivara FP. Injuries from fireworks.
Pediatrics 1985;75:877-82.
6. McCauley RL, Stenberg BA, Rutan RL, Robson MC, Heggers JP,
Herndon DN Class C firework injuries in a pediatric population J.
of Trauma 1991;31:389-91.
7. Clarke JA, Langley JD. Firework related injury in New Zealand. N
Z Med J 1994; 107:423-5.
8. Smith GA, Knapp JF, Barnett TM, Shields BJ. The rockets’ red
glare, the bombs bursting in air: Fireworks-related injuries to children
Pediatrics1996; 98:1-9.
9. Lee RTY. Fire-cracker injury to the eyes in Hong Kong Br. J.
Ophthal 1966; 50:666-69.
10. Newell FW. Fireworks blindness Am. J Ophthalmol 1972; 74:
167-68.
11. Wilson RS. Ocular fireworks injuries Am. J. Ophthalmol. 1975;
79:449-51.
12. Wilson RS. Ocular firework injuries and blindness Ophthalmology
1982;89:291-97.
13. Vernon SA Fireworks and the eye J R Soc. Med 1988; 81:569-71.
14. Gupta D, Vishwakarma SK. Toy weapons and firecrackers: a source
of hearing loss Laryngoscope1989; 99:330-34.
15. Sihota R, Tandon R. Parson’s Diseases of the Eye. 20th ed. Elsevier,
2007;61-76.
16. World Health Organization Strategies for the prevention of blindness
in national programmes. Geneva.WHO.74, 1984.
17. Sheller JP, Muchardt O, Jonsson B. Burn Injury caused by fireworks:
Effect of prophylaxis. Burns1995; 21:50-3.
18. D’Argenio P, Cafaro L, Santonastasi F, Taggi F, Biking N
Cappodano Senza Danno (New Year’s without harm): The effects
of an intervention program on fireworks injuries in Naples Am.
J. Public Health 1996; 86:84-6.

(Trang không có chữ)

5 Section Burns of Special Sites

(Trang không có chữ)

Facial Burns
26
PS Bhandari
Chapter
INTRODUCTION
The face can be defined as a composite structure of bone,
muscles, nerves, fat, blood vessels, skin and other tissues.
However, face is more than a sum of its tissues. Rather, it
is a functional, dynamic and aesthetic region. It plays an
important role in formal introduction, interaction and
communication. It is the physical basis of self image. Any
facial disfigurement leads to great psychological trauma to
the burn victim. He/she becomes crippled both socially and
psychologically. Most of the scars in the body can be hidden
by clothing and other means but facial scars are visible at
first sight. Apart from the initial depth of burn, it is the
better standards of treatment of the burned face in the acute
stage that decides the improved overall aesthetic and
functional outcome.
Facial burns rarely occur in isolation. Almost all the flame
burns involve the face to a lesser or greater extent. Facial
burns can be broadly classified into two types, one which
heal within 2-3 weeks of time without or minimal scarring
and those which do not heal within 2-3 weeks time (Figs
26.1 and 26.2). The latter category of facial burns lead to
scarring and contraction (Fig. 26.3). This type of burn injury
requires surgical intervention. Unfortunately, there is no
objective measurement which can predict whether a facial
burn will heal of its own or will require surgical intervention.
This is because the appearance of burn wounds changes
with time and also after application of various types of
antimicrobial creams/ointments. Furthermore, a given
anatomical depth of burn may not heal in a non-hair bearing
area whereas the same depth of burn may heal reasonably
well in a hair-bearing area such as bearded portion of male
Fig. 26.1: Superficial burns of the face which are best treated by
only conservative management–Exposure treatment
Fig. 26.2: Deep burns of the face which require surgical
intervention for faster healing and to give good results

346
Principles and Practice of Burn Care
face because of abundance of hair follicles of which majority
lie in the deeper portions of dermis and even in the
subcutaneous tissues. Their deeper locations make them
withstand the onslaught of burn injury.
ACUTE STAGE
Management of facial burns in acute stage is a controversial
topic in the overall management of burns. There is no
consensus among burn specialists regarding the type of
treatment, timing of surgical intervention, the technique to
be used or the follow up of case. Because of its excellent
blood supply, a facial burn is almost resistant to infection
and has very good ability to heal. Traditionally, management
of facial burn has been conservative for several reasons:
(1) High potential of facial skin for spontaneous
epithelialization (2) difficulty in evaluating the depth of facial
burn injury (3) excessive bleeding during early tangential
excision (4) Excision of subcutaneous fat may lead to severe
contour deformity.
In all cases of facial burn there can be associated
respiratory burn. If present, they should be given priority
and be treated accordingly. Sometimes, there can be massive
swelling in the neck area due to looseness of tissues. There
can be disproportionate loss of fluid which may warrant
intravenous fluid replacement. At times in full thickness
burns around the neck, due to tough unyielding eschar, fluid
can collect in the deep tissues around the neck leading to
difficulty in swallowing and breathing. Patients with facial
burns should be nursed in head elevated position as this
reduces edema by increasing the venous return and also
helps in breathing by facilitating diaphragmatic excursion.
Management: The facial burns can be managed by either
exposure technique or closed technique though the former
is followed most commonly. The burned area should be
cleansed gently with normal saline. Mild debridement can
be done but sharp debridement should be avoided as it is
often difficult to determine the exact depth of injury. Flash
or scalds usually result in superficial partial thickness burn
which heals within 2-3 weeks of time. However, because
of rich vascularity, there is large amount of oozing and
soakage from the burn wound surface. This fluid forms a
thick crust on drying. It can develop cracks due to dryness
and may be bleed or serve as a culture medium for bacteria.
An antibiotic ointment must be applied to the burn wound
to prevent bacterial growth and crust formation, to soften
the crust and to prevent it from cracking and bleeding until
they heal. It also prevents deepening of depth of burn wound.
Eyes must be protected from the topical cream applied to
the face by leaving a periorbital margin uncovered by the
cream or alternatively applying an ophthalmic antibiotic
ointment over the face so that even if it enters into the eyes,
does no harm to the eye.Topical antimicrobial creams /
ointments should be replaced by wet saline or Povidone
iodine impregnated gauze on 12-14 day post burn. It helps
in superficial debridement of necrotic tissues. These
dressings are applied wet over the wound and are removed
only when dry (Fig. 26.4). Necrotic debris gets attached to
the dry dressing and on removal, the necrotic tissue also
comes out with the dressing. Removal of dressing in this
manner is associated with some bleeding and considerable
pain. Patient should be given injectable analgesics to alleviate
the pain during the change of dressing. This should continue
for a limited period of time till the granulation tissue starts
appearing. In superficial dermal burns, the wound heal
spontaneously and as the healing of the facial region is very
good, the facial wounds are, therefore, best left exposed by
applying local antimicrobial ointment or Vaseline gauze only.
This keeps the wound lubricated, prevents its drying up
and the paraffin gauze when applied and removed does not
peel off the epithelializing surface (Fig. 26.5). The application
of collagen dressings is also useful in such cases as it seals
the wound, keeps it well humidified which encourages faster
healing (Fig. 26.6). Even in chemical burns of the face the
best method of treatment is to leave the wound open and
dry as the wound epithelializes rapidly under the eschar and
the eschar separates by itself (Figs 26.7A to D).
Fig. 26.3: Neglected facial burns in which wounds healed by severe
scarring and contraction–Severe contraction of neck with ectropion
of lids and lips and left eye corneal loss and nose deformity. These
cases are very difficult to manage for correction of all the deformities
(Courtesy: Editor)

Facial Burns
347
Fig. 26.4: Wet to dry dressing in case of deep burns of face
for early separation of eschar
Fig. 26.5: Exposed technique of managing facial burns by applying
antibiotic impregnated paraffin gauze only
Fig. 26.6: Collagen application on facial burns
Fig. 26.7A: Superficial dermal chemical burns of face
involving the eyes
Fig. 26.7B: Ten days later almost healed wounds after leaving the
wounds exposed and eschar separated by itself as the wounds
healed
Fig. 26.7C: Another patient with extensive mixed burns due to
chemical injury

348
Principles and Practice of Burn Care
With the appearance of granulation tissue, use of
biological dressings should be encouraged. It helps in
formation of healthy granulation tissue, early wound closure
and shortens the period of grafting. Surgical debridement
of necrotic tissue can also be done by forceps and scissors.
When the granulation tissue is healthy, it is covered by sheets
of split thickness skin grafts by exposure method. Mesh
graft are rarely, if ever, recommended unless the surface is
bleeding profusely and there is risk of hematoma formation
under the graft (Figs 26.8A and B). When the patient is
taken up for grafting of raw areas, if any ectropion is
developing in the lids, they can be released at the same
sitting, thus, preventing any damage to the cornea.
Patients with sponteneously healed partial thickness burns
and with full thickness burn where grafting has been done
should be advised to avoid exposure to sunlight to prevent
hyperpigmentation for at least 6-12 months following burn
injury. Thereafter, sunscreen lotions should be applied if
they wish to move out during the sun. Because of loose and
mobile nature of tissues in the face, post burn contractures
after healing and grafting are common after facial burns.
Patients should be advised to do regular massage of the
healed and grafted areas.They should be instructed to use
Fig. 26.7D: One month later completely healed areas after leaving
the wounds exposed with only antibiotic ointment application
pressure garment(s) 24 hours a day to prevent contracture
formation and scar maturation (Figs 26.9A and B).
Although traditionally, the management of facial burn is
conservative, this may sometimes lead to poor aesthetic
result. Facial burns which take more than 21 days to heal
run a risk of developing hypertrophic scarring. Several
authors1-5 have reported gratifying results after early
tangential excision and grafting of facial burn within 3-5
days of burn injury in selected patients where the
burn wound is unlikely to heal within 21 day (Figs 26.10A
and B).
Fig. 26.8B: Split skin graft applied to the raw area of face following
deep burn. Graft meshed because of excessive bleeding from the
wounds. Lids also released to correct the exposed eye
Fig. 26.8A: Post burn raw areas of scalp grafted once the
granulation is healthy

Facial Burns
349
POST BURN FACIAL SCARRING
Severe facial disfigurement is a devastating physical handicap
in which depression and social isolation are common. Facial
disfigurement elicits anxiety, fear and a wish to remove it
from one’s sight. For scarred facial structures, thick split
thickness skin graft6, full thickness skin graft7 and various
types of flaps8-13 have been described by different authors
to improve aesthetic look of the burn patient (Figs 26.11A
to C). Tissue expansion is a good option to transfer normal
skin to the scarred areas. Face transplantation is also a
possibility now. Face transplantation may be expected to
not only improve the appearance but also to provide remedy
to the prejudice and discrimination attached to this stigma.
When the surgeon thinks of face transplant he must compare
the risks and benefits of this innovative procedure with
known risks and benefits of autogenous facial
reconstruction. As on today, following face transplantation,
the possibility of life threatening consequences of
immunosuppression, the likelihood of graft rejection and/or
graft failure appears more than the gain of receiving a normal
face as compared to a surgically reconstructed face with
autogenous tissues. Risks are too high when compared with
the relative gain of normal facial appearance versus a
reconstructed face.
MANAGEMENT OF BURNS IN DIFFERENT
PARTS OF THE FACE
Nostrils: Nostril should be carefully cleaned and a thin film
of lubricating antimicrobial ointment should be applied with
Fig. 26.9A: Postoperative picture of skin grafted post burn raw
areas of face
Fig. 26.9B: Pressure garment in the form of a tailor made mask to be
worn over the face for preventing hypertrophy of scars
Fig. 26.10A: Preoperative picture of early tangential excision of
deep burns of face
Fig. 26.10B: Postoperative picture of same patient with full
‘take’ of skin graft over the excised area

350
Principles and Practice of Burn Care
a cotton applicator to prevent crust formation which can
compromise breathing. In case of deep burns of the nose
where the wounds heal by secondary intention there can be
severe stenosis of the nostrils. This can be prevented by
using nostril splints. In case the nostrils are stenosed due to
burns, they can be opened up by release and skin grafting.
In such cases, repeated release may be required because
chances of re-stenosis are high and postoperative splintage
is required to prevent it. This can be treated by another
procedure called “Starplasty”, in which two incisions
perpendicular to each other are given in skin and mucosa to
raise 4 skin flaps and 4 mucosal flaps (Figs 26.12A to C).
The skin and mucosal flaps are then interposed with each
other in the form of a ‘Star’ to achieve a good nostril
opening. Hence, this procedure has been given the name of
Starplasty. The main advantage of this procedure is that it
not only gives a wide opening but the interposed flaps break
the scar line, preventing the scar re-contracture. Thus, the
chances of re-stenosis are minimized. No postoperative
splintage is required as no graft is applied.14
Hypertrophic scars on dorsum of nose can be excised
and resurfaced with split skin graft. If entire nose is
destroyed, the forehead or arm tube flap is used to
reconstruct the nose in stages, with costal cartilage for
support.
Eyelid and Globe Burn
Injuries to the globe are rare in thermal injuries due to
protective mechanism of blink reflex and reflex protective
movement of the head at the time of injury. Nevertheless in
all patients of facial burn, corneal injury must be ruled out
by thorough clinical examination. Ophthalmologic
examination must be done early, because subsequent
periorbital edema makes the examination almost impossible,
if delayed. Foreign body sensation in the eye is suggestive
of corneal injury and must be ruled out or confirmed by
fluorescin test. Occasionally, cloudiness of cornea is
observed with flash injuries which clear out in the next few
days. Corneal injuries are common in chemical burns.
All chemical burns of the eye are potentially serious.15-18
Damage is caused by a high or a low pH and by collagenases
released by damaged epithelial cells and granulocytes. This
inhibits the epithelial regeneration leading to corneal
ulceration. The actual damage depends upon the volume of
the chemical, its concentration, its duration of contact and
the unique property of some chemicals. Ammonia can
penetrate to the interior of globe within 30 seconds. Alkalis
Fig. 26.11A: Post acid burn hypertrophic scarring with stenosed
right nostril and severe microstomia
Fig. 26.11B: Release of microstomia and excision of hypertrophic
scar and coverage of lower lip and chin with expanded neck flaps
and nose and upper lip with skin graft. Second stage tissue expander
placed in forehead and scalp for reconstructing nose and upper lip
Fig. 26.11C: Reconstructed nose and upper lip with expanded
forehead and scalp flap

Facial Burns
351
pH of 11-11.5 due to particles lodging in the conjunctival
sac that are not easily irrigated away. The hydroxide ions
cause saponification of plasma membrane, denature collagen
and cause vascular thrombosis in the vessels of the
conjunctiva, episclera and anterior uvea. Burns caused by
phosphorus demand careful removal of all the particles.
If the burn injury is chemical in nature, irrigation of the
eye with copious amounts of normal saline is done to
minimize the injury to the eye. Ideally, this should be initiated
at the scene of injury with even plain water and should
continue till the arrival of the patient in the emergency
department. Litmus paper is useful in knowing that a normal
pH has been achieved. Specific diluent for a particular agent
is not required.
Subsequent care of the eye focuses on cleaning of eye
with normal saline and maintenance of adequate lubrication
by antibiotic drops or ointment to prevent corneal
desiccations (Figs 26.7A and B). A corneal abrasion may
progress to corneal ulceration and ultimately perforation
with the potential loss of eye (Fig. 26.13). Cornea should
be frequently evaluated. If a corneal injury is present, topical
antibiotic drops and atropine should be started to prevent
ciliary spasm. Chemical injuries may also require maneuvers
to prevent adhesion from forming between conjunctival
surfaces (Fig. 26.14A). All corneal injuries should be covered
(patched). Intense periorbital edema in the early postoperative
period serves the same purpose. Subsequently, if lid
retraction occurs specific methods to prevent corneal
exposure are necessary. Examples include scleral lens,
antibiotic ointment or some other technique. Tarsorrhaphy
is one of the means to close the eye.
The use of tarsorrhaphy in the acute management of
eyelid burns and their subsequent reconstruction is
controversial.Tarsorrhaphy involves the surgical
approximation of eyelid margins (Figs 26.14C and D). Two
techniques are generally advocated to achieve adherence of
the eyelid margin, the opposition technique and the tongue
in groove technique. In apposition technique, the epithelium
of margins of both the eye lids is surgically removed and
then both the eyelids are sutured with the help of bolster
sutures to prevent scarring of eyelids. Tongue in groove
technique ensures a stronger union between the two lid
margins. However, it leads to significant distortion of lid
margins.
In cases where major portion of eyelids and lid margins
have been destroyed significantly, local conjunctival flaps
can be used to cover and protect the eyes.
Fig. 26.12A: Post burn nasal stenosis
Fig. 26.12B: Starplasty—Mucosal and skin flaps raised
Fig. 26.12C: Interposed mucosal and skin flaps in the form of a star
are more dangerous than acids because acid produce
immediate protein precipitation which, to some extent,
protects the cornea whereas the OH ions rapidly penetrate
the cornea producing corneal ulceration and potential for
phthisis bulbi. Lime burns are notorious with a persistent

352
Principles and Practice of Burn Care
Fig. 26.13: Corneal ulceration /impending perforation
When most of the skin of both eyelids is destroyed,
masquerade procedure is used to protect the eye. The
conjuctival flaps are developed by dissecting conjuctiva from
surrounding tissues. After suturing the flaps together with
absorbable sutures, it is covered by split thickness skin graft
(Fig. 26.14A).
After eyelid edema subsides and as the healing progress,
the eyelids may contract, leading to exposure of globe which
may cause conjunctivitis or corneal ulceration. If the lid
retraction occurs with risk of corneal exposure, a temporary
tarsorrhaphy can be performed to achieve the lid closure
(Fig. 26.14B).
If timely debridement and grafting for deep burns of
eyelids is not done, they tend to heal with contracture leading
to ectropion of the lids. To prevent corneal damage from
exposure, the ectropion of the lids should be released early
even if the scars are not mature (Figs 26.15A to C). Ideally
the upper lids should be released first and grafted with
medium thickness skin graft followed by release of the lower
lids and full thickness grafting of the defect. In case of
severe ectropion, repeated release may be required if
surrounding skin of face is also scarred and contracting
(immature scars) (Fig. 26.16).
Ear Burn
All ear burns may lead to cosmetic deformity if not cared
for properly. The cartilage of the ear is covered with a very
thin layer of subcutaneous tissue and skin which is easily
damaged or destroyed by burn. Cartilage has no intrinsic
blood supply. It survives by diffusion from the surrounding
soft tissues. If the cover, which is very thin, gets burned, the
cartilage gets exposed and may slough out due to dryness
and infection. It leads to loss of supporting structure of the
ear and ultimately results in deformity of the ear (Figs 26.17A
and 26.18A to E)
The external ear enjoys a special place in society all
over the world. Women use wide range of jewellery pieces
to enhance its beauty. With changing trends in fashion world,
nowadays, even males adorn their ear with variety of
ornaments. Because of its limited functional significance,
management of a burned ear is often neglected. Management
Fig. 26.14A: Symblepharosis in right eye and in left eye total loss of
both lids for which upper and lower conjunctiva was mobilized, sutured
over exposed cornea and skin graft applied over it
Fig. 26.14B: Deep burns of the lids with retraction of lids exposing the
cornea –Temporary tarsorrhaphy done in both eyes and raw area
was later grafted after debriding the dead skin over the lids

Facial Burns
353
pertaining to survival and function takes the precedence
over burnt ear management. External ear is particularly
vulnerable to thermal injury due to its prominent location on
the side of the face. In most of the cases of facial burns,
external ear is also involved. In burns, ear may get involved
either because of direct trauma or chondritis.19 The skin
covering the anterolateral surface of cartilage is thin,
adherent and unprotective and hence, is most easily damaged
from thermal injury. Posterior aspect of ear is covered by
thicker layer of sub-cutaneous tissue and skin which give
some protection to the underlying cartilage.
In full thickness burns, the underlying cartilage gets
exposed with subsequent risk of chondritis which can occur
in 25% of cases. Chondritis leads to sloughing of cartilage
ultimately resulting in deformity of pinna. All cases of burned
ear must be treated aggressively to prevent this complication.
The deformity of pinna following thermal injury can range
from minor scarring to near total destruction of external
ear. Because of the poor quality and quantity of skin in the
auricular region, total ear reconstruction in post burn
deformity is a daunting task. Every attempt should be made
C
D
Figs 26.14C and D: Line diagram to show the technique
of tarsorrhaphy
Fig. 26.15A: A case of neglected face burns developing severe
ectropion of both upper and lower lids with exposure keratitis in
left eye
Fig. 26.15B: One week postoperative picture after release and
grafting of upper lids
Fig. 26.15C: Late postoperative picture after release of all 4 lids
with well settled grafts

354
Principles and Practice of Burn Care
to prevent a deformity. Majority of ear burns heal without
surgical intervention. To avoid pressure which can harm
the burnt pinna, pillows are never used under the head and
the patient is not allowed to lie on either side. A ‘donut’ can
be kept under the head and it keeps the head lifted up without
the ears touching it. Hence, there are no chances of pressure
necrosis on the burned ears (Fig. 26.17B). Application of
local antibiotic cream / ointments and avoidance of pressure
help in preventing the development of chondritis in deeper
ear burns. Mafenide cream is the most effective topical
agent used in ear burn. In addition to topical cream, protecting
the ear from external compression also helps in preventing
pressure necrosis and further progress of skin loss. Usually
this is achieved by the used of soft foam around the ear. If
contour dressing is done, a minimal pressure should be
applied while bandaging. With local wound care, application
of mafenide cream and contour dressing, the swelling
subsides and partial thickness burn heals with time. If
perichondrium has been preserved, it will ‘take’ the graft.
If cartilage is exposed in a small area, debridement and split
thickness skin graft over the cut end of cartilage is
recommended. In a large area of full thickness burn where
perichondrium has been damaged leading to exposure of
cartilage, some form of vascularized coverage is necessary
to salvage the remaining cartilage. Unfortunately, local
surrounding tissues can not be used as they are also injured
and in severe burns. Regional or distant flaps20, 21 have been
described to cover the exposed cartilage. These include
Fig. 26.16: Severe ectropion of both lower lids with immature scars in
the surrounding face. Leading to persistent watering from the eyes
and exposure of conjunctiva and lower cornea. Requires early release
with grafting and may even need re-release because of contraction
of the surrounding immature scar
Fig. 26.17A: Acute ear burns showing how the thin skin over the
anterolateral surface of the ear gets blistered and lifted off the
underlying cartilage, thus impairing the blood supply to it. This can be
prevented by early contoured dressing of the burned ear
Fig. 26.17B: ”Donut” used for ear burns
platysma myocutaneous flap and the temporoparietal facial
flap. Temporoparietal facial flap is a thin pliable and very
versatile flap and is the best choice for coverage of exposed
cartilage (Figs 26.18A to E). Whether the best option should
be exhausted for primary coverage of exposed cartilage or
not, is a difficult decision. Besides this, weak ear cartilage
may not withstand the forces of contractions of split skin
graft which is applied over the temporoparietal fascia.
Hence, it leads to deformity. Post auricular fascia, if not
damaged by burn, can also be used to provide cover to the
exposed cartilage. Rosenthal22 has described 12 zones of
the partially burned ear which are divided into three major
regions which include six zones that may be used for donor

Facial Burns
355
Fig. 26.18A: Deep burns of the ear with cartilage exposed after
debridement of dead skin
Fig. 26.18B: Temporoparietal fascial flap exposed and marked
Fig. 26.18C: Raised temporoparietal fascial flap
Fig. 26.18D: Flap inset over the exposed cartilage
Fig. 26.18E: One week postoperative picture with full graft take
over the flap – Cartilage was therefore saved
sites for advancement and resurfacing, three zones which
may excised and closed without significant deformity and
two zones which should be preserved, if at all possible.
Chondritis is a dreaded complication of burns of the
pinna. It is characterized by rapid onset of pain, tenderness
and erythematous swelling of external ear (Figs 26.19A
to G). There is throbbing pain in the ear not relieved by
analgesics. The cephaloconchal angle is increased which is
considered diagnostic. Early diagnosis is essential to achieve
the best results. Chondritis can develop even 4-5 weeks
after the burn. The most common organism responsible
for chondritis are Pseudomonas aeruginosa and

356
Principles and Practice of Burn Care
Fig. 26.19A: Superficial dermal burns of ear – Showing skin raised
as a blister over the underlying cartilage
Fig. 26.19B: Same patient as in Figure 26.19A neglected and developed
chondritis and chondral abscess indicated by the erythema, swelling,
severe pain and tenderness
Fig. 26.19C: Increased cephaloconchal angle diagnostic of chondritis
Fig. 26.19D: Incision given in the rim and pus drained and loose and
dead cartilage if any removed
Fig. 26.19E: Cavity packed
Fig. 26.19F: Contoured dressing over the treated ear

Facial Burns
357
Staphylococcus aureus. The infection is treated by a bivalving
type of incision. Incision is made at the helical rim that
splits the ear into anterior and posterior surfaces. All infected
and necrotic cartilage should be removed. The bivalved ear
is packed with fine mesh gauze impregnated with anti-
bacterial solution. A contour dressing is done with mild
pressure. The dressing should be changed after 24 hours
and ear should be examined for any left over necrotic
cartilage which should also be excised. Dressings should
continue till the wound heals.
In a post burn ear deformity, very often, the skin around
the auricular region is burned and hence, not available for
draping of cartilage framework. Reconstruction of ear is
usually accomplished by costal cartilage framework/
Medpore® and temporoparietal fascial flap23,24 cover or in
cases where majority of the cartilage is intact but deformed,
the ear can be reconstructed by using local flaps from post
auricular region without adding any cartilage framework
(Figs 26.20A to 26.21B).
Perioral Burns
In extensive facial burns, lips and mouth are commonly
involved. In all cases of perioral burns, oral care should be
given to the patients after every meal by the nursing staff
and/or by the family member of the patient or by the patient
himself. Oral care includes daily inspection of the mouth to
see any sign and symptoms of fungal infection. If it can be
spotted, treatment should be started immediately before it
becomes severe enough to prevent feeding and healing of
the wound. Lips are frequently burnt and antibiotic ointment
should be applied to soften the crust and prevent cracking
and bleeding until they heal. After every meal lubrication by
Fig. 26.19G: Same ear after I month with well maintained contours
and minimal deformity
Fig. 26.20A: Post burn deformity of ear – Preoperative
Fig. 26.20B: Costal cartilage framework draped by temporoparietal
fascial flap
Fig. 26.20C: Postoperative result 3 months after
the surgery

358
Principles and Practice of Burn Care
definitely non-viable tissues are debrided; there is a risk of
secondary hemorrhage from the labial artery in the waiting
period and its possibility and the technique of control by
pressing the vessel between finger and thumb should be
taught to the parents of the child. All patients of perioral
burn should be asked to use an oral splint during the period
of scar contraction. In minor burns, the oral splints can
avoid the need for surgery while in moderate to severe burns
the splint can minimize deformity. However, the type of
oral appliances, the time and the duration of splint therapy
has not been standardized. The oral splints have been
described by Hartford et al,25 Colcleugh and Ryan.26 Patients
are advised to wear oral splints 24 hours a day for initial 3-
4 months, only to be removed during eating and oral hygiene.
During scar maturation patients are advised to use it for
further 6 months during night only along with the massage.
If proper care is not taken in acute stage in partial thickness
burn and in full thickness burn, a perioral burn can result in
distortion of commissure. Commissure can be reconstructed
by the technique described by Converse and Wood Smith.27
Pensler and Rosenthal28 have recommended advancement
of orbicularis muscle as a part of commissuroplasty.
Scalp Burn
Management of scalp burn is governed by depth and extent
of injury. Because of its rich blood supply and high density
of hair follicles, even deep partial thickness burn can heal
of its own. This means that most of the scalp burn wounds
will heal with conservative treatment alone. In case of full
thickness burns of scalp, if underlying pericranium is intact,
it will ‘take’ the graft (Fig. 26.22). Full thickness burns of
scalp exposing the bone without pericranium require a
Fig. 26.21A: Post burn ear deformity with constricting effect due to
loss of helical rim cartilage
Fig. 26.21B: Ear reconstruction done after releasing the constricted
ear with postauricular flaps
ointment should continue to prevent crusting. Isolated burns
of lip and mouth are common in children. The majority of
oral burns in children are result of a child biting on a live
wire or inserting the exposed ends of an electric plug into
his/her mouth. These are usually low tension injuries and
the path of the current is difficult to predict because the
moisture inside the mouth lowers the resistance to current
flow. It may be difficult to assess the depth and extent of
injury at the initial examination. It is debatable whether their
primary excision should be done or else left for 10 days or
so to allow clear demarcation of the zone of injury. The
former may end up in excising tissues whose viability is
doubtful but may eventually survive. In the latter, only
Fig. 26.22: Post burn raw area scalp covered with split skin graft

Facial Burns
359
vascularized flap cover29-31 because bare bone without
pericranium does not ‘take’ the graft. However, the well
vascularized diploe is an excellent bed for skin grafting.
Two methods are available to reach to the diploic space. In
one, the outer exposed and devitalized calvarial table is
removed and underlying cancellous bone graft is split skin
grafted. But, the graft ‘take’ is poor. Alternatively the outer
table can be chiseled out and is covered with moist dressings
or multiple burr holes, 3-4 mm apart, are made in the outer
table to promote the production of granulation tissue from
diploe. Granulation tissues come out through the burr hole,
spread over the exposed bone ultimately meeting each other
and provide a bed to accept a skin graft. Full thickness
burns with exposed underlying calvarium can also be closed
by rotation or transposition flap of scalp. Before mobilizing
Fig. 26.23A: Post burn full thickness defect of scalp involving
calvarium following electrical injury
Fig. 26.23B: After debridement – Preoperative
Fig. 26.23C: After coverage by rotation flap
the flap, debridement of all non-viable soft tissue and
devitalized bone should be done. There is a controversy
regarding the amount of bony debridement in full thickness
burn of scalp. Hunt et al noted a 56% complication rate
associated with removal of devitalized bone. Re-growth of
devitalized bone has been documented after coverage with
vascularized flap. It has been suggested that limited
debridement of grossly infected bone followed by immediate
flap cover should be done (Figs 26.23A to D).
Eyebrow Burn
Eyebrow is a very important segment of face. It plays an
important role in emotional expression of a person. Eyebrows
should never be excised in acute stage even in full thickness
burns or in a situation of early burn alopecia. Re-growth of
Fig. 26.23D: Postoperative result – Well healed flap

360
Principles and Practice of Burn Care
hair in eyebrow is unpredictable and can occur weeks after
injury. It is because hair follicles are situated very deep in
the dermis and sometimes in the sub-cutaneous tissues and
hence, remain intact in deep burns. The growth of scalp
hair is very long and slow, thus they appear after long period
of burns. Partial hair loss within the eyebrow can be
reconstructed by excision and primary closure.32
Reconstruction of eyebrow can be done by hair
transplantation, punch graft, composite strip graft, scalp
flap and pedicled island temporoparietal flap based on
temporal branch of superficial temporal artery33-36 (Figs
24A to C). To restore the normal appearance of eyebrow is
extremely difficult and hence, conservative management is
the rule.
SUMMARY
All major burns usually involve the face and isolated facial
burns are uncommon. Although resuscitation of an
extensively burnt patient as a whole is a priority, the
involvement of face cannot be ignored as it is also an
indicator of inhalation injury and demands immediate
attention. As a number of aesthetically important structures
like nose, pinna, eyebrows, etc. are located on the face, it is
of utmost importance to look after each of them with equal
seriousness as it may affect the final outcome and have a
significant bearing on the burn victim’s successful return
back to society.
REFERENCES
1. Cole J, Engrav L, Heimbach DM, et al. Early excision and grafting
of face and neck burns in patients over 20 years. Plast Reconstr.
Surg 2002; 109:1266-73.
2. Jonsson C-E, Dalsgaard C-J. Early excision and skin grafting of
selected burns of the face and neck. Plast Reconstr. Surg 1991;
88:83-94.
3. Hunt J, Purdue GF, Spicer T, et al. Face burn reconstruction - does
early excision and autografting improve aesthetic appearance?
Burns1987; 13:39-44.
4. Warden GD, Saffle RJ, Schnebly A, et al. Excisional therapy of facial
burns. J Burn Care Rehabil 1986; 7:24-28.
5. Jonsson C-E. The surgical treatment of acute facial burns. Scand J
Plast Reconstr Surg 1987; 21:235-36.
6. Celikoz B, Deveci M. Duman H, et al. Reconstruction of facial
defects and burn scars using large size freehand full-thickness skin
graft from lateral thoracic region. Burns 2001; 27:174-78.
7. Snow S, Stiff M, Lambert D, et al. Freehand technique to harvest
partial-thickness skin to repair superficial facial defect. Dermatol
Surg 1995; 21:153-57.
Fig. 26.24A: Post burn loss of bilateral eyebrows
Fig. 26.24B: Hair bearing island flap based on temporal branch of
superficial temporal artery
Fig. 26.24C: Postoperative result after reconstruction of both
eyebrows by superficial temporal artery flap

Facial Burns
361
8. Acarturk TO, Glaser D, Newton ED. Reconstruction of difficult
wounds with tissue-expanded free flaps. Ann Plast Surg 2004;
52:493-500.
9. Angrigiani C, Grilli D. Total face reconstruction with one free flap.
Plast Reconstr Surg 1997;99:1566-75.
10. Ariyan S. The transverse platysma myocutaneous flap for head
and neck reconstruction. Plast Reconstr Surg 1997; 99:340-47.
11. Bauer B, Margulis A. The expanded transposition flap: shifting
paradigms based on experience gained from two decades of pediatric
tissue expansion. Plast Reconstr Surg 2004; 114:98-06.
12. Jia C, Chen B, Su Y. Pre-fabricated lined axial flaps for reconstruction
of extensive post-burn facial and forehead full-thickness composite
defects. Burns 2002; 28:688-90.
13. Pribaz J, Fine N, Orgill D. Flap prefabrication in the head and neck:
a ten year experience. Plast Reconstr Surg 1999; 103:808-20.
14. Tiwari VK, Sarabahi S.Starplasty: an ideal method for correction of
occluded external nares following burns. Journal of Plastic,
reconstructive and aesthetic surgery 2006, 59: 1105-09.
15. Asch MJ, Moylan JM, Bruck HM, Pruitt BA. Ocular complications
associated with burns: Review of a 5-year experience including 104
patients, J. Trauma 1971;11:857.
16. Lewis GK.: Chemical burn. American Journal of surgery
1959;98:928-37.
17. Mazingo DW, Smith AA, McManus WF, Pruitt BA, Majon DD.
Chemical burn. Journal of Trauma 1988;28:642-47.
18. Rozenbaum D, Baruchin AM, Dafna Z. Chemical burns of eye with
special reference to alkali burns. Burns 1991;17:136-40.
19. Mills DC, Roberts LW, Mason AD, et al. Suppurative chondritis: its
incidence, prevention and treatment in burn patients. Plast Reconstr
Surgery;1988:82;267-76.
20. McGrath MH, Ariyan S. Immediate reconstruction of full-thickness
burn of an ear with an undelayed myocutaneous flap: case report.
Plast Reconstr Surg 1978;62:618.
21. Achauer BM, Witt PD, Lamb R. Salvage of ear cartilage in patients
with acute full-thickness burns. J Burn Care Rehabil 1991;12:339.
22. Rosenthal JS The thermally injured ear: A systematic approach to
reconstruction Clin. Plast. Surg. 1992;19:645.
23. Bhandari PS Total ear reconstruction in post burn deformity. Clinics
in Plastic Surgery.2002;29:213-20.
24. Bhandari PS Total ear reconstruction in post burn deformity. Burns
1998; 90:355.
25. Hartford CE, Kealey GP, Lavelle WE et al. An appliance to prevent
and treat microstomia from burns. J Trauma 1975;15:356-60.
26. Colcleugh RG, Ryan JE. Splinting electrical burns of the mouth in
children. Plast Reconstr Surg 1976; 58:239-41
27. Converse JM, Wood-Smith D. Techniques for the repair of defects
of the lips and cheeks. In: Converse JM, ed. Reconstructive Plastic
Surgery: Principles and Procedures in Correction, Reconstruction
and Transplantation, 2nd edn. Philadelphia: WB Saunders;
1977:1574-78.
28. Pensler JM, Rosenthal A. Reconstruction of the oral commissure
after an electrical burn. J Burn Care Rehabil 1990;11:50-3.
29. Hunt J, Purdue J, Spicer T. Management of full thickness burns of
scalp and skull. Arch Surgery.1983;118:621-25.
30. Worthen EF. Regeneration of skull following deep electrical burn.
Plast. Reconstr. Surgery.1971;4:1-4.
31. Leighton WD, Johnson ML, Freidland JA Use of temporary soft
tissue expander in post traumatic alopecia. Plast Reconstr.
Surg,1986;77:737-47.
32. Cedars MG. Reconstruction of the localized eyebrow defect Plast
Reconstr Surg 1992; 100:685-89.
33. Goldman GD. Eyebrow transplantation. Dermatol Surg 2001;
27:352-54.
34. Nordstrom RE. Eyebrow reconstruction by punch hair
transplantation. Plast Reconstr Surg 1977; 60:74-6.
35. Sloan DF, Huang TT, Larson DL, et al. Reconstruction of eyelids and
eyebrow in burned patients. Plast Reconstr Surg 1976; 58:340-46.
36. Ziccardi VB, Lalikos JF, Sotereanos GC, et al. Composite scalp
strip graft for eyebrow reconstruction: case report. J Oral Maxillofac
Surg 1993; 51:93-6.

362
Principles and Practice of Burn Care
Hand Burns
27
S Raja Sabapathy
Chapter
INTRODUCTION
Optimal hand function has a very positive impact on the quality
of life of a post burn patient. This assumes considerable
importance because the ultimate integration of the burn patient
back into the society depends upon the functional status of
the hands to carry out the daily activities and make an
independent living. Tredget1 found that in patients with a
mean total body surface area (TBSA) burn of 15%, 54% of
the patients sustained burns of the hand and upper extremity.
Sheridan2 analyzed the outcome of 1047 acutely burned
hands in 659 patients treated over a 10-year period. They
found that in patients with superficial burns, 97% had normal
hand function while in those with deep dermal and full
thickness injuries requiring surgery, only 81% regained
normal hand function. Although only 9% of those with
injuries involving the extensor mechanism, joint capsule or
bone had normal functional outcomes, 90% were able to
perform activities of daily living independently. This high
percentage of good function is achieved when hand burns
are properly assessed at presentation and timely surgical
intervention is done for those who need it. If the opportunity
is missed, the result is a bad, scarred hand with severe
contractures which are difficult to correct (Figs 27.1A and
B). It is a preventable complication. The purpose of this chapter
is to guide the surgeon to meet the specific demands of the
burn injured hand and obtain the best possible outcome.
ACUTE HAND BURNS
Anatomical Considerations
The palm of the hand is covered with thick glabrous skin
which is attached to the bone by fibrous septa. The dorsal
Figs 27.1A and B: An 18-month-old child who sustained flame burns
to the dorsum of the hand with severe contractures due to allowing
the deep burns to heal spontaneously
A
B

Hand Burns
363
surface is covered with thin skin, loosely attached to the
underlying structures. Post burn edema causes significant
swelling on the dorsum which leads to un-physiological
joint positions. On the other hand, on the palmar aspect,
although the edema may not be apparent, it can lead to
severe physiological disturbances by causing pressure on
the vessels in the palm and the median nerve in the carpal
tunnel. The swelling in the palm can cause arterial
insufficiency while the swelling on the dorsum can
compromise the venous return. The combination results in
compartment syndrome of the intrinsic muscles.
The collateral ligaments are taut when the
metacarpophalangeal (MCP) joints are in full flexion and
the interphalangeal (IP) joints are in extension. This is the
ideal position of immobilization of these joints after injury.
If stiffness occurs with the MCP joints in extension and the
IP joints in flexion, the contracted collateral ligaments resist
correction. The joints of hand form a system of intercalated
joints wherein the distal joint takes up the deformity opposite
to that of the proximal joint. The wrist joint is the key. If
not splinted, the joints take up the position of maximum
comfort which is exactly the opposite of what is ideal for
function. In the stage of edema, if the hand is unsupported,
the wrist gets flexed, the MCP joints become hyperextended
and the PIP joints become flexed (Figs 27.2A and B). If the
central slip gets attenuated or the dorsal skin over the PIP
joint becomes thin, the stage is set for the development of
the boutonnière deformity. Alternatively, if the intrinsic
muscles suffer compartment syndrome, swan neck
deformity develops in the fingers and first web contracture
occurs. The optimum treatment of a burnt hand revolves
around keeping the joints in the position of optimum function,
regularly making the joints go through the full range of
movement while achieving healing of the wound as early as
possible.
Assessment
It is advisable to admit all cases of hand burns with the
exception of very minor ones. This is because, should a
complication occur, the morbidity produced far outweighs
the cost and efforts involved in in-patient treatment.
If the hands are burnt as part of a major burn injury, the
general management of the patient should rightfully deserve
all the attention. Whatever be the total percentage of burns,
a preliminary examination of the affected hand is done. One
should look for associated injuries like hand and finger
amputations, fractures and dislocations. The depth of burns
is assessed. Second degree superficial dermal burns are
pink, moist and painful and blanch on pressure. Blisters are
considered to be characteristic of superficial burns. Deep
dermal burns are waxy white in appearance. Full thickness
burns are obvious by the thick leathery skin, appearance of
thrombosed subcutaneous veins through the skin and
absence of pain to pin prick. Assessing ends of extremes is
easy but assessing deeper partial thickness burns can be
difficult. Newer technologies like laser Doppler flowmeter,
intravenous Fluorescein and ultrasound have been tried but
traditional clinical assessment remains unsurpassed by new
technology.3 If the area does not blanch on pressure, is dull
to pin prick then probably it is a deep partial thickness injury.
The areas in question must be marked in a drawing and
attached to the case records. This must be done before the
application of topical antimicrobials, as otherwise the
assessment may become difficult later.
In circumferential full thickness burns and deep partial
thickness burns the edema can cause circulatory
compromise. Ultrasound recordings, pulse oximetry,
photoelectric plethysmography have been tried but
escharotomy must be performed on clinical grounds.
Significant increase in survival of fingers has been found
following lateral digital escharotomy compared with those
not decompressed.4 If the hand starts feeling cold and
palmar arch pulse disappears on Doppler, it is better to
decompress the part. Escharotomy has to start proximally
in the arm depending upon the involvement. If proximal
Figs 27.2A and B: (A) The edema of the acute stage of the burns
occurs predominantly on the dorsum of the hand due to the loose
tissue on the dorsum. This results in hyperextension of MCP joints. (B)
If the joints are not properly splinted in the acute stage, this typical
deformity of wrist flexion, MCP hyperextension and IP joint flexion
occurs. This is an avoidable disaster which is difficult to correct
A
B

364
Principles and Practice of Burn Care
escharotomy does not make the fingers warm it has to be
continued to the hand and digits. In the digits it is done on
the ulnar side of the index, middle, ring and little fingers and
the incision can be carried proximally into the dorsum of
the hand. For the thumb, the initial incision is on the radial
side. Escharotomy is done with fine cautery and some
patients may need anesthesia. Hemostasis must be carefully
secured after release.
The edema may mask the onset of compartment
syndrome of the intrinsic muscles. High levels of suspicion
are necessary. The Finochietto intrinsic tightness test must
be done (Fig. 27.3). The MCP joint is passively extended
and when in that position the PIP joint is passively flexed.
Presence of good resistance is an indication for the release
of the intrinsic muscles. This requires anesthesia. The
escharotomy incisions can be used to release the intrinsic
compartments and usually in such instances the carpal
tunnel and the Guyon’s canal are also decompressed. If
nerve compression is the predominant problem, claw hand
deformity results (Figs 27.4A to J). If intrinsic muscle
contracture is the main issue, swan neck deformity results.
Initial Management
Once assessment of the depth of injury is made and recorded
and the need for decompression is taken care of, the hand
is dressed with moist non adherent dressings. Dry dressings
Fig. 27.3: Intrinsic tightness test (Finochietto-Bunnell). When intrinsics
are tight it becomes difficult to flex the PIP joint with the MCP joint
hyperextended. If this is positive then the intrinsics have to be released.
When the MP joint is in extension, the contracted interosseous muscle
impede flexion of the PIP joint because of the traction exerted on the
extensors. Flexion of the MP joint relaxes the extensors and flexion
becomes possible at the PIP joint
and exposure method is not recommended for hand burns.
The hand is dressed with topical antimicrobials like silver
sulfadiazine 1% cream. After dressing, the hand is
immobilized with a splint with the wrist in mild dorsiflexion,
the MCP joints in about 70 degrees of flexion and the IP
joints in extension. Between two dressings, the hand should
be put through possible range of movement at least twice a
day. In the initial stage the dressings may need to be done
daily and the movements must be started on Day 1, even in
critically ill patients.
If the depth of burns is assessed as superficial the wound
can be dressed, splinted and left as such for 4-5 days. An
earlier dressing change may be indicated in case there is
soakage of dressing or the patient complains of undue pain,
fever or foul smell/discharge, etc. Very frequent dressing
changes in such cases disturbs the healing epithelium and
may increase the chances of infection. Another method
suggested for the management of superficial burns is to
smear the hand with silver sulfadiazine and place the hand
inside a sterile surgical glove and allow continuous
movement. The glove can be replaced when it gets soiled.
Good healing with absence of contracture has been shown
by this technique.5
If one is unsure of the depth of burns or if the dressings
get extensively soaked, the wound is redressed. Lack of
adherence of the dressings to the wound is considered
another indication of deep burns.6 At all times, the hand is
diligently splinted in functional position and early motion
exercises started. The hand is kept elevated and in a splint
at all times except when the patient is on therapy. By about
3 to 5 days the wound can be reassessed and decision made
for continuation of conservative management or operative
intervention.
EARLY SURGERY FOR BURNS OF HAND
Early surgery for a burnt hand can be done for second
degree deep dermal, third degree full thickness or in the
fourth degree burns when underlying tendons, bone or joints
are also involved. In second degree deep dermal burns, the
aim is to obtain near normal function, while in the deeper
degree burns the aim is to maximize the restoration of function.
Tangential Excision
Early tangential excision and coverage of burns initiated by
Janzekovic (1970)7 is a milestone in burn care (Figs 27.5A
to J). It involves shaving off of the deep dermal burns up to
viable dermis and immediate coverage with skin. It is done

Hand Burns
365
Figs 27.4A to J: A 12-year-girl with electrical burns of both hands admitted after 14 hours of injury. She had numbness in all the finger tips (A
and B). Carpal tunnel and Guyon’s canal decompression was done in both the hands (C). Despite this, he patient developed complete intrinsic
paralysis in both hands (D to F). The intrinsics recovered in 3 months time (G to J). If the nerves are not decompressed in time, patients usually
end up with gross deficit
A
B
C
D
E
F
G
H
I
J

366
Principles and Practice of Burn Care
Figs 27.5A to J: Deep dermal flame burns involving both hands (A to D). Patient had tangential excision of the burns and skin grafting.
Good functional results seen during follow-up (E to J)
A
B
C
D
E
F
G
H
I
J

Hand Burns
367
around 4 days post burn when the patient has recovered
from the burn shock phase. The burnt surface is
successively shaved with a grafting knife, set to cut a thin
slice, until fine punctuate bleeding is encountered as the
tips of the vertical dermal capillaries are shaved off. This is
done under tourniquet and confirmed after deflation.
Between the sites of dermal bleeding, dermal collagen is
exposed and some epithelium remains viable in the deep
skin adnexae. This surface supports a skin graft applied
immediately so that it does not dry out. Grafts survive by
picking up a blood supply from the capillary loops which
have been transected. The intervening dermis becomes
incorporated beneath the graft. Healing is faster and better
cosmetic and functional results are achieved because the
deeper dermis of the native skin is saved. To prevent the
problem of hematoma formation beneath the graft,
tourniquet is released after shaving and all brisk bleeding
points are coagulated till it is felt that the fine ooze can be
controlled with pressure. When all brisk bleeding points
have been coagulated, the tourniquet is inflated again, grafts
applied, gentle compression dressing given and then the
tourniquet can be released. If there is doubt about
hemostasis, the first dressing can be done at 48 hours to
drain the sub graft collection.
It is ideal to apply a split thickness sheet graft with a
thin layer of dermis (0.010 to 0.012 inches thickness) to
cover the raw areas (Figs 27.6A and B). 1:1.5 meshing of
the skin graft can be done, but it should not be expanded.
In tangential excision, thick grafts and meshed grafts must
not be applied. They give a poor cosmetic result.8 Remnants
of epithelium which grow after graft ‘take’ may produce
small inclusion cysts on the surface for some months. As
the cysts appear beneath the thin skin graft they can be
decompressed and they settle well. In the tangential excision
technique, the area shaved must always be covered with
graft either immediately or at least within 2 hours. If left
uncovered, the exposed dermis desiccates and the deep
dermal burns get converted into a full thickness injury. The
technique involves blood loss and hence should always be
done under tourniquet. Blood loss is not a problem when
surgery for hand burns is done under tourniquet. At any
particular session not more than 10% of body surface area
must be shaved and grafted. Tangential excision requires
correct choice of patient, blood, infrastructure and skill. It
is suitable for experienced personal. For others, the safer
option is the conservative management with dressings and
grafting the raw areas at the earliest.
In tangential excision, a layer of viable dermis must be
left behind to be covered with thin skin graft. It must not be
confused with excision of the burns done for full thickness
injuries which is dealt with later. Tangential excision is good
for deep dermal burns involving the dorsum of the hand. It
is generally not used for the palm.
Excision of Burns
When the injured area is limited, definitely full thickness
and the general condition of the patient permits, the burn
wound can be excised and skin cover provided. In hand
burns it is usually applicable to limited area full thickness
burns overlying joints, tendons and bone (Figs 27.7A to D).
In such circumstances if allowed to take the natural course,
the necrosing burnt area will be complicated by infection
Figs 27.6A and B: When early tangential excision of burns is done
the raw area must be immediately covered with thin graft. Figures
show the recommended thickness of the graft
A
B

368
Principles and Practice of Burn Care
and loss of critical tissue. Early excision and flap cover in
such circumstances helps to salvage critical structures. In
burns of upper limb, it is better to limit this excision to such
instances. When done for wide areas of the forearm and
arm, the level of excision has to be up to the deep fascia.
Mere excision of the full thickness skin will expose the
subcutaneous fat which may not be a good bed for the
survival of the split skin graft.
Timing of Surgery
To obtain a better understanding of the parameters involved
in the long-term functional outcome of hand burns a
retrospective study was performed by VanZuijlen et al on
88 consecutive patients with hand burns (143 hands).9
Patients were followed for 12 months. Hand function was
assessed by seven objective test criteria (7-OTC) described
by Jebsen10 (Table 27.1). Five parameters were found to
have a significant predictive value for long-term hand
function. In order of predictive value, these were finger
amputations, age at admission, impaired autograft ‘take’,
the full thickness hand burn surface area and the full thickness
total body burn surface area. No relationship was found
between the post burn day of operation and the long-term
hand function. This finding is inconsistent with the
consensus that functional outcome is improved by early
excision and grafting. While provision of early cover to the
hand burns is beneficial, in a patient with major burns general
measures and coverage of large segment raw area takes
priority. It is the opinion of this author that hand function is
well preserved when burns of uncertain depth are treated
expectantly, followed by selective debridement and grafting.
Advantages include reduced blood loss, no loss of vital tissue
and a reduction of the need for donor sites.
If a diagnosis of full thickness burn of the hand is
certain, early primary excision and grafting is advocated. If
diagnosis is a clear deep dermal second degree burns of the
dorsum of the hand and fingers, tangential excision and
grafting is done within 4-5 days. Rehabilitation is commenced
as early as possible and the length of hospital stay is reduced.
If the assessment of burn depth is difficult, the operation
can be postponed to prevent excision of vital tissues allowing
those areas with partial thickness burns to heal spontaneously.
A ‘wait and see’ approach to hand burns of uncertain depth
is valid. The function of the hand will not be adversely
affected by delayed surgical treatment in those patients with
extensive burns in whom early large area wound closure
takes priority.9 The aim is to achieve skin cover to the hand
within 2-3 weeks from injury before infection sets in.
However, till wound healing is achieved the hand has to be
splinted in the functional position and range of movement
exercises have to be provided. After grafting, if there are
areas of graft losses, re-grafting of the areas is important.
Allowing healing by secondary intention results in poor
outcome.
Table 27.1: Jebsen’s10 objective test criteria
1. Writing words as quickly and clearly as possible with dominant
and non-dominant hands.
2. Turning over five 3 x 5 inch index cards (simulated page turning)
3. Picking up small common objects: Asked to pick up a coin and
paperclip, placed on a desk.
4. Simulated feeding: Had to pick up peas from a plate with a
teaspoon and bring it to his/her mouth.
5. Stacking checkers: A stack had to be made with five small wooden
checkers, placed in front of the patient.
6. Picking up large light objects: The patient was asked to pick up
an empty can with a diameter of 10 cm
7. Picking up large heavy objects: Was asked to pick up a full can
(600 grams) with a diameter of 10 cm.
Figs 27.7A to D: Localized deep burns of the hand can be excised
primarily and covered with local flaps
A
B
C
D

Hand Burns
369
FLAP COVER TO THE DEEP BURNS OF THE HAND
In fourth degree burns, it is wiser to resort to early flap
cover than just rely on positioning the joints. Various local,
regional pedicle flaps like radial and posterior interosseous
flaps, distant pedicle flaps and free flaps can be used to
cover post burn raw areas (Figs 27.8A to J). Any of them
can provide good result provided care is taken to keep the
joints in functional position during flap transfer. Critical to
the success of flap transfer is debridement of the area. The
base has to be debrided to viable depth and the wound margins
excised to good viable skin. This is crucial for success, for
otherwise the flap detaches and slips off from the edges. A
vascular flap cannot make the dead burned tissues in the
base alive.
It is rare for palmar side to need flap cover. Palmar skin
is thick and during most injuries the palm escapes deep
burns because of the clenched fist position during injury.
Deep palmar burns usually require flap reconstruction only
when there is associated flexor tendon exposure or loss.
Skin grafting is preferred because it produces the fixity and
resistance necessary for satisfactory grip (Figs 27.9A to E).
As with all hand burns it is essential to ensure total ‘take’ of
the graft. When flap cover is required to the palm it has to
be thin. Bulky flaps give a sense of fullness in the hand and
prevent gripping of objects.
Reconstruction of severely burned fourth degree
hand burns: Circumferential fourth degree burns may need
amputation. In all other burn injuries all effort must be made
to save available length of the hand. A very common pattern
A
B
C
D
E
F
G
H
I
J
Figs 27.8A to J: A 3-year-old child was brought three weeks after electrical burns to the hand involving the thumb, index and middle fingers
(A to C). The wounds were radically debrided and the bones stabilized by K-wire (D to F). Small abdominal flaps were given to the thumb and
middle finger and the index raw area skin grafted (G). Good functional result achieved (H to J)

370
Principles and Practice of Burn Care
Figs 27.9A to E: Deep burn of the palm sustained during an epileptic attack (A). The area was excised and covered with split skin graft
(B and C). Good after care with compression garment and massage gave satisfactory outcome (D and E)
A
B
C
D
E

Hand Burns
371
Figs 27.10A to G: Deep burns involving the dorsum of the hand with loss of extensors, exposed joints and phalanges (A). The wound was
well debrided (B), and an abdominal flap planned including both the groin and hypogastric territories (C to G). The flap was subsequently
thinned. He had reasonable function of the hand even without extensor tendon reconstruction
A
B
C
D
E
F
G
of injury is very deep dorsal injury exposing burned bone
with viable volar side (Figs 27.10A to 27.11K). Advances in
flap cover and microsurgery can make these hands
functional. Early flap cover rather than simple K wire stabi-
lization is advocated for salvage of these hands.11
AFTERCARE OF BURNED HANDS
Totally healed burned hand is a good platform to start
rehabilitation. Even small areas of unhealed wounds give
rise to inflammation, need regular dressing, are painful and
make the patient uncooperative for rehabilitation schedules.

372
Principles and Practice of Burn Care
The aim is to minimize the edema, increase the range of
movement and prevent scar hypertrophy. Daily supervised
physiotherapy is essential.
The value of pressure to prevent hypertrophy of scar
was advocated by Parks 12 and Larson.13 They advocated
continuous controlled pressure of the magnitude of 25 mm
Hg above the capillary pressure. Custom made compression
garments are prescribed and the patient is made to wear it
at all times other than at the time of exercises. They must
be worn for at least 6 months. These are most effective in
the early stages and hypertrophic scar is responsive to
pressure in the first 3 months (Figs 27.12A to H). For this
reason it is emphasized that the end point of acute burn
management of the hand is to get stable healing of all the
wounds. Patient compliance with pressure garments is not
good if they are worn over dressed wounds. The bleeding
from the wound and the pain deter them from wearing the
pressure garment and ranging of the joints. Hence it is our
practice to readmit the patients even when there is a small
area of skin loss and re-graft to get good stable healing. It is
common for contractures to occur in the web. One of the
effective ways to prevent it is to roll the micropore plaster,
place it in the web and hold it by tapes (Fig. 27.13).14
Perkins15 initiated the use of silicone gel in scar for
controlling hypertrophic burn scars. Though the mode of
action of the gel is still uncertain, clinically it has been found
to be effective. Probably they act by decreasing the
evaporation of water from the skin and maintaining the
optimum hydration of the stratum corneum. Like pressure
garments it also has to be applied for a few months. Silicone
gel application allows early pain free movements of stiff
joints. When applied over healed skin grafts it prevents
contraction of the grafts and when applied over hypertrophic
scars, the scars soften and make them more amenable to
pressure therapy. It is the practice of the author to use both
silicone gel sheet and pressure garment together whenever
possible in conjunction to get optimum results. Silicone
product improvement has been done and now it is available
in a tube as a gel. It has the advantage of easier application
in areas of varying contour and patients find it easier to
comply. Equally good results have been claimed.16
It is to be emphasized that prime consideration in the
prevention of hypertrophic scar and contracture is to obtain
early and complete healing of the burn wound in the hand.
POST BURN HAND DEFORMITIES AND
THEIR MANAGEMENT
Complications of hand burns are due to poor wound healing,
namely hypopigmented scars, hypertrophic scars and joint
contractures. They cause both functional and esthetic
problems.
Hypopigmented areas are due to delayed wound healing
and are areas which would have benefitted from early
grafting. If cosmetically disfiguring, the areas are excised
and covered with partial thickness skin graft. Complete
excision has to be done as otherwise remnants at the rim
give poor outcome and are difficult to treat.
Hypertrophic scars again are due to delayed wound healing
and occur in areas which would have benefitted from early
skin grafting. They may be associated with contractures.
Release of contractures by incising the hypertrophic scars
and grafting will release the tension in the scar. Initially the
variations in contour may appear unsightly, but aftercare
with compression garments allows it to settle down and
provide quite acceptable results.
Contractures result in great functional problems.
McCauley17 proposed a classification system which
correlates the severity of burn scar contractures to hand
function (Table 27.2).Contracture release is done when the
scar equilibrium has been obtained which is evident by
absence of scar tenderness and redness. This usually occurs
in 3 to 6 months. Recurrences after release are less common
when release is done at this period. It is usual to obtain the
release of axilla and elbow contractures before the hand
contractures are dealt with. Technical aspects of release of
some common joint contractures are dealt with in detail.
Metacarpophalangeal Joint Contractures: An MCP joint
contracture can be in extension or in flexion. A well
functioning MCP joint along with a good first web are the
cornerstones for obtaining good function in the hand. When
releasing extension contracture an assessment is made about
the type of skin cover needed. If flap cover is to be provided
Table 27.2: McCauley’s17 classification of burn scar
contractures in hand
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 IV contractures A:
Flexion contractures B: Extension contractures C:
Combination of flexion and extension contractures

Hand Burns
373
Figs 27.11A to K: Fourth degree burns of the dorsum of the hand, forearm and arm with relative sparing of the volar side in an industrial
accident (A and B). The dead skin was excised (C), which revealed the damage to the muscles (D). The wound was serially debrided and the
arm and forearm were grafted. The hand was subsequently debrided and covered with a groin flap to achieve a satisfactory functional
outcome (E to K)
A
B
C
D
E
F
G
H
I
J
K

374
Principles and Practice of Burn Care
an incision can be made over the MCP joints to obtain release.
Otherwise a transverse incision is made 2 cm proximal to
the joint line and flap raised. After contracture release the
distal skin migrates to cover the joint while skin graft is
applied proximally (Figs 27.14A to D). Collateral ligament
release and pericapsular dissection may be needed to obtain
full release. Two major problems exist in MCP joint extension
contractures which need attention. One, the contracted
collateral ligament needs release (Capsulotomy). Second, a
pocket needs to be created on the volar side for the base of
the proximal phalanx to slide down the head of the
metacarpal. For capsulotomy, the capsule is entered by
making an incision over the extensors and by gentle sweep
of a No.11 blade the contracted collateral ligament is incised.
When released it is possible to flex the proximal phalanx but
without the pocket in the volar side, the joint subluxates
Figs 27.12A to H: A deep dermal burn of
the dorsum of the hand treated by early
tangential excision (A and B). The grafts settle
well and yield good results (C to E). When
followed up with custom made compression
garments (F to H)
Fig. 27.13: To prevent web creep after grafting of the web spaces,
compression is needed. It can be obtained by placing a rolled micropore
plaster retained by a tape
A
B
C
D
E
F
G
H

Hand Burns
375
(Figs 27.15A to C). This needs to be taken care of. By a
combination of usage of curved scissors and curved
dissectors, the adhesions on the volar aspect of the MCP
joint are released. Proper translation of the base of the
proximal phalanx over the head of the metacarpal is
confirmed both clinically and radiologically. If there is
resistance for maintaining the position, the joint should be
pinned and most often, flap cover is required in such cases.
Extension contracture of the MCP joints is frequently
associated with flexion contracture of the IP joints. Release
of the MCP joint may make the finger tips bury into the
palm. Usually it is difficult to correct all the contractures at
the same time and this temporary problem has to be explained
to the patient beforehand. If the PIP joint contracture needs
volar release, it is done in another sitting. For some cases,
arthrodesis of the PIP joint may be the chosen option and in
that case both the MCP and the PIP joint releases can be
done at the same time.
Proximal Interphalangeal Joint Problems: Although
regaining of movement in all the joints is the aim of every
hand surgeon, in burned hands particularly at the PIP joints,
arthrodesis may be one of the common operations resorted
to. This is because of the original damage to the extensor
apparatus that occurred at the time of injury or subsequently
due to edema, poor positioning of the joint and loss of skin
over the PIP joint. It is best to prevent the problem since an
established PIP joint contracture is resistant to treatment.
In the acute situation the PIP joints are splinted in extension.
If there appears to be a risk of skin loss over the joint an
oblique K wire is passed through the joint to keep it in
extension. This reduces the stress on the skin. It may heal
or else granulate enough to be covered with skin graft. This
step may prevent loss of extensor tendons and joint exposure.
This is a crucial step in the care of hand burns. Otherwise,
the central slip ruptures and the lateral bands slide down
resulting in a boutonnière deformity. If the joint is exposed
early debridement and cover with local flap is tried. If not,
distant flaps have to be resorted to. In isolated hand burns
this is practical, but if this problem occurs in a major burn
the joint may be lost in debridement and the wound heals
with the finger shortened.
Boutonnière deformity is due to the attenuation or rupture
of the central slip and the sliding volarwards of the lateral
bands. The deformity has two components – flexion at the
PIP joint and extension at the DIP joint (Figs 27.16A and
B). If a boutonnière deformity is passively correctable, the
Figs 27.14A to D: For the release of dorsal contractures, an incision
as in the figure will slide the distal flap to cover the joint after release.
Joint release can also be done under the flap. If the release process
does not expose critical structures skin graft may be applied to the
raw areas
A
C
B
D

376
Principles and Practice of Burn Care
PIP joint is splinted in extension and the patient is encouraged
to flex the DIP joint. The flexion of the DIP joint in turn
makes the lateral bands slide up at the PIP joint level. Therapy
is very important in boutonnière deformity correction and
no surgery is likely to succeed unless both the components
of the deformity are passively correctable. If passively
correctable and the dorsal skin overlying the PIP joint is of
good quality,correction can be attempted by reinserting the
central slip, freeing the lateral bands from the volar side and
plicating them dorsally. The limiting factor is the skin
condition over the joint which usually is of poor quality. So
arthrodesis of the PIP joint is the commonly advocated
procedure.
The aim of arthrodesis of the PIP joint is to bring the
joint in a position so that it can achieve good contact with
the thumb pulp. If stable fingers achieve pulp to pulp contact
with the thumb, the hand becomes functional. To this end,
the recommended angle of arthrodesis of the PIP joints are
25-35° for index, 30-40° for middle, 35-45° for ring and
40-50° for little finger. This angle may be varied according
to the length of the finger and the movement possible in
each of the components. Technically, a few points are worth
noting. It is better to access a too much flexed joint by a
gentle curvilinear incision than a longitudinal incision. When
a hyperflexed joint is arthrodesed, secondary to bone
shortening which is part of the procedure, the incision may
open up into a diamond making closure difficult. The flap is
carefully raised and the joint entered by making a longitudinal
incision in the midline. The collateral ligaments are divided
by a gentle sweep of No.11 blade along the sides and the
two articular surfaces are brought out to view. To obtain
the correct angle of arthrodesis, one of the components is
transected transversely and the other at the recommended
angle of arthrodesis. The author finds this easier than trying
to adjust the angle on both sides. K wires are used for
stabilization. The bone is osteoporotic and fixation has to
be done by single pass of K wires. As the fingers are
immobilized, even a single oblique K wire is sufficient.
The K wires are retained for a minimum period of 4 weeks
and if the skin condition is good the wire may be retained
for 6 weeks. The MCP joints are mobilized during this
period.
Distal Interphalangeal Joint Problems: Deep dorsal burns
over the DIP joint cause attrition rupture of the extensor
insertion resulting in a mallet finger. This can also,
secondarily, lead to swan neck deformity. Mallet finger and
swan neck deformities are functionally more disabling than
boutonnière deformity. Due to poor quality of the skin
overlying the joint, tendon reconstructions are usually not
possible. Arthrodesis of the joint in 0-5 degrees is done by
wedge resection of the articular surfaces. Performed early,
it may prevent the development of swan neck deformity. In
burns, the swan neck deformity is more often due to scar
hypertrophy and contracture of the dorsal skin of the fingers.
In these situations, incision release of the hypertrophic scar
in two places preferably over the proximal and middle
phalanx and grafting the residual raw areas is very useful.
When the hyperextension at the PIP joint is addressed and
the DIP joint remains flexed, the deformity becomes non-
functional. The DIP joint then needs to be arthrodesed in
0-5 degrees.
Web space problems: First web contracture—The problems
of contracture of the first web are different from the
contracture of other web spaces. While web contractures
in the fingers affect the individual mobility of the fingers
and the ability to spread, first web contracture affects the
span of the hand. It reduces the working space of the hand
and is functionally more crippling.
Figs 27.15A to C: During the release of the hyper extension contracture
of the MCP joints of the fingers, it is important to clear the tissues on
the volar aspect of the head of the metacarpal and create a pocket
(A and B). Otherwise the joint subluxates (C) and if pinned in that
position the contracture will recur

Hand Burns
377
In the acute phase, the general tendency of the thumb is
to lie in an adducted and extended position. Left as such,
the narrowing of the first web occurs and thenar muscles
and joints get stuck in that position. The contracture may
be due to the tight skin or may be associated with intrinsic
contracture and joint contracture. If it is due to the skin
only, the contracture can be corrected by Z plasty or its
various modifications (Figs 27.17A to D). Frequently, it
needs further release and in such situations, the author prefers
to extend the dorsal limb of the skin incision proximally to
access the deeper structures. The fascia over the
interosseous and the adductor is incised.The Z plasty flaps
are transposed. This provides good skin in the web and the
defect on the dorsal aspect of the web is skin grafted
(Fig. 27.18). If the contracture is more severe, the first
dorsal interosseous muscle is released from its origin at the
first metacarpal and the adductor pollicis origin is shaved
off from the third metacarpal. This enables them to retain
their blood and nerve supply. The badly contracted first
Figs 27.16A and B: Boutonnière deformity in the ring finger (A).
Correction is difficult because of poor quality skin on the dorsum. In
spite of the deformity function is preserved in most cases
A
B
Figs 27.17A to D: Z plasty and its modifications are good for the
release of band contractures (A and B). When done in the fingers
bigger Zs are better than small flaps (C and D)
A
B
C
D

378
Principles and Practice of Burn Care
web needs further release at the first CMC joint. Only then
the web opens up. While doing this, one has to be careful
not to damage the radial artery which passes from dorsal to
the volar side close to the joint. The released web is
maintained by a K wire spacer and a flap cover is provided.
As the local flaps are generally not available, a posterior
interosseous flap or a distant groin flap has to be used (Figs
27.19A to J).
Post burn syndactylization of fingers: Fingers may need
syndactyly correction or correction of the web creep. Minor
web contractures can be corrected by Z plasties –four flap
technique or V-M plasty. More recently the author is using
the square flap technique which is also useful for more
severe syndactylization (Fig. 27.20). It is important to achieve
good primary healing of the wounds after surgery so that
pressure garments and silicone gel compression can be
instituted early. Physical therapy is the corner stone for the
prevention of web creep.
Volar Contractures: Contracture of the volar aspect of
the fingers is more common than that of the palm. Little
finger is more often affected and more severely than other
fingers and correction is also more difficult. Incision release
is done for these contractures and the resulting raw areas
are preferentially covered with full thickness skin grafts.
Sometimes the volar plate and the joint capsule need release.
In such situations the joint needs stabilization with a K wire
till the skin cover settles. Limiting factor for release is distal
vascularity. After obtaining the release possible, the
tourniquet is released and vascularity of the fingertip is
checked. If it is slow to pick up, the joint is gradually flexed
to the extent where the fingertip turns pink and the joint
fixed at that level. Checking the vascularity of the fingertip
is important at the completion of contracture release and in
the immediate postoperative period. If joint release is done
or the flexors and the nerves are exposed it is preferable to
provide flap cover. Cross finger flap is a common flap used
in this situation (Figs 27.21A to C). The author has a low
threshold for using flaps on the volar aspect of the fingers
after contracture release. In marginal situations if skin graft
is applied over the flexor sheath and digital neurovascular
bundles, the graft may be expected to ‘take’. In the event
of recurrent contracture during revision surgery chances
of injury to the digital neurovascular bundles is very high.
Color of the skin graft on the volar aspect of the fingers
is a cause for concern for some patients. If the raw area to
be covered is small, second layer of palmar graft from the
hypothenar eminence is a good source for a better color
match; other sources are grafts from the instep area. The
morbidity at the donor sites and the limited area of skin
available are factors against their common use. Skin grafts,
in course of time, become supple and the patient acceptability
increases with time.
Amputations: Finger and hand amputations occur in
circumferential fourth degree burns and in major electrical
burns injury. While it is unavoidable in such situations,
amputations must not be allowed to occur due to infective
complications. Functionality of the hand depends upon the
capability of the thumb stump to meet the tips of fingers.
Length of the remaining fingers, the depth and the span of
the first web are the limiting criteria of function. Following
salvage procedures are possible.
Phalangisation is one of the early procedures
recommended for the reconstruction of the mitten hand.
This involves deepening of the first web, receding the
adductor insertion proximally and excising the index ray
remnant. There is an increase in the first web space at the
expense of the palm width.This was succeeded by
Pollicization wherein the index ray remnant is transferred
over the thumb stump.18 This is a technically demanding
procedure particularly if the web skin is intact. If the index
stump has some sensate volar skin it is transferred with the
nerve. In both techniques the result depends upon the intact
thenar musculature and the length of the remaining stumps.
The third alternative is distraction lengthening of the stumps.
If the whole of the first metacarpal is intact, distraction
Fig. 27.18: For release of the first web space,
a Z plasty incision extended on the dorsum
gives good exposure. The transposed Z flaps
cover the web and the raw area may be
covered with graft

Hand Burns
379
Figs 27.19A to J: A severe contracture of the hand (A to C). Release requires complete excision of all scar tissue (D). Creating a good first web
is important for function and is retained by a K wire (E). A groin flap cover is given (F), and aggressive physiotherapy is essential (G).
Satisfactory functional outcome can be achieved (H to J)
A
B
C
D
E
F
G
H
I
J

380
Principles and Practice of Burn Care
lengthening as first advocated by Matev may be used.
Subperiosteal transverse osteotomy is done in the middle
third of the first metacarpal and distraction of 25 mm can
be achieved. Skin quality must be good both at the stump
and in the line of the pins. Otherwise prior flap cover is
advised.
Advent of microsurgery has increased the options of
reconstruction. The most valuable is toe transfer. This
procedure gives a good functional and cosmetic result in
one stage. This is the best possible reconstruction in isolated
thumb and finger losses due to electrical burns and work
place burn injuries. In children, it has the added advantage
of retaining the growth potential (Figs 27.22A to G).
The last alternative is osteoplastic thumb reconstruction.
Though the literature is abounding with articles against it,
the author finds it as a very valuable technique for a person
who is unwilling to sacrifice the toe. When done well, the
results of osteoplastic thumb reconstruction matches in
function with other types of reconstruction.19 Osteoplastic
thumb reconstruction must be used only if there is a potential
for performing the neurovascular island flap to provide
sensation. Otherwise bone resorption rate is high. This is a
limiting factor in the use of this technique in post burn
reconstruction.
REHABILITATION ISSUES IN HAND BURNS
Helms20 studied the time to return to work following hand
burns in 70 patients in relation to several variables. 1. Total
body surface area (TBSA) burned, 2. Hand burned, 3.
Grafting, 4. Patient’s age, 5. Occupational category. When
assessed at 8 months, 74% had returned to work. The best
predictor of time to return to work was TBSA burned,
followed by ‘grafting’ and the ‘hand burned’. No significant
differences or predictors were found for patient’s age,
occupational category or between non burn hand trauma
patients in prior reports.
The sight and condition of the burnt hand is frightening
to the conscious burn patients. It produces doubts and fears
about their future in the work place and possible dependence
on others for day-to-day existence. Along with good
treatment, presence of reassuring physicians and therapists
goes a long way to allay the fears and boost confidence in
the patient. It encourages them to comply with the exacting
schedules of physiotherapy and look up to a good future.
Fig. 27.20: Square flap technique for deepening of the web
Figs 27.21A to C: Volar contracture in the middle finger covered
after release by a cross finger flap
A
B
C

Hand Burns
381
REFERENCES
1. Tredget E. Management of the acutely burned upper extremity.
Hand Clin 2000;16:187-202.
2. Sheridan RL, Hurley J, Smith MA, Ryan CM, Bondoc CC, Quinby
WC, Tompkins RG, Burke JF. The acutely burned hand: Management
and outcome based on a ten-year experience with 1047 acute hand
burns. J Trauma 1995;38:406-11.
3. Foucher G, Smith D. Acute care and reconstructive management of
hand burns. Current Opinion in Orthopaedics 1995; 7: 2-9.
4. Sykes PJ. Severe Burns of the Hand: A Practical Guide to their
Management. J Hand Surg 1991; 16B: 6 -12.
A
B
C
D
E
F
G
Figs 27.22A to G: A 5-year-old child with electrical burns involving right upper limb and abdominal wall (A). The thumb necrosed and the rest
of the raw areas were skin grafted (B and C). Two months after the injury, thumb reconstruction was done with great toe transfer (D), with
excellent functional result (E to G)
5. Sykes PJ, Bailey BN. Treatment of hand burns with occlusive bags:
A comparison of 3 methods. Burns 1976;2:162-68.
6. Falcone PA, Edstrom LE. Decision making in the acute thermal
hand burn: An algorithm for treatment. Hand Clin 1990;6:233-38.
7. Janzekovic Z. A new concept of the early excision and immediate
grafting of burns. Journal of Trauma. 1970;10:1103-8.
8. Hunt JL, Sato R, Baxter CR. Early Tangential Excision and
Immediate Mesh Autografting of Deep Dermal Hand Burns. Ann
Surg. 1979;189:147-51.
9. VanZuijlen PPM, Kreis RW, Vloemans AFPM, Groenevelt F, Mackie
DP. The prognostic factors regarding long-term functional outcome
of full thickness hand burns. Burns, 1999; 25:709-14.

382
Principles and Practice of Burn Care
10. Jebsen RH. An objective and standardized test of hand function.
Arch Phys Med Rehabil 1969;50:311-19.
11. Nuchtem JG, Engrav LH, Nakamura DY, Dutcher KA, Heimbach
DM, Veder NB. Treatment of fourth-degree hand burns. J Burn
Care Rehabil 1995;16:36-42.
12. Parks DH, Baur PS Larson DL. Late problems in burns. Clin Plast.
Surg 1977;4:547-60.
13. Larson DL, Abston S, Willis B et al. Contracture and scar formation
in the burn patient. Clin Plast Surg 1974;1:653-66.
14. Perera C (personal communication) 2007.
15. Perkins K, Davey RB, Wallis KA. Silicone gel: a new treatment for
burn scars and contractures. Burns 1982; 9:205-13.
16. Mustoe TA. Evolution of Silicone Therapy and Mechanism of
action in Scar management. Aesth Plast Surg 2008; 32:82-92.
17. McCauley RL. Reconstruction of the paediatric burned hand. Hand
Clin 2000;16:249-59.
18. May JW, Donelan MB, Toth BA, Wall J. Thumb reconstruction in
the burned hand by advancement pollicization of the second ray
remnant. J Hand Surg 1984;9:484-89.
19. Sabapathy SR, Venkatramani H, Bharathi RR. Functional Evaluation
of Great Toe Transfer and Osteoplastic Technique for Thumb
Reconstruction in the Same Individual. J Hand Surg 2003;28B:405-
08.
20. Helms PA, Wlaker SC, Peyton SA. Return to work following hand
burns. Arch Phys Med Rehabil 1986; 67:297-98.

Burns of Perineum and External Genitalia
383
Burns of Perineum and
External Genitalia
28
Deepak Nanda
Chapter
INTRODUCTION
The perineum is naturally protected by a deep furrow
between the thighs, often getting spared from burns and
other injuries. Burns of the perineum and external genitalia
usually occur in patients with extensive burns although
isolated injuries are not uncommon. According to Lund and
Browder’s chart for body surface area estimation, only 1%
of the total body surface has been allocated to external
genitalia and perineum. However, American Burns
Association has classified burns of this region as major burns
similar to those of face and hand. Burns of these areas can
result in great psychological trauma which may be
disproportionate to the percentage of total body surface
area involved.
Michielsen et al (1998)1 found an incidence of 2.7% for
burns involving genitalia and perineum out of more than
4,200 patients admitted over a period of 15 years. One-
fourth of them were children with a preponderance of males
(2.4:1). Angel et al (2002) 2, reporting from Shriners hospital
(Texas) catering to children only, found 76 patients out of a
total of more than 2,300 over a period of 10 years, having
burns of this region, again with boys outnumbering girls by
1.5 to 1. A study by Chicago Burn Centre3 indicates that out
of 1600 patients admitted for burns, 93 had involvement of
genitalia and perineum (5.8%). Another study from Japan4
revealed that the percentage of patients with involvement
of genitalia and perineum was higher; about 21.5%. Severity
of burn injury to external genitalia was more in males for
obvious anatomical reasons.
ETIOLOGY AND PATHOGENESIS
The commonest cause of perineal burns is hot liquids or
scalds which varied from 55% to 85%.1,2,5 Second most
common cause was the flame burns accounting for 24%,
30% and 7% respectively in these studies. Other common
causes are electrical contact and flash burns and chemical
burns. Some rare causes of burns of perineum and genitalia
have been enumerated like alkali leak into baby diaper,
ignition of collected spirit based cleaning agent on plastic
sheet by diathermy, involvement of the area by blasts injuries
and during brachytherapy for prostatic malignancy.
The burns of perineum and external genitalia involve
people of all ages from infancy to elderly (86 years). Studies
from USA have suggested child abuse where the ‘ring sign‘
is supposed to be pathognomic and these children are usually
branded for life. In the study from Japan, ‘Sitz bath’ has
been blamed for burns of perineum in old people especially
during the winter months when these baths are a custom
(Figs 28.1A and B).
Abdel-Razek6 reported cases of rare isolated chemical
burns of genitalia and perineum from King Saud Hospital.
These burns constituted about 3.4 percent of total burns at
his center. They were due to sulfuric acid used for water
closet cleaning which was accidentally used to wash genitalia
as an initial step of making Wodoa before praying in Islam.
Sulfuric acid and its precursor sulfuric trioxide are strong
acids and desiccants which cause coagulative necrosis of
parts involved. These burns are either second degree deep
dermal or third degree full thickness, the latter being more
common (Fig. 28.2).

384
Principles and Practice of Burn Care
full thickness burns of perineum and partial or total loss of
external genitalia (Fig. 28.5). Scalds are more common in
children below two years while flame burns are commoner
in the older age groups. Psychological consequences of
these injuries cannot be ignored. Repeated examination of
private anatomical area tends to affect modesty as well as
self respect. Fear of sexual dysfunction and unattractiveness
leads to depression. About 25 % adult patients complain of
loss of libido and orgasmic dysfunction.3
Fig. 28.1A: Accidental superficial burns of scrotum and perineum
by concentrated potassium permanganate during sitz bath
Fig. 28.1B: Same patient after 1 week with healed areas showing
hypopigmentation
Rare cases of genitalia and perineal burns have been
reported due to fireworks during Guy Fawkes nights and a
case has been reported where a mentally depressed woman
inserted a rocket two inches into her vagina and ignited it
while trying to commit suicide!7
Burns due to scalds are usually second degree burns
(Fig. 28.3). Out of these, superficial dermal are 1.5 to 2
times more common than deep dermal injuries. Third degree
or full thickness burns constitute a small proportion only.
Flame burns are usually deeper as compared to scalds (Fig.
28.4) while high voltage electrical contact burns may produce
Fig. 28.2: Accidental acids burns showing track of acid trickling down
from the abdomen towards perineum with deep burns over one side
of penis causing lateral curvature with edema of penile skin
Fig. 28.3: A 10-year-old child with scalds of the perineum leading to
superficial dermal burns with blister formation